Order Code IB98037
Issue Brief for Congress
Received through the CRS Web
Tax Benefits for Health Insurance:
Current Legislation
Updated October 28, 2002
Bob Lyke and Christopher Sroka
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

CONTENTS
SUMMARY
MOST RECENT DEVELOPMENTS
BACKGROUND AND ANALYSIS
Tax Benefits in Current Law
Overview of Current Provisions
Employment-Based Plans
Medical Expense Deduction
Individual Private Market Policies
Self-Employed Deduction
Cafeteria Plans
Flexible Spending Accounts
Medical Savings Accounts
Tax Credit for Trade-Displaced Workers
Military and Veterans Health Care
Medicare and Medicaid
Some Consequences of the Tax Benefits
Increases in Coverage
Source of Coverage
Increase in Health Care Use and Cost
Equity
Current Proposals
Medical Savings Accounts
Self-Employed Deduction
Cafeteria Plans
Flexible Spending Accounts
Expanded Tax Deduction
Tax Credit
Small Employer Tax Credit
Foundation Grants and Loans
LEGISLATION
FOR ADDITIONAL READING
Appendix


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Tax Benefits for Health Insurance: Current Legislation
SUMMARY
The 107th Congress has been considering
certain types of insurance. (5) Coverage under
a number of new or expanded tax benefits for
Medicare and Medicaid is not considered
health insurance. Proposals being considered
taxable income. (6) With some exceptions,
include creating a refundable tax credit for all
benefits received from private or public insur-
workers, expanding and permanently extend-
ance are not taxable.
ing medical savings accounts (MSAs), creat-
ing tax credits for small employers, and ex-
By lowering the after-tax cost of insur-
panding tax benefits for the self-employed.
ance, the tax benefits help extend coverage to
Proponents argue that new tax benefits are
more people; they also lead insured people to
needed to extend coverage to the uninsured
obtain more coverage than otherwise. The
and to address efficiency and equity problems;
incentives influence how coverage is acquired:
opponents claim they would primarily benefit
the uncapped exclusion for employer-paid
higher income taxpayers and do little for those
insurance, which can benefit nearly all work-
without coverage.
ers and is easy to administer, is partly respon-
sible for the predominance of employment-
Current law contains significant tax
based insurance in the United States.
benefits for health insurance. (1) Most im-
Employment-based insurance has both advan-
portant is the exclusion of employer-paid
tages and disadvantages for the typical
health insurance from the determination of
worker. The tax benefits also increase the
income and employment taxes. Over b of the
demand for health care by enabling insured
noninstitutionalized population under age 65
people to obtain services at discounted prices.
are insured through employment-based insur-
This is one reason health care prices have
ance; on average, large employers pay about
risen more rapidly than the general inflation
80% of its cost, though some pay all and
rate. Moreover, since many people would
others none. The exclusion also applies to
likely obtain some insurance without the tax
health insurance provided through cafeteria
benefits, they can be an inefficient use of
plans. (2) Self-employed taxpayers may
public dollars. They also raise questions of
deduct 70% of their health insurance pay-
equity, largely because the tax savings they
ments, a proportion scheduled to rise to 100%
generate depend upon the taxpayer’s marginal
in 2003. (3) Taxpayers who itemize deduc-
tax rate. When viewed as a form of personal
tions may deduct insurance payments to the
consumption, giving tax incentives for health
extent they and other medical expenses exceed
insurance provides more benefits to higher
7.5% of adjusted gross income. While not
income families who may not need them.
widely used, this deduction benefits some
Comprehensive reforms (e.g., capping the
with employment-based insurance (for the
employer exclusion or replacing it with deduc-
employee share), some self-employed (the
tions and credits) might address some of these
remaining 30% of their cost) and others who
concerns, though they could be difficult to
purchase individual market policies. (4)
implement and may cause serious inequities of
Workers displaced by trade can receive an
their own.
advanceable, refundable tax credit to purchase
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MOST RECENT DEVELOPMENTS
On August 6, 2002, President Bush signed into law the Trade Act of 2002 (P.L. 107-
210). The law provides workers displaced by trade with a refundable, advanceable tax
credit for the purchase of health insurance. The credit is worth 65% of the premiums paid
by the displaced worker for qualified health insurance. Qualified health insurance includes
continuation of coverage under COBRA, an individual insurance policy (if the worker was
covered by an individual policy at least 30 days prior to becoming unemployed), and certain
types of state-sponsored health insurance. Some policymakers have stated that this
legislation could become a model for a tax credit for the general population.

The House-passed patient protection bill (H.R. 2563, sponsored by Representative
Ganske) contains several tax provisions relating to health insurance. These provisions
would expand and extend the use of Archer medical savings accounts (MSAs), allow self-
employed individuals to deduct 100% of their health insurance premiums, provide a tax
credit for small employers, and change the requirements for qualified health benefit
purchasing coalitions. The Senate-passed patient protection bill does not have these tax
provisions. As of October 28, 2002, a conference to reconcile the bill differences has not
been appointed.

BACKGROUND AND ANALYSIS
Tax Benefits in Current Law
Current law provides significant tax benefits for health insurance. The tax
subsidies—for the most part federal income tax exclusions and deductions—are widely
available, though not everyone can take advantage of them. They reward some people more
than others, raising questions of equity. They influence the amount and type of coverage that
people obtain, which affects their ability to choose doctors and other providers. In addition,
the tax benefits affect the distribution and cost of health care.
