House-passed Affordable Health Care for America Act (H.R. 3962):
– $460.5 billion over 10 years from a 5.4 percent Surtax on individuals making more than $500,000 and families earning more than $1 million (begins 2011)
– $135 billion as part of an 8 percent tax of a firm’s payroll ($750,000 or more) and a lower rate if firm payroll is between $500,000 $749,999 (begins 2013)
– $33 billion as part of a 2.5 tax on modified adjusted gross income (AGI) for those individuals that do fail to secure “acceptable” health coverage (begins 2014)
– $20 billion from a 2.5 percent excise tax on medical devices (begins 2013)
– $17.1 billion in corporate information reporting requirements (applies to payments made after December 31, 2011)
– $13.3 billion from a cap on Flexible Spending Accounts (FSAs) at $2,500 and indexed forward to the CPI-U (begins 2011; currently there is no cap)
– $7.5 billion for the limitation of tax treaty benefits related to U.S. withholding tax imposed on deductible related-party payments
– $6 billion from a “worldwide interest allocation” repeal (begins 2011)
– $5.7 billion as a result of codifying the economic substance doctrine and imposing penalties on underpayments
– $5 billion for reforming the definition of medical expenses under FSAs, health savings accounts, Archer Medical Savings Accounts, and health reimbursement arrangements, including the exemption of over-the-counter medications prescribed by a doctor (begins 2011)
– $2.2 billion as part of an end to the Medicare Part D subsidy (begins 2013)

Senate-passed Patient Protection and Affordable Health Care Act (H.R. 3590):
- $148.9 billion as part of a 40 percent nondeductible excise tax on insurance plans of more than $8,500 for individuals and $23,000 for families and indexed to the CPI-U plus 1 percentage point (begins 2013)
- $101 billion in yearly nondeductible fees on manufacturers and importers of pharmaceuticals (begins 2010), on manufacturers and importers of medical devices (begins 2011), and health insurance providers (begins 2011)
- $86.8 billion as part of Medicare Payroll tax increase from 1.45 to 2.35 percent for individuals with wages of more than $200,000 and $250,000 for joint filers (begins 2013)
- $28 billion from employer penalties on full-time workers that receive subsidies to purchase coverage through new insurance exchanges
- $17.1 billion in corporate information reporting requirements (applies to payments made after December 31, 2011)
- $15.2 billion from an increase in the floor for deductible medical expenses from 7.5 percent of AGI to 10 percent of AGI and a “carve-out” for those older than 65
- $15 billion in tax penalties on individuals who fail to secure “qualified” health coverage (begins 2014)
- $13.3 billion from a cap on Flexible Spending Accounts (FSAs) at $2,500 and indexed forward to the CPI-U (begins 2011; currently there is no cap)
- $5.4 billion as part of an end to the Medicare Part D subsidy (begins 2011)
- $5 billion for reforming the definition of medical expenses under FSAs, health savings accounts, Archer Medical Savings Accounts, and health reimbursement arrangements, including the exemption of over-the-counter medications prescribed by a doctor (begins 2011)

The House- and Senate-passed bills clearly deviate from one another on the types of revenue-generating mechanisms included to maintain at least a “deficit-neutral” CBO score. The House bill relies punitively on both a surtax on high-income individuals as well as employers (even reaching small businesses). Alternatively, the Senate bill predominantly relies largely on a Medicare payroll tax on high-income individuals, fees on pharmaceutical medical device and health insurance providers, as well as an excise tax on high-value health insurance plans.

It is unclear, and will likely remain unclear until a final bill is passed, regarding the exact mix of revenue-generating mechanisms included to finance a final health care reform bill. What is clear, however, is that American individuals and businesses should begin bracing now for higher taxes—they are coming in one form or another!

On Thursday, September 24th, the Senate Finance Committee continued to vote on amendments to the “Chairman’s Mark” of the America’s Healthy Future Act of 2009. As the committee continues to consider more than 500 amendments, it is becoming clear that Senators are directly undercutting the high profile promises that President Obama made to the American people in his widely broadcasted address to Congress on September 9, 2009. Consider several health policy decisions made by members of the Senate Finance Committee:

Cutting Medicare Advantage (Crapo-Kyl-Roberts Amendment D1)

The White House and Congressional leaders routinely insist that they are not going to cut Medicare benefits, only unnecessary spending or spending properly considered to be waste, fraud and abuse in the Medicare program. Senators Mike Crapo (R-ID), Jon Kyl (R-AZ), and Pat Roberts (R-KS) proposed an amendment to change the Chairman’s mark and remove provisions in Title III, Subtitle D which would result in cuts to Medical Advantage, a program which allows Medicare users to obtain coverage through private insurers. Cuts in payments to Medicare Advantage plans would result in decreased choice and competition for seniors. This amendment failed on a procedural vote (9-9).

