House Legislation Would Cause 350,000 People to Forgo Health Coverage and Could Jeopardize Health Reform
The House is set to consider legislation this week that would make a
change in the subsidies that health reform (the Affordable Care Act)
provides to help low- and moderate-income people buy health insurance,
causing 350,000 of them to forgo coverage and making it harder for
health reform’s insurance exchanges to work effectively.
The
proposed change in the subsidies is designed to offset the cost of (1) a
proposed repeal of health reform’s excise tax on medical devices (as
demanded by the medical device industry, which has waged a misleading
campaign against it), and (2) proposed changes in flexible spending
accounts (FSAs) and health savings accounts (HSAs) that do not represent
either sound health policy or sound tax policy and would
disproportionately favor higher-income people.
[1]
The
change in the subsidies to purchase insurance would substantially
increase the repayment charges that the Internal Revenue Service would
impose at tax time on many low- and moderate-income people who received
subsidies to help them afford coverage during months of the year when
their incomes were low, but whose incomes rose later in the year when
they found a job or received a promotion or for another reason.
Consider
a married couple with one child whose household income is 145 percent
of the poverty line ($27,680 in today’s dollars) from one spouse’s
earnings. The sponsor’s job doesn’t provide health coverage, and the
family receives a subsidy to buy coverage in the exchange. At the start
of September, the other spouse gets a job that does provide coverage
and that raises the household’s income for the year to 260 percent of
poverty ($49,634 in today’s dollars). The family enrolls in this
employer’s health plan and ceases to receive subsidies. Under the House
provision, the family would owe about $2,100 to the IRS at tax time.
The prospect of having to pay very large sums back to the IRS would
likely deter many people from using the subsidies in the first place,
causing them to remain uninsured.
Indeed,
for many families
in such a situation, the amounts they would have to repay to the IRS if
they received subsidies would be more than five times higher than the
penalty they would owe if they remained uninsured in 2014. In the
example above, the penalty would be about $330 if the family had forgone
coverage for the first eight months of the year, as compared to the
$2,100 or so they would owe to the IRS. That’s why the Joint Committee
on Taxation estimates the House provision would cause 350,000 people who
would otherwise purchase coverage to forgo it instead.
Those
who forego coverage would disproportionately be people who are healthier
than average. As a result, the pool of people seeking coverage through
the health insurance exchanges would be a somewhat sicker pool, which
would push up premiums for insurance purchased through the exchanges and
thereby weaken the exchanges’ ability to function effectively. (This
may be an unstated goal of the provision; some of health reform’s
Congressional opponents have said that if they cannot repeal the law
outright, they will seek to pull out “threads” to try to unravel it.)
Congress
already has acted twice since health reform’s enactment in March 2010
to raise the amounts that households that receive health insurance
subsidies can be required to pay to the IRS — thus raising the amount
that the family in the example above would pay, from $400 (under the
Affordable Care Act (ACA) as originally enacted) to $1,500. Those
changes, which were used to finance two earlier pieces of legislation,
have boosted families’ potential repayment amounts by up to six times,
which already will cause an estimated several hundred thousand people to
forgo coverage.
[2]
Now, the legislation that the House is set to consider this week would
go substantially further, raising the repayment amounts for many
families enough to threaten the viability of health reform.
Congress Has Raised the Repayment Amounts Substantially
Under
the ACA, people who are not eligible for Medicaid and lack access to
affordable employer-sponsored coverage can receive subsidies to help
them purchase private coverage if their income is below 400 percent of
the poverty line. However, people whose income for the year as a whole
turns out to make them eligible for a smaller subsidy than they received
during the year (or for no subsidy) must pay back some or all of the
subsidy they received when they file their income taxes, even if they
received the correct subsidy amount based on their income in the months
that they actually got the subsidies. This provision of the ACA differs
sharply from how most other means-tested programs work. Other programs
base eligibility on current income; if a household’s income rises
during the year, it ceases to receive assistance or receives a reduced
benefit, but it is not made to pay back the aid it received during its
period of need.
To prevent the requirement to repay subsidies
from undermining the ACA’s goal of covering people while they are out of
work or otherwise in need and are uninsured, Congress, in crafting the
ACA, limited the amount that a family can be required to pay back to
$400 ($250 for an individual) unless the family’s income ends up over
400 percent of the poverty line. In that case, the family would have to
pay back the entire amount of any premium subsidies it received.