Overview of Current Provisions
This section summarizes the current tax treatment of the principal ways that people
obtain health insurance. It describes general rules but does not discuss all limitations,
qualifications, and exceptions. An outline of the tax provisions discussed in this section is
provided in Table 1. To understand possible effects on tax liability, readers may want to
refer to the Appendix for an outline of the federal income tax formula. (For example,
exclusions are items that are omitted from gross income, while deductions are subtracted
from gross income in order to arrive at taxable income.) Section number references are to
the Internal Revenue Code of 1986 as amended.
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Table 1. Summary of the Tax Treatment of Health Insurance
Plan type
Tax treatment for individual
Tax treatment for employer
Traditional
–Premiums paid by employee are deductible if –Employer contributions deducted as
employer-
(1) employee itemizes and (2) premiums plus a business expense, and they are not
sponsored plan
other unreimbursed medical expenses exceed counted for employer’s share of
7.5% of adjusted gross income (AGI)
employment taxes
–Premiums paid by employer are excluded for
income and employment tax purposes
–Insurance benefits excluded from employee’s
gross income
Individual market –Premiums are deductible if (1) the individual –N/A
policies
itemizes and (2) premiums plus other
unreimbursed medical expenses exceed 7.5%
of AGI
Policies purchased
–Individual can deduct premiums (up to 70% in 2002) from adjusted gross income;
by self-employed
deduction does not have to exceed 7.5% of AGI
individuals
–Premiums not deducted using the self-employed deduction can be deducted if (1) the
individual itemizes and (2) the remaining premiums plus unreimbursed medical
expenses exceed 7.5% of AGI
Cafeteria plans
–Premiums and other health benefits are – Employer contributions deducted
excluded for income and employment tax as a business expense, and they are
purposes
not counted for employer’s share of
employment taxes
Flexible spending
–All contributions excluded for income and – Employer contributions deducted
accounts
employment tax purposes
as a business expense, and they are
not counted for employer’s share of
employment taxes
Medical savings
–Employer contributions excluded for income – Employer contributions deducted
accounts
and employment tax purposes
as a business expense, and they are
not counted for employer’s share of
–Individual contributions deductible for employment taxes
income tax purposes
–Only for self-employed individuals with high-
deductible insurance or employees of a small
business providing high deductible insurance
Military and
–Benefits and coverage provided under – N/A
veterans health
military and veterans health care programs are
care
not considered taxable income
Medicare and
–Benefits and coverage provided under the –N/A
Medicaid
Medicare and Medicaid programs are not
considered taxable income
–Premiums paid for Medicare are deductible if
(1) the individual itemizes and (2) premiums
plus other unreimbursed medical expenses
exceed 7.5% of AGI
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Employment-Based Plans. Health insurance paid by employers generally is
excluded from employees’ gross income in determining their income tax liability; it also is
not considered for either the employee’s or the employer’s share of employment taxes (i.e.,
social security, Medicare, and unemployment taxes). (Sections 106 and 3121, respectively)
The income and employment tax exclusions apply to both single and family coverage, which
includes the employee’s spouse and dependents. Premiums paid by employees generally are
not deductible, though they may be counted towards the itemized medical expense deduction
or subject to a premium conversion arrangement under a cafeteria plan (both of which are
discussed below).
Over two-thirds of the noninstitutionalized population under age 65 is insured under an
employment-based plan. On average, large employers pay about 80% of the cost for
employment-based insurance, though some pay all and others pay none. Employers typically
pay a smaller percentage for family than for single coverage.
Insurance benefits paid from employment-based plans are excluded from gross income
if they are reimbursements for medical expenses or payments for permanent physical injuries.
Benefits not meeting these tests are taxable in proportion to the share of the insurance costs
paid by the employer that were excluded from gross income. (Sections 104 and 105)
Benefits are also taxable to the extent taxpayers received a tax benefit from claiming a
deduction for the expenses in a prior year (for example, if taxpayers claimed a medical
expense deduction for expenditures in 2000 and then received an insurance reimbursement
in 2001). In addition, benefits received by highly-compensated employees under
discriminatory self-insured plans are partly taxable. A self-insured plan is one in which the
employer assumes the risk for a health care plan and does not shift it to a third party.
Employers may deduct their insurance payments as a business expense. The deduction
is not a tax benefit but a calculation necessary for the proper measurement of the net income
that is subject to taxation. Revenue loss attributable to this deduction is not considered a tax
expenditure.
The Joint Committee on Taxation (JCT) estimates the FY2003 federal revenue loss
attributable to the exclusion for employer contributions for health insurance, medical care
(including that provided through cafeteria plans and flexible spending accounts, described
below) and long-term care insurance will be $75.1 billion. The estimate does not include the
effect of the exclusion on employment taxes.
Medical Expense Deduction. Taxpayers who itemize their deductions may deduct
unreimbursed medical expenses, but only the amount of such expenses that exceeds 7.5%
of adjusted gross income (AGI). (Section 213) Medical expenses include health insurance
premiums paid by the taxpayer, such as the employee’s share of premiums in employment-
based plans, premiums for individual private market policies, and part of the premiums paid
by self-employed taxpayers. More generally, medical expenses include amounts paid for the
“diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of
affecting any structure or function of the body.” They also include certain transportation and
lodging expenditures, qualified long-term care service costs, and long-term care premiums
that do not exceed certain amounts. Currently, the deduction is intended to help only those
with catastrophic expenses.