The Ability of Americans to Keep Their Existing Coverage. (Hatch Amendment C2, Cornyn Amendment C1)

Senator Orrin Hatch (R-UT) and Senator John Cornyn (R-TX) introduced amendments to preserve Americans’ existing private health insurance coverage. This would be in accord with the President’s promise that “nothing in this plan will require you or your employer to change the coverage or the doctor you have.” Senator Hatch’s amendment would have required that the Secretary of Health and Human Services certify to Congress that the final piece of legislation would not result in more than 1 million Americans losing their current coverage. Senator Hatch’s amendment failed on a party line vote (10-13).
Senator Cornyn’s amendment also sought to guarantee that Americans enrolled in self-insured employer coverage would be able to keep their current coverage by amending Title I, Subtitle D of the Chairman’s mark. The amendment simply provided that any health insurance plan governed by the Employee Retirement Income Security Act (ERISA) would be deemed to have met the personal responsibility requirement. This amendment also failed. It was a party line vote (10-13).

A Middle Class Tax. (Bunning Amendment C3)

President Obama promised repeatedly during the 2008 presidential campaign that, “If you’re a family that’s making $250,000 a year or less, you will see no increase in your taxes.” Since that time, the President has reversed himself on the desirability of imposing an individual mandate for health insurance. In the House bill the penalty for non compliance with the individual mandate is explicitly referred to in the legislative language as a tax. In the Senate Finance Committee “Mark” , the mechanism is an excise tax: the means of enforcing the mandate, requiring Americans who do not comply with the government purchasing requirement to pay a tax, with the size of the tax dependent on their income. During the Senate mark-up, Senator Mike Ensign (R-NV) asked Thomas A. Barthold, chief of staff of the Joint Committee on Taxation, what the penalties would be if taxpayers deliberately refused to pay the tax. In a handwritten note, Barthold replied that under current law a willful failure to pay means that the taxpayer could be charged with a misdemeanor and face a penalty of up to $25,000 and not more than one year in prison. Meanwhile, Senator Jim Bunning (R-KY) offered an amendment requiring that any taxpayer requesting exemption from the personal responsibility excise tax be granted an exemption. Senator Bunning’s amendment failed (9-14).

Medicaid Expansion and State Flexibility. (Ensign Amendment C14, Crapo Amendment C2, Enzi Amendment C9)

Medicaid is a welfare program, funded by both the federal government and the states. In many states, Medicaid spending is crowding out other state budget priorities, such as education and law enforcement. States are struggling and many want relief, as well as flexibility in the administration of the Medicaid program. Senators John Ensign (R-NV), Mike Crapo (R-ID), and Mike Enzi (R-WY) introduced separate amendments to curb the negative effects of the proposed mandatory Medicaid expansion on the states. Senator Ensign’s amendment would have allowed states that experienced an increase in Medicaid spending of more than 1 percent from the previous year to opt out of the Medicaid expansion provisions as detailed in Title I, Subtitle G. This amendment failed along a party line vote (10-13).
Senator Crapo’s amendment sought to block unfunded federal mandates on the states to expand Medicaid by amending Title I, Subtitle G. The objective was to protect the states from incurring future additional and unwanted costs. This amendment failed along a party line vote (10-13).
Senator Enzi also offered an amendment that would have protected states from the Medicaid expansion if their revenues had declined for the two most recent fiscal year quarters to the date of the enactment of the bill. Senator Enzi’s amendment also failed along a party line vote (10-13).

Curtailing Choice of Medicaid Patients. (Enzi Amendment C6)

Senator Enzi (R-WY) offered an amendment to provide for additional options for Americans who qualify for Medicaid. Sen. Enzi’s amendment would allow Americans who would otherwise enroll in Medicaid also to have the option of enrolling in a qualified private health plan. The private plan would be one available through their state health exchange, a new institution created under the Baucus bill. This amendment would have increased choice for Medicaid enrollees, as well as lowering costs for the privately insured by increasing the numbers of younger persons in the private insurance risk pools. The Enzi amendment to expand patient choice was defeated (10-13).

Next week, Senate Finance Committee will continue its mark-up of America’s Healthy Future Act of 2009. Meanwhile, ordinary Americans will be able to monitor the relationship between rhetoric and reality, the gap between words and deeds, the promises and the provisions. With each passing day, as the Senators plod through their massive health care bill, the gap widens.

This post was co-authored by Kathryn Nix

“That enacting the proposed changes would lead to an average increase in premiums for Part D beneficiaries, above those under current law, of about 5 percent in 2011. That effect would rise over time and reach about 20 percent in 2019. Beyond the 10-year budget window, the premiums would increase slightly more until the doughnut hole was eliminated in 2022; beyond that point, enrollees’ premiums would grow along with the cost for covered drugs.”

CBO director Douglas Elmendorf goes on to write, “the proposed changes would also reduce beneficiaries’ average cost sharing and their average total drug spending.” But while, on average, seniors might save on their total drug costs, Elmodorf explains, “The net effect on drug spending would differ among beneficiaries depending on the amount of their purchases in a year.”

Translation: average premiums for Medicare Part D would increase over time.

But the effect on total spending would vary among beneficiaries. CBO acknowledges this by saying, “Those who ended up purchasing a relatively small amount of drugs in a year would pay more in additional premiums than they would gain from lower cost sharing, while those who purchased a relatively large amount of drugs in a year would gain more from lower cost sharing than they would pay in higher premiums.” Unfortunately, the CBO has not yet “estimated the number of beneficiaries who would fall into each of those groups.”