Over
the past year and a half, however, Congress raised the $400 cap sharply
to secure offsets for other legislation: in December 2010, to help pay
for extending Medicare physician relief for 2011; and in April 2011, to
help pay for repeal of an ACA provision designed to curb business tax
avoidance. As a result of these changes, the $400 cap has tripled for
many families and increased for others by as much as six times
,
depending on the family’s income for the year and the timing of that
income. Many families already face requirements to pay back very large
amounts.
To offset the cost of repealing the medical device tax
and providing bigger tax breaks through FSAs and HSAs, the House would
now eliminate the repayment caps altogether, with serious consequences
for tens of thousands of families and potentially for health reform
itself.
Repayment Amounts Would Often Far Exceed Penalty for Forgoing Coverage
If
the caps on repayment are eliminated, the amounts that families would
be required to repay in 2014 would, in many cases, be well over five
times the penalty they would face in 2014 under the ACA’s individual
mandate if they failed to obtain coverage. (The ratio is even wider
when the individual’s upfront share of premium costs is taken into
account.) Health insurance exchanges will have to inform applicants of
their potential obligation to repay subsidies if their income increases
and may ask applicants to attest that they understand they may have to
repay any subsidies they receive.
[3]
Those who are unemployed but expect to get a job during the year will
have to be told that they will have to repay some or all of their
subsidy if their income increases.
As knowledge spread of the
large year-end tax repayments that families could face, many people
would — quite rationally — decide to remain uninsured. This is why the
Joint Committee on Taxation projects that by 2022, an additional 350,000
people would forgo coverage because of the pending House provision, on
top of the several hundred thousand who will forgo coverage as a result
of the big increases already made in the required repayment amounts in
the legislation enacted in December 2010 and April 2011. Our analysis
indicates that 38 percent of the estimated $43.9 billion in savings
credited to this provision comes from the reduction in the number of
people who would enroll in coverage in the exchanges.
[4]
As
noted, because people who decided to forgo coverage would
disproportionately be healthy individuals, the pool of people enrolling
with the exchanges would be sicker on average, which would push up
everyone’s premiums for insurance. The higher premiums, in turn, would
lead additional healthy people to forgo coverage. The result would be
“adverse selection” that could weaken the viability of the exchanges.
Under
the ACA as originally enacted, the repayment requirement for the family
in our example would have been $400 — not out of line with the $330
penalty the family would face for failing to have coverage in 2014. The
$400 cap took into account the fact that the subsidies such a family
received would have appropriately reflected its income and circumstances
during the months it received assistance. But Congress’s subsequent
increases in repayment amounts raised the amount this family would owe
to $1,500, already a dangerously high amount that is well out of line
with the penalty the family would owe if it failed to obtain coverage in
2014.
There would also be problems for people who received
Christmas or year-end bonuses, only to find they now had to pay back
part of their health insurance subsidy as a consequence.
More
broadly, the fact that many families who had “played by the rules” and
done nothing wrong — receiving subsidies accurately based on their
current incomes, promptly reporting changes in their incomes, and
ceasing to receive subsidies (or receiving smaller subsidies) when their
incomes increased — would nonetheless face large repayments would
likely trigger widespread backlash against the ACA by many lower-middle
and middle-income families. These people would have been required to
buy coverage, only to find that they had to pay up to several thousand
dollars in increased taxes to the IRS at the end of the year. The
ensuing backlash could make repeal of the law more likely.
Those
pushing to eliminate limits on repayment amounts have claimed that many
households will receive subsides much larger than they are entitled to
because the health insurance exchanges will base households’ subsidy
amounts on outdated income information from the households’ prior-year’s
tax returns. Such charges may have appeared to have merit after the
ACA was enacted but no longer do. The ACA requires the Secretary of
Health and Human Services to develop procedures to take changes in
household circumstances into account when determining eligibility for,
and the amount of, the subsidies that a household will receive, but
contains no specifics on how to do so, leaving that to the Secretary.
How this would work wasn’t initially clear. But HHS issued its final
rule on the eligibility determination on March 27, 2012, and the rule
requires
applicants for subsidies to validate and update the information on
their prior tax return; if their income has increased in the interim,
the
updated information must be used to determine their subsidy
amount. This rule also requires people who receive subsidies to report
changes in income or other circumstances within 30 days. The preamble
explains that “it is important for the Exchange to accept and identify
changes to help ensure that an enrollee’s eligibility reflects his or
her true circumstances.”