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The medical expense deduction is not widely used. For most taxpayers, the standard
deduction is larger than the sum of itemized deductions; moreover, most do not have
unreimbursed expenses that exceed the 7.5% AGI floor. In 1998, about 31% of all individual
income tax returns had itemized deductions, and of these only about 15% (i.e., about 4.5%
of all returns) claimed a medical expense deduction.
The JCT estimates the FY2003 revenue loss attributable to the medical expense
deduction (including long-term care expenses) will be $6 billion.
Individual Private Market Policies. Payments for private market health insurance
purchased by individuals are a deductible medical expense, provided the taxpayer itemizes
deductions and applies the 7.5% AGI floor as just described. Premiums for the following
insurance, however, are not deductible: policies for loss of life, limb, sight, etc.; policies
that pay guaranteed amounts each week for a stated number of weeks for hospitalization; and
the part of car insurance that provides medical coverage for all persons injured in or by the
policyholder’s car. Benefits paid under accident and health insurance policies purchased by
individuals are excluded from gross income, even if they exceed medical expenses.
About 6% of the noninstitutionalized population under age 65 is insured through these
private policies. Likely purchasers include early retirees, young adults, employees without
access to employment-based insurance, and the self-employed.
Self-Employed Deduction. Self-employed taxpayers may deduct payments for
health insurance in determining their AGI. (Section 162) Their insurance typically is an
individual private market policy. The self-employed deduction, an “above-the-line”
deduction, is not restricted to itemizers, as is the medical expense deduction. Following
enactment of the Omnibus Consolidated and Emergency Supplemental Appropriations Act
for Fiscal Year 1999 (P.L. 105-277), the deduction was 60% of insurance payments in 1999
through 2001; the deduction is 70% in 2002 and will increase to 100% in 2003 and
thereafter. So limited, the deduction cannot exceed the net profit and any other earned
income from the business under which the plan is established, less deductions taken for
certain retirement plans and for one-half the self-employment tax. It is not available for any
month in which the taxpayer or the taxpayer’s spouse is eligible to participate in a subsidized
employment-based health plan (that is, one in which the employer pays part of the cost).
These restrictions prevent taxpayers with little net income from their business (which may
not be uncommon in a new business, for example, or in a part-time business that grows out
of a hobby) from deducting much if any of their insurance payments. However, the portion
not deductible under these rules may be treated as an itemized medical expense deduction.
For additional information, see CRS Report 98-515 E, Tax Treatment of Health Insurance
Expenditures by the Self-Employed: Current Law and Selected Economic Effects,
by Gary
Guenther.
Self employed individuals include sole proprietors (single owners of unincorporated
businesses), general partners, limited partners who receive guaranteed payments, and
individuals who receive wages from S-corporations in which they are more than 2%
shareholders. (S-corporation status may be elected by corporations that meet a number of
Internal Revenue Code requirements. Among other things, they cannot have more than 75
shareholders or more than one class of stock. S-corporations are tax-reporting rather than
tax-paying entities, in contrast to C-corporations that are subject to the corporate income tax.)
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In 1998, about 3.4 million tax returns (about 2.7% of all returns) claimed the self-
employed health insurance deduction. For FY2003, the JCT estimates the revenue loss
attributable to the deduction (including the deduction for long-term care insurance) to be $2.4
billion.
Cafeteria Plans. Health benefits provided through a cafeteria plan are excludable for
both income and employment tax purposes. A cafeteria plan is a written benefit plan under
which employees may choose between receiving cash and certain nontaxable benefits such
as health coverage or dependent care. (Cash here includes any taxable benefits.) Under an
option known as a premium conversion plan, employees may elect to reduce their taxable
wages in exchange for having their share of health insurance premiums paid on a pre-tax
basis; the effect is the same as if employees could claim an above-the line deduction for their
payments. Starting in October, 2000, federal employees who participate in the Federal
Employees Health Benefits Program (FEHBP) generally can elect this option. Federal
retirees may not use their annuities on a pre-tax basis for FEHBP premiums.
Nontaxable benefits provided through cafeteria plans are exempt from income and
employment taxes under the Internal Revenue Code rules applicable to those benefits, such
as employer-paid insurance. A separate statutory provision (Section 125) extends these
exclusions to situations in which employees are given the option of receiving cash; were it
not for this provision, the nontaxable benefit would be taxable since the employees had been
in constructive receipt of the cash.
Flexible Spending Accounts. Benefits paid from flexible spending accounts
(FSAs) are also excludable for income and employment tax purposes. FSAs and cafeteria
plans are closely related, but not all cafeteria plans have FSAs and not all FSAs are part of
cafeteria plans. FSAs funded through salary reductions are exempt from taxation through
cafeteria plan provisions (since otherwise employees would be in constructive receipt of
cash) while FSAs funded by nonelective employer contributions are exempt directly under
provisions applying to employer-paid insurance. For additional information on FSAs, see
CRS Report 96-500, Flexible Spending Accounts and Medical Savings Accounts: A
Comparison
, by Bob Lyke and Chris L. Peterson.
Health care FSAs must exhibit some of the risk-shifting and risk-distribution
characteristics of insurance. Among other things, participants must elect a specific benefit
amount prior to the start of a plan year; this election cannot be revoked except for changes
in family status. The full benefit amount (less any benefits paid) must be made available
throughout the entire year, even if employees spread their contributions throughout the year.
Any amount unused at the end of the year must be forfeited to the employer (thus, “use it or
lose it”). FSAs cannot be used to purchase insurance; however, they can be combined with
premium conversion plans under cafeteria arrangements to achieve the same tax effect.
