A Better Alternative to Taxing Those Without
Although the public debate on health insurance coverage centers on a thumbs-up, thumbs-down fight over the Accountable Care Act (ACA, also called Obamacare), our national system needs a lot of smaller fixes. Many items on this long list of fixes make sense under either a Republican alternative to Obamacare (like the one recently but only partially laid out by Representative Paul Ryan) or Democratic amendments to the existing plan. One example: rethinking the tax penalty on people who do not buy insurance, an issue receiving increased attention as the IRS assesses its first penalties. We can achieve the same end much more effectively by requiring households to purchase health insurance if they want to receive the other government benefits to which they are entitled. No separate tax is required.
The History of the Tax Penalty
A system of near-universal insurance -- where most people of the same age, regardless of their health conditions, can buy insurance at approximately the same price -- needs a backup. This need became clear when health reform proposals were first introduced in 2009. Without a backup, individuals have a strong incentive to avoid buying insurance until they are sick, thus effectively getting someone else to pay for their health care. This incentive exists regardless of income level: even a wealthy person who buys health insurance only after becoming sick could hoist his bills on those with lesser incomes who pay for insurance year-round and every year.
The ACA's partial response to this incentive is to tax those who fail to buy health insurance. The tax for failure in 2014 was either 1 percent of income or $95 per person; it rises to 2.5 percent of income or $695 (adjusted for inflation) after 2015. At the beginning of 2015, millions of people discovered that they owed this tax as they started filing their federal tax returns for 2014.
Practical considerations have always led toward some individual requirement to buy insurance, simply because there are limits on how much government can spend on subsidizing everyone. Our very expensive health care system now entails average health costs per household of about $24,000. The federal government would have to spend just about all its revenues trying to cover all those costs. A mandate to purchase insurance is a partial alternative to ever-more subsidies -- as Governor Romney knew when he implemented a related mandate in Massachusetts. At one point, the mandate idea was favored by conservatives even more than liberals as a way to avoid an even more expensive government-controlled system, such as Medicare for all.
What Might Work Better
The problem with the Obamacare tax penalty isn't the idea; it's the design. This problem, in various forms, occupied the federal courts needlessly. The central dilemma that pre-occupied an earlier Supreme Court decision was whether government could mandate that we had to buy some particular product (maybe not, it said, but, at least in Chief Justice Roberts' opinion, it could impose a tax).
Another type of requirement avoids many past and current issues surrounding the Obamacare tax penalty. Simply deny to taxpayers other government benefits if they do not obtain insurance for themselves and their families. There has been no debate over whether government can -- indeed, at some level administratively must -- set conditions for determining who receives benefits.
This type of requirement could be implemented in various ways. The personal exemption or the child credit or home mortgage subsidies could be limited; some portion of low interest rates for student loans could be denied. This approach entails no new "tax" for not buying insurance; it simply adds to the conditions for receipt of other government benefits.
Designed well, the denial of any tax benefit could easily be reflected in withholding, so there are fewer end-of-year surprises. Employers, for instance, could adjust withholding for months in which employees did not declare insurance for themselves. As for the many poor receiving benefits like SNAP, most tend to be eligible for Medicaid, so the requirement than they sign up could be handled better by the related administrative offices that deal with them than by the IRS imposing some surprise penalty at the end of the year.
For both administrative and political reasons, this type of requirement can also be made stricter than the current extra tax. The IRS has always had trouble collecting money at the end of the year, and people react more negatively to an additional tax than to a requirement that they shouldn't shift health costs onto others if they want to receive some other government benefit.
The Road Ahead
I doubt that any future government, Democratic or Republican, is going to deny people the ability to buy health insurance at a common community rate, even if they are sick or have failed to purchase health insurance previously. The world has already changed too much. Insurance companies have adapted, and so have hospitals. Before health reform, uninsured people could generate partial benefits or coverage by receiving treatment in emergency rooms (where such care is often required by law), and then not paying their bills. With some major exceptions, that practice has declined since the ACA was implemented. No one wants to go back to the old ways.
In a partisan world, of course, a fix of almost any type becomes difficult. Republicans are afraid to fix almost any aspect of Obamacare for fear it would involve a buy-in to the plan's success; Democrats dread amending Obamacare because it might hint at some degree of failure. Watching the current Supreme Court battle, you sense that many enjoy the fight more than anything else. Still, this simple fix should be added to the list of reforms for consideration when and if we decide we want something better.
Eugene Steuerle is an institute fellow and the Richard B. Fisher chair at the Urban Institute. This piece originally appeared at his blog, the Government We Deserve.