[5]
Separate
provisions of the ACA provide for a full set of enforcement actions,
including substantial fines, to be taken against households that receive
excess subsidies due to misrepresentation or fraud.
Some have
questioned whether it is equitable to allow two households that end up
with the same annual income to receive different amounts of premium tax
credits over the year. Our example shows, however, that while such
families might have the same
annual income, their circumstances
and ability to afford health insurance are very different over the
course of the year. Families without a job for part of the year cannot
pay the same amount for coverage in those months as a family with income
that is steady throughout the year. The family in our example could not
have paid for coverage during the first part of the year without the
help that it received based on its income at the time, which was lower
than its income at the end of the year.
Requiring very large
repayments at tax time from people who accurately reported their
circumstances but subsequently gained a job, had a child leave their
home, or experienced another such change later in the year (and reported
that as well) does not represent sound policy. Congress has already
raised the repayment limits to a danger point, at which a substantial
number of healthy families and individuals are likely to choose to
remain uninsured rather than buy coverage. Going further in this
direction could be exceedingly unwise and could threaten the viability
of health reform itself.
End notes:
[1]
Paul N. Van de Water, “Excise Tax on Medical Devices Should Not Be
Repealed: Industry Lobbyists Distort Tax’s Impact,” Center on Budget
and Policy Priorities, Updated May 31, 2012,
http://www.cbpp.org/cms/index.cfm?fa=view&id=3684. Paul N. Van de
Water, “Limitation On Use Of Tax-Advantaged Health Accounts Should Not
Be Repealed,” Center on Budget and Policy Priorities, June 5, 2012,
http://www.cbpp.org/cms/index.cfm?fa=view&id=3789 .
[2]
Minority members of the House Ways and Means Committee issued a paper
dissenting from the April 2011 legislation raising the repayment
amounts. That paper cites an estimate from the Joint Committee on
Taxation (JCT) that the change in that legislation would cause 266,000
people to forgo coverage. The pending legislation would cause an
additional 350,000 people to forgo coverage, according to JCT.
[3]
HHS issued its final rule on the determination of eligibility for
advance payments of premium tax credits in March 2012. The preamble
states that HHS intends to provide further guidance regarding
attestations “that may be asked of individuals, which may include an
attestation from a tax filer acknowledging that he or she understands
the potential impact of reconciliation.” 77 Fed. Reg. at 18356. (March
27, 2012)
[4]
The Congressional Budget Office (CBO) has estimated enrollment in the
exchanges and the average per-enrollee federal premium subsidy under
current law for each year from 2014 through 2022. From this estimate,
we calculated the percentage that the loss of enrollment in exchange
coverage that would be caused by the proposed increase in the repayment
amounts — 350,000 people according to JCT — would represent of total
exchange enrollment that year. Using this percentage reduction, we
determined the enrollment loss resulting from raising the repayment caps
for each year from 2014 through 2021. For each year, we then
multiplied that estimated enrollment loss by the CBO estimate of the
average per-enrollee subsidy for that year to determine the federal
savings associated with the enrollment loss. Using this method, we
estimate that approximately $16.8 billion (38 percent) of the savings
attributed to increasing the caps are due to decreased enrollment in the
exchanges.
[5] 77 Fed. Reg. at 18371. (March 27, 2012)
The VHA of course is stating that everything is all rosy and great, even though in reality the VETS are really getting a raw deal with long wait times especially for audiology and rehab medicine. The problem is that nobody who is in charge of the hospitals want to tell the truth because they will not get their bonuses and performance pay. People in the VHA who are leaders are not capable at this point of really keeping the VET in mind by telling everybody the truth. The truth is that VETS are waiting up to 2-3 months to get into speciality and also to get a PCP appt in high population areas.
I could go on and on about how the statistics and the archaic appt menu system needs to be changed.
It does not take a rocket scientist to look and ask the question: ‘why is everybody being seen within the 14 days of the desired date” , but the the third next available appt time is out 3 months? REALLY?
I think a journalist like yourself could do every Veteran in this country a favor by doing some investigative reporting about this issue.
The house of smoke and mirrors is alive and well, and of course charging the country for admission.
Keep up the good work….the data is out there and you are smart enough to drill down to the reality of the situation! We need people like you.