In 1997, about 40% of full-time employees in medium and large size private firms could
have a health care FSA. Actual participation likely was far less.
Medical Savings Accounts. Medical savings accounts (MSAs) are personal
savings accounts for unreimbursed medical expenses. They are used to pay for health care
not covered by insurance, including deductibles and copayments. Currently, a limited
number of MSAs may be established by individuals who have qualifying high deductible
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insurance (and none other, with some exceptions) and who either are self-employed or are
employees covered by a high deductible insurance plan established by their small employer
(50 or fewer employees on average). The formal name of MSAs is now Archer MSAs.
Employer contributions to MSAs are excludable for both income and employment tax
purposes, while individuals’ contributions (allowed only if the employer does not contribute)
are deductible for determining AGI. Contributions are limited to 65% of the insurance
deductible for single coverage and 75% for family coverage. Account earnings are
excludable as well, as are distributions used for unreimbursed medical expenses, with some
exceptions. Non-qualified distributions are included in gross income and an additional 15%
penalty is applied. For further information, see CRS Report 96-500, Flexible Spending
Accounts and Medical Savings Accounts: A Comparison
, by Bob Lyke and Chris L. Peterson.
The original medical savings account legislation (the Health Insurance Portability and
Accountability Act of 1996, P.L. 104-191), authorized a limited number of MSAs under a
demonstration beginning in 1997. Eligibility was to be restricted after the earlier of (1)
December 31, 2000, or (2) specified dates following a determination that the number of
taxpayers with accounts exceeded certain thresholds (eventually, 750,000). Once eligibility
was restricted under these tests, MSAs generally would have been limited to individuals who
either were active participants (had contributions to their accounts) prior to the cut-off date
or became active participants through a participating employer. The Community Renewal
Tax Relief Act of 2000 (P.L. 106-554) included an extension of eligibility for new
participants until December 31, 2002; it also changed the formal name to Archer MSAs for
the retiring chairman of the House Ways and Means Committee. The Job Creation and
Worker Assistance Act (P.L. 107-147) extended eligibility for new participants until
December 31, 2003.
The IRS has estimated that 62,232 MSAs received contributions in tax year 2000 and
that an additional 22,640 were established prior to July 1, 2001. MSAs are not counted
towards the cut-off threshold if the owners were previously uninsured; thus, not all of these
can be compared to the 750,000 ceiling. MSAs should be distinguished from
Medicare+Choice MSAs, which are discussed below under the tax treatment of Medicare and
Medicaid.
Tax Credit for Trade-Displaced Workers. On August 6, 2002, President Bush
signed into law the Trade Act of 2002 (P.L. 107-210). The law allows workers displaced by
trade to receive a tax credit for purchasing insurance. The amount of the credit is equal to
65% of the premiums paid by the worker for qualified health insurance. The credit is
advanceable, meaning that workers can receive the credit when purchasing insurance rather
than receiving it after filing their tax returns. The credit is also refundable; eligible workers
can receive the credit even if they have zero tax liability for the year. To be eligible for the
credit, a worker must be (1) a recipient of a trade readjustment allowance under the Trade
Act of 1974; (2) an individual who is not eligible for a trade readjustment allowance because
he or she has not exhausted all rights to unemployment insurance; (3) a displaced worker
whose current job pays less than the job lost to trade and who is receiving a supplemental
wage allowance; or (4) an individual who is over the age of 55 and is receiving a pension
benefit from the Pension Benefit Guaranty Corporation (PBGC).
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The tax credit for workers displaced by trade can be used for limited types of health
insurance. The tax credit can be applied towards premiums paid to continue employer-
sponsored health insurance under the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA). The credit can also be used to purchase an individual health insurance
policy (if the worker was covered by an individual policy at least 30 days prior to becoming
unemployed) or to purchase a group policy offered through a spouse’s employer. An eligible
worker can use the credit to purchase various types of state-based insurance coverage, such
as coverage through a state-sponsored high-risk pool, coverage through a health insurance
program offered to state employees, and coverage through an arrangement between private
entities and the state. State-based coverage must be guaranteed issue, cannot limit coverage
due to pre-existing conditions, cannot charge higher premiums than those charged to
individuals who do not receive the tax credit, and must offer the same benefits as those
provided to individuals who do not receive the tax credit.
Some Democratic Members of the Senate have stated that the law was not intended to
allow states to enter into agreements with private insurers offering individual coverage.
Some House Republicans, however, argue that the intent of the law was to allow states to
enter into agreements with private insurers, even those offering individual coverage. Some
believe that this legislation could serve as a model for a tax credit for the general population.
Military and Veterans Health Care. Coverage under military and veterans health
care programs is not taxable income, nor are the benefits these programs provide. The tax
exclusion (Section 134) applies as well to the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) and Tricare, which serve military dependents, retirees, and
retiree dependents. In 1996, about 2.2% of the noninstitutionalized population under age 65
had military or veterans health care as their primary form of coverage. The FY2003 revenue
loss attributable to CHAMPUS and Tricare is estimated to be $1.5 billion. For more
information, see CRS Issue Brief IB93103, Military Medical Care Services: Questions and
Answers
, by Richard A. Best.
