Having failed to repeal and replace the Affordable Care Act, Congress is now working on a tax overhaul. But it turns out the tax bills in the House and Senate would also reshape health care.
Here are five big ways the tax bill could affect health policy:
1. Repeal the requirement for most people to have health insurance or pay a tax penalty.
Republicans failed to end the so-called individual mandate this year, when they attempted to advance their health overhaul. Now the idea is back, at least in the Senate’s version. The measure would not remove the requirement for people to have insurance, but would eliminate the fine for people who choose to remain uninsured.
The Congressional Budget Office estimated that dropping the requirement would result in 13 million fewer people having insurance over 10 years.
It also estimated that premiums would rise 10 percent more per year than without this change. That is because healthier people would be most likely to drop insurance in the absence of a fine, so insurers would have to raise premiums to compensate for sicker customers. Those consumers would then be left with fewer affordable choices, the CBO predicted.
State officials worry that insurers will leave the individual market if there is no requirement for healthy people to sign up, but they still must sell to people who know they will need care.
Ironically, the states most likely to see this kind of insurance-market disruption are reliably Republican. An analysis by the Los Angeles Times suggested that the states with the fewest insurers and the highest premiums — including Alaska, Iowa, Missouri, Nebraska, Nevada, and Wyoming — would be left with no coverage or options too expensive for most consumers in the individual market.
2. Repeal the medical expense deduction.
The House-passed tax bill, although not the Senate’s, would eliminate taxpayers’ ability to deduct medical expenses that exceed 10 percent of their adjusted gross income.
The medical expense deduction is not widely used — just under 9 million tax filers took it on their 2015 tax returns, reported the IRS. But those who use it generally have high medical expenses, often for a disabled child, a chronic illness or costly long-term care not covered by insurance.
Among those most opposed to ending the deduction is the senior advocacy group AARP. It called eliminating the deduction “a health tax on millions of Americans with high medical costs — especially middle-income seniors.”
3. Trigger major cuts to the Medicare program.
The tax bills include no specific Medicare changes, but analysts note that passing them in their current form would trigger another law to kick in. That measure requires cuts to federal programs if the budget deficit is increased.
Because the tax bills in the House and Senate would add $1.5 trillion to the deficit over the next 10 years, both would result in automatic cuts under the Statutory Pay-As-You-Go Act of 2010, known as PAYGO. According to the CBO, if Congress passes the tax bill and does not waive the PAYGO law, federal officials “would be required to issue a sequestration order within 15 days of the end of the session of Congress to reduce spending in fiscal year 2018 by the resultant total of $136 billion.”
Cuts to Medicare are limited under the PAYGO law, so the Medicare reduction would be limited to 4 percent of program spending, which is roughly $25 billion of that total. Cuts of a similar size would be required in future years. Most of that would likely come from payments to providers.
4. Change tax treatment for graduate students and those paying back student loans.
The House bill, though not the Senate’s, would for the first time require graduate students to pay tax on the value of tuition that universities do not require them to pay.
Currently, graduate students in many fields, including science, often are paid a small stipend for teaching while they pursue advanced degrees. Many are technically charged tuition that’s waived as long as they work for the university.
The House tax bill would eliminate that waiver and require them to pay taxes on the full value of the unpaid tuition, which would result in many students with fairly low incomes seeing very large tax bills.
The House tax bill would also eliminate the deduction for interest paid on student loans. This would disproportionately affect young doctors.
According to the Association of American Medical Colleges, 75 percent of the medical school class of 2017 graduated with student loan debt, with nearly half owing $200,000 or more.
5. Change or eliminate the tax credit that encourages pharmaceutical companies to develop drugs for rare diseases.
Congress created the so-called Orphan Drug Credit in 1983, as part of a package of incentives to entice drug makers to develop drugs to treat rare diseases, those affecting fewer than 200,000 people. With such a small market, it doesn’t make sense for companies to spend the millions necessary to develop treatments.
To date, about 500 drugs have come to market using the incentives, although drug makers have sometimes manipulated the credit for extra gain.
The House bill would eliminate the tax credit; the Senate bill would scale it back. Sen. Orrin Hatch (R., Utah), chairman of the tax-writing Finance Committee, was an original sponsor of the orphan drug law.
The drug industry has been relatively quiet about the potential loss of the credit, but the National Organization for Rare Disorders called the change “wholly unacceptable” and said it “would directly result in 33 percent fewer orphan drugs coming to market.“