Review your lectures. Then: Identify, how many Americans remain uninsured despite the PPACA (Patient Protection and Affordable Care Act), using th

7Congressional Digest ■■■■■ www.CongressionalDigest.com ■■■■■ March 2016

From the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation Data Point report Health Insurance Coverage and the Af- fordable Care Act, September 22, 2015.

Impact of Obamacare on Coverage Reduction in the Number of Uninsured

In March 2015, the U.S. Department of Health andHuman Services Office of the Assistant Secretary for Plan- ning and Evaluation (ASPE) estimated that 16.5 million uninsured people had gained health insurance coverage as several of the Affordable Care Act’s (ACA) coverage provi- sions took effect. Using updated data, ASPE now estimates that 17.6 million uninsured people have gained health in- surance coverage.

Coverage gains refer to different sources of coverage, including Medicaid, the Health Insurance Marketplace, and individual market coverage; therefore, gains are not limited to Marketplace-eligible individuals.

● 15.3 million adults gained health insurance coverage since the beginning of open enrollment in October 2013 through September 12, 2015. Over that period, the uninsured rate declined from 20.3 percent to 12.6 percent — a 38 percent (or 7.7 percentage point) re- duction in the uninsured rate.

● 2.3 million additional young adults (aged 19 to 25) gained health insurance coverage between the enact- ment of the Affordable Care Act in 2010 and the start of open enrollment in October 2013 due to the ACA provision allowing young adults to remain on a parent’s plan until age 26.

■ Uninsured Rates by Race and Ethnicity

The uninsured rate declined across all race/ethnicity categories since the baseline period. There were greater declines in the uninsured rate among African Americans and Hispanics than among whites.

● Among whites, the uninsured rate declined by 6.0 per- centage points, from a baseline uninsured rate of 14.3

percent to 8.3 percent, resulting in 7.4 million adults gaining coverage.

● Among African Americans, the uninsured rate declined by 10.3 percentage points, from a baseline uninsured rate of 22.4 percent to 12.1 percent, resulting in 2.6 million adults gaining coverage.

● Among Hispanics, the uninsured rate declined by 11.5 percentage points, from a baseline uninsured rate of 41.8 percent to 30.3 percent, resulting in about 4.0 percent of adults gaining coverage.

■ Uninsured Rates by State Medicaid Expansion Status

Health insurance coverage gains continued to be especially strong in Medicaid expansion States.

● Expansion States experienced a decline in their unin- sured rate of 8.1 percentage points, from an average baseline of 18.2 percent to 10.1 percent.

● Non-expansion States experienced a decline in their un- insured rate of 7.3 percentage points, from an average baseline rate of 23.4 percent to 16.1 percent.

■ Uninsured Rates for Young Adults

Coverage gains for young adults aged 19 to 25 started in 2010 with the ACA’s