Medicare and Medicaid. Coverage under Medicare or Medicaid is not taxable
income. Similarly, benefits paid from either program are not subject to taxation. Medicare
covers over 38 million people, including 96% of those ages 65 and older. Medicaid covers
over 41 million people. The JCT estimates the revenue loss attributable to the exclusion of
Medicare benefits will be $27.1 billion in FY2002. Medicaid beneficiaries, who must meet
certain categorical requirements (aged, blind, or disabled, or specified members of families
with dependent children) are generally poor and unlikely to have tax liability.
The employment tax individuals pay for Medicare Part A is not a deductible medical
expense. However, premiums paid by individuals who voluntarily enroll in Part A are
deductible, provided the taxpayer itemizes deductions and applies the 7.5 % AGI floor as
described above. (Medicare Part A is insurance for hospitalization, skilled nursing facilities,
home health and hospice care. Individuals age 65 and older may voluntarily enroll in Part
A if they or their spouse do not have at least 10 years of Medicare-covered employment.)
Medicare Part B premiums are also deductible subject to those same limitations, as are
premiums for Medigap insurance. (Medicare Part B is supplementary insurance for doctors’
fees and outpatient services. Medigap insurance is private insurance that covers Medicare
deductibles, co-payments, and benefits not covered under Medicare.)
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Beginning in 1999, legislation allowed a limited number of Medicare beneficiaries to
elect Medicare+Choice medical savings accounts instead of traditional Medicare.
Contributions to these accounts (made only by the Secretary of Health and Human Services)
are exempt from taxes, as are account earnings. Withdrawals are likewise not taxed nor
subject to penalties if used to pay unreimbursed medical expenses, with some exceptions.
No Medicare+Choice MSA plans have ever been offered.
Some Consequences of the Tax Benefits
Increases in Coverage. By lowering the after-tax cost of insurance, the tax benefits
described above help extend coverage to more people. This of course is the intention:
Congress has long been concerned about whether people have access to health care. The
public subsidy implicit in the incentives (foregone tax revenues) usually is justified on
grounds that people would otherwise under-insure, that is, delay purchasing coverage in the
hope that they will not become ill or have an accident. Uninsured people are an indication
of market failure; they impose spill-over costs on society in the form of public health risks
and uncompensated charity care (the free-rider problem). Moreover, if insurance were
purchased only by people who most need health care, its cost would become prohibitive for
others (the adverse selection problem).
However, the tax benefits also lead insured people to obtain more coverage than they
would otherwise choose. They purchase insurance that covers more than hospitalization and
other catastrophic expenses, such as routine doctor visits, prescription drugs, and dental care.
They obtain coverage with smaller deductibles and copayments. On the other hand,
comprehensive coverage and lower cost-sharing are thought to lead to better preventive care
and possibly long-run savings for certain medical conditions.
Source of Coverage. Tax benefits influence the way in which insurance coverage
is acquired. The uncapped exclusion for employer-paid insurance, for example, which can
benefit nearly all workers and is easy to administer, is partly responsible for the
predominance of employment-based insurance in the United States. In contrast, restrictions
on the itemized deduction allowed for individual private market insurance may be one reason
why that insurance covers only 6% of the population under age 65.
Employment-based insurance carries both advantages and disadvantages for the typical
worker. Generally costs are lower, and usually individual premiums do not vary by age or
risk. (Thus, young and healthy workers may pay more than their actuarial risk would cost,
though they are protected as they get older or need additional health care.) However, plans
chosen by employers may not meet individual workers’ needs (particularly if there are
limited options), and changing jobs may require both new insurance and doctors.
Increase in Health Care Use and Cost. The tax benefits increase the demand for
health care by enabling insured people to obtain services at discounted prices. This induced
demand can be beneficial to the extent it reflects needed health care (that which society
deems everyone should have) that financial constraints otherwise would have prevented. It
can be wasteful to the extent it results in less essential or ineffective care. In either case,
many economists argue, the additional demand is one reason why prices for health care have
risen more rapidly than the general rate of inflation.
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Whether insurance coverage could be encouraged without increasing the cost of health
care has been a matter of debate. Comprehensive reforms that might accomplish this goal
include capping the exclusion for employer-paid insurance and replacing both the exclusion
and the deduction with a limited tax credit. But these changes could be difficult to
implement and may create serious inequities. A 1994 Congressional Budget Office study,
The Tax Treatment of Employment-Based Health Insurance, provides an overview of the
issues and questions these approaches raise.
Many people probably would obtain some health insurance even without the tax
benefits. The cost of subsidizing people for what they would otherwise do is an inefficient
use of public dollars. Ideally, the tax incentives should lead to insurance being purchased
only to the extent it results in better health care for society as a whole. But how they could
be revised to accomplish this goal is a difficult question given the different ways insurance
is provided, the various ways it is regulated, and the voluntary nature of decisions to purchase
it.
Equity. Questions might be raised about the distribution of the tax incentives. Since
as a practical matter they are not available to everyone, problems of horizontal equity arise.
Workers without employment-based insurance generally cannot benefit from them, nor can
many early retirees (people under the age of 65). Even if these individuals itemized their
deductions, they can deduct health insurance premiums only to the extent that they (and other
health care expenditures) exceed 7.5% of AGI. In contrast, the exclusion for employer-paid
insurance is unlimited.
Even if everyone could benefit from the tax incentives, there would be questions of
vertical equity. Tax savings from the exclusions and deductions described above generally
are determined by taxpayers’ marginal tax rate. Thus, taxpayers in the 15% tax bracket
would save $600 in income taxes from a $4,000 exclusion (i.e., $4,000 x 0.15) for an
employer-paid premium, while taxpayers in the 36% bracket would save $1,440 (i.e., $4,000
x 0.36). If health insurance is considered a form of personal consumption (such as food or
clothing), this pattern of benefits would strike many people as unfair. It is unlikely that a
government grant program would be designed in this manner. However, to the extent that
health insurance is considered a way of spreading an individual’s catastrophic economic risk
over multiple years, basing tax savings on marginal tax rates might be justified.
For additional information on the economics of health insurance, see CRS Report
RL30762, Tax Subsidies for Health Insurance for the Uninsured: An Economic Analysis of
Selected Policy Issues for Congress
, by Gary Guenther.
Current Proposals
In the 107th Congress, a number of new or expanded tax benefits for health insurance
are being discussed: expanded eligibility for medical savings accounts, 100% deduction for
the self-employed starting in 2002 rather than 2003, carryovers and rollovers for flexible
spending accounts, and expanded (above-the-line) tax deductions or tax credits. Proponents
generally argue that these changes are needed to extend coverage to the uninsured and to
address efficiency and equity problems, while opponents generally argue that tax benefits are
unlikely to make much difference for people who do not now purchase insurance.
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This Issue Brief does not attempt to identify all bills relating to tax benefits for health
insurance; rather, its focus is on bills that have been reported from committee or considered
on the House or Senate floor. For a comprehensive list of bills providing tax benefits for
health insurance, Congressional offices can use the Legislative Information System (LIS)
available through the CRS home page [http://www.crs.gov].
Medical Savings Accounts
As described above, relatively few tax-advantaged Archer medical savings accounts
(MSAs) have been established since they first became available in 1997. The slow growth
can be attributed to a number of factors including product unfamiliarity, consumer aversion
to financial risk, and the reluctance of insurance agents to sell lower-priced policies;
however, statutory restrictions undoubtedly have played some role. MSA proponents are
urging Congress to expand eligibility and modify restrictions on the required high deductible
insurance. In their view, MSAs ought to be encouraged since they can make insurance more
affordable, allow a wider choice among doctors, and protect patient rights better than
government regulation. Critics generally oppose expansion, arguing that MSAs will result
in adverse selection among health plans, underutilization of preventive care, and unwarranted
tax breaks for high income families. (For an analysis of these and other questions, see CRS
Report 96-500, Flexible Spending Accounts and Medical Savings Accounts: A Comparison,
by Bob Lyke and Chris L. Peterson.)
The House-passed patient protection bill (H.R. 2563, Representative Ganske) would
expand and permanently extend the authorization for MSAs. (Under current law, the
authorization for new MSAs is set to expire December 31, 2003.) Effective after December
31, 2001, H.R. 2563 would:
! repeal limits on the number of accounts;
! make active accounts generally available to anyone with qualifying high
deductible insurance (thus repealing restrictions limiting them to employees
of small employers and self-employed individuals);
! allow contributions up to the amount of the insurance deductible (thus
deleting the 65% and 75% ceilings);
! allow contributions to be made both by employers and account owners;
! lower minimum insurance deductibles from $1,500 to $1,000 for single
coverage and $3,000 to $2,000 for family coverage (indexed from 2000);
! allow to be offered through cafeteria plans;
! allow the qualifying insurance not to have a deductible for preventive care,
even if this is not required by state law; and
! allow the qualifying insurance to have higher deductibles and out-of-pocket
limits for out-of-network expenses.
Comparable changes were recommended in President Bush’s FY2003 budget and are
contained in H.R. 1524 (introduced by Representative Thomas, Chairman of the House
Committee on Ways and Means) and S. 1067 (Senator Grassley, Chairman of the Senate
Committee on Finance).
On the July 25, 2002, the House passed the Improving Access to Long-Term Care Act
of 2002 (H.R. 4946, introduced by Representative Hayworth). The bill would allow
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enrollees in Medicare+Choice MSAs to open an Archer MSA. The Medicare+Choice MSA
would qualify as a high-deductible plan for purposes of the Archer MSA. For
Medicare+Choice MSA enrollees, the limit on monthly contributions to the Archer MSA
would be increased to 100% of 1/12 of the annual deductible. (For other individuals with
Archer MSAs, the limit would remain at 65% of 1/12 of the annual deductible.)
Self-Employed Deduction
The House-passed patient protection bill (H.R. 2563, Representative Ganske) would
allow self-employed taxpayers to deduct 100% of the cost of their insurance beginning in
2002. Several similar bills have been introduced in both the House and the Senate.
The principal argument for increasing the deduction is equity. People who have
employment-based insurance—over two-thirds of those under age 65—may exclude from
their gross income the amount of insurance paid by the employer. The exclusion, which is
uncapped, also applies to employment taxes. (In contrast, self-employed taxpayers may not
deduct their health insurance expenditures in calculating their self-employment tax.)
Equitable treatment between corporate owners and owners of unincorporated businesses
would remove an incentive to choose the form of business organization merely for tax
reasons. Since Congress has already decided to allow the full deduction, advancing the date
it becomes available may raise only budget, not policy issues.
Nonetheless, questions might still be raised about whether a 100% deduction would be
equitable. As mentioned above, large employers on average pay about 80% of the cost of
the insurance they offer, leaving employees to pay the other 20% with after-tax dollars.
Perhaps capping the deduction at 80% would be the equivalent, though this would not offset
the employment tax exclusion. Moreover, self-employed taxpayers are owners; for the most
part, they can choose whatever insurance they want, even expensive coverage. A full
deduction might not lead them to be as cost-conscious as corporate owners. Finally, it is
debatable whether accelerating the deduction would make it more likely that the employees
of self-employed owners will be provided health insurance. Some argue that the deduction
should not be increased unless it is coupled with a nondiscrimination requirement. The
original authorization for the deduction in 1986 had such a requirement, but it was repealed
in 1989, leaving the owners with tax advantages their employees do not have.
Cafeteria Plans
As mentioned above, federal employees generally may pay their FEHBP premiums on
a pretax basis; however, this cannot be done by federal retirees. H.R. 2125 (Tom Davis) and
S. 1022 (Warner) would extend the benefit to federal civilian and military retirees. With
respect to equity, it would seem appropriate to allow retirees as well as active workers to pay
FEHBP premiums on a pretax basis, especially since retirees generally have less income. On
the other hand, one might question why federal but not other retirees should have this benefit.
Flexible Spending Accounts
President Bush’s FY2003 budget would allow up to $500 in unused balances in health
care flexible spending accounts (FSAs) to be carried over to the following year without being
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taxed. Under current law, unused balances must be forfeited to the employer. The proposal
would also permit unused balances to be distributed to participants (in which case they would
be taxed) or rolled over into certain qualified deferred compensation plans (section 401(k),
403(b), and 457 plans).
The principal argument for allowing these options is that taxpayers might be more
willing to participate in FSAs if unused balances at the end of the year were not lost.
Allowing carryovers or rollovers might also discourage participants from spending remaining
balances carelessly, just to use them up. FSAs generally do not restrict patients’ choice of
doctors; thus, some might favor them as a way around limitations of managed care.
However, the options might result in tax breaks that are unwarranted, particularly for
higher income families. Some participants might increase their FSA contributions just to
take advantage of them. The health care FSA carryover could become another form of MSA,
though limited in size and without account earnings that accrue to the employee. It is not
clear in the President’s proposal when rollovers to deferred compensation plans would occur;
employers generally would need time to run nondiscrimination tests to see if additional
contributions to these plans would be permissible.
Expanded Tax Deduction
Two bills have been introduced in the 107th Congress that would allow individuals to
deduct 100% of their insurance premiums, regardless of whether they itemize (H.R. 1127,
introduced by Representative Stearns, and H.R. 4801, introduced by Representative Chabot).
An expanded tax deduction would improve horizontal equity since more taxpayers could
receive tax benefits similar to those associated with employer-paid coverage. (An above-the-
line deduction has the same income tax effect as the exclusion allowed that coverage.) As
discussed above, the deduction allowed under current law is restricted to taxpayers who
itemize and is further limited to insurance and medical costs that exceed 7.5% adjusted gross
income; thus, most taxpayers cannot benefit from it.
At the same time, an expanded deduction would not improve vertical equity since the
tax benefits generally would be proportional to the taxpayer’s marginal tax rate. A $2,000
premium would result in tax savings of $720 for someone in the 36% bracket (i.e., $2,000
x 0.36) but only $300 for someone in the 15% bracket (i.e., $2,000 x 0.15). It might also be
doubted whether tax savings of 15% would enable more lower income taxpayers to obtain
insurance.
Tax Credit
President Bush’s FY2003 budget included a refundable tax credit for health insurance
for individuals under age 65. For low-income taxpayers, the credit would equal 90% of the
premium and would be decreased for higher incomes; the credit would be phased out at
$30,000 for individuals and at $60,000 for families. The amount of the credit is limited to
$1,000 for an adult covered by a policy and $500 for each child, up to two children.
Individuals participating in public health plans (such as Medicaid or the State Children’s
Health Insurance Program) or employer health plans would not be eligible for the credit. The
credit could be claimed through the normal tax-filing process. Alternatively, beginning July
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1, 2003, an individual could use the credit in advance to reduce payments to the insurance
company. The insurer would then receive the credit directly from the U.S. Treasury.
A tax credit could be attractive in several respects. If it were generally available, a
credit could aid taxpayers who do not have access to employment-based insurance (or who
are dissatisfied with it) and who cannot claim the medical expense deduction. A credit could
provide all taxpayers with the same dollar reduction in final tax liability; this would avoid
problems of vertical equity associated with the tax exclusion and tax deduction. A credit
might also provide lower income taxpayers with greater tax savings than either the exclusion
or the deduction; this might reduce the number of the uninsured. If the credit were
refundable, it could even help taxpayers with limited or no tax liability.
But the effects of tax credits can vary widely, depending on how they are designed. One
important question is whether the credit would supplement or replace existing tax benefits,
particularly the exclusion for employer-paid insurance. Another is whether the credit would
be the same for all taxpayers or more generous for those with lower incomes. Ensuring that
lower income families benefit from any credit may be difficult if they cannot afford to
purchase insurance beforehand. Similarly, it might be asked whether the credit would vary
with factors that affect the cost of health insurance, such as age, gender, place of residence,
or health status. Whether the insurance must meet certain standards for benefits,
coinsurance, and underwriting might also be a factor. For additional analysis, see CRS
Report RL30762, Tax Subsidies for Health Insurance for the Uninsured: An Economic
Analysis of Selected Policy Issues for Congress
, by Gary Guenther.
Small Employer Tax Credit
The House-passed patient protection bill (H.R. 2563, Representative Ganske) would
authorize a tax credit for small employers (on average 2 to 50 employees) that previously
have not offered coverage, limited to the first 48 months. The basic credit would equal 20%
of the cost of coverage (or 30% if it were obtained through a small business purchasing pool)
not exceeding $2,000 for individuals and $5,000 for families.
The Health Insurance Access Act of 2002 (S. 2679, Senators Baucus and Gordon Smith)
would provide a tax credit for employers with fewer than 50 employees. The tax credit
would equal 50% of the cost of coverage for firms with fewer than 25 employees, 40% of the
cost of coverage for firms with 26 to 35 employees, and 30% of the cost of coverage for
firms with 36 to 50 employees. To qualify for the credit, a firm that did not previously offer
coverage would have to contribute at least 50% towards the premium for the first five years
of the program. Firms offering new coverage after the first five years of the program and
firms currently offering coverage would have to contribute at least 70% (for an individual
policy) or 60% (for a family policy) towards the premium to qualify for the tax credit.
Foundation Grants and Loans
The Internal Revenue Code imposes excise taxes on private foundations that fail to
make timely distributions of income for qualifying charitable purposes. The House-passed
patient protection bill (H.R. 2563, Representative Ganske) would provide that distributions
to a qualified health benefit purchasing coalition would meet this test as long as the coalition
does not use the distributions to purchase real property, to pay or provide benefits to coalition
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members (including employees and affiliates), or to pay for expenses more than 48 months
after the coalition is established. Under the bill, a qualified health benefit purchasing
coalition is a private not-for-profit corporation that sells health insurance through state
licensed issuers to small employers and meets a number of other tests.
LEGISLATION
S. 1022 (Warner) / H.R. 2125 (Davis)
A bill to allow Federal civilian and military retirees to pay health insurance premiums
on a pretax basis and to allow a deduction for TRICARE supplemental premiums.
Introduced June 12, 2001. Referred to the Committee on Finance (S. 1022) and the
Committee on Ways and Means (H.R. 2125).
S. 1067 (Grassley) / H.R. 1524 (Thomas)
Medical Savings Account Availability Act of 2001. H.R. 1524 introduced April 4, 2001
and referred to the Committee on Ways and Means. S. 1067 introduced June 20, 2001 and
referred to the Committee on Finance.
H.R. 1127 (Stearns)
Health Care Tax Deduction Act of 2001. Introduced March 20, 2001. Referred to the
Committee on Ways and Means, Subcommittee on Health.
H.R. 2563 (Ganske)
Bipartisan Patient Protection Act. Introduced July 19, 2001. Passed by the House
August 2, 2001. Placed on the Senate Legislative Calendar.
S. 2679 (Baucus)
Health Insurance Access Act of 2002. Introduced June 25, 2002. Referred to the
Committee on Finance.
H.R. 4946 (Hayworth)
Improving Access to Long-Term Care Act of 2002. Introduced June 17, 2002. Reported
by the Committee on Ways and Means June 19, 2002. Passed by the House July 25, 2002.
FOR ADDITIONAL READING
Cunningham. Laura E. National Health Insurance and the Medical Deduction. Tax Law
Review. V. 50 (1995), p. 237-264.
Gruber, Jonathan and Larry Levitt. Tax Subsidies for Health Insurance: Costs and Benefits.
Health Affairs. V. 19 (2000), p. 72-85.
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Gruber, Jonathan and James Poterba. Tax Incentives and the Decision to Purchase Health
Insurance: Evidence from the Self-Employed. The Quarterly Journal of Economics.
V. 109 (1994), p. 701-733.
Kaplow, Louis. The Income Tax as Insurance: The Casualty Loss and Medical Expense
Deductions and the Exclusion of Medical Insurance Premiums. California Law Review,
v. 79 (1991), p. 1485-1510.
Kahn, Charles N. and Ronald F. Pollack. Building a Consensus for Expanding Health
Coverage. Health Affairs. V. 20 (January/February 2001), p. 40-48.
Pauly, Mark. Taxation, Health Insurance, and Market Failure in the Medical Economy.
Journal of Economic Literature. V. 24 (1986), p. 629-675.
Pauly, Mark and Bradley Herring. Expanding Coverage via Tax Credits: Trade-Offs and
Outcomes. Health Affairs. V. 20 (January/February, 2001), p. 9-26.
Sheils, John and Paul Hogan. Cost of Tax-Exempt Health Benefits in 1998. Health Affairs.
V. 18 (1999), p. 176-181.
U.S. Congress. Congressional Budget Office. The Tax Treatment of Employment-Based
Health Insurance. Washington, March, 1994.
U.S. Congress. House. Committee on Ways and Means. Subcommittee on Health. Health
Insurance Premium Tax Deductions for the Self-Employed. Hearings, 104th Congress,
1st session. January 27, 1995. Washington, U.S. Govt. Print. Off., 1996.
U.S. General Accounting Office. Medical Savings Accounts: Results from Surveys of
Insurers GAO/HEHS-99-34. Washington, December, 1998.
Appendix
Listed below is the general formula for calculating federal income taxes. The list omits
some steps, such as prepayments (from withholding and estimated payments) and the
alternative minimum tax.
1.
Gross income
2.
minus Deductions (or adjustments) for AGI (i.e., “above the line”)
3.
= Adjusted gross income (AGI)
4.
minus Greater of standard or itemized deductions
5.
minus Personal and dependency exemptions
6.
= Taxable income
7.
times Tax rate
8.
= Tax on taxable income (“regular tax liability”)
9.
minus Credits
10. = Final tax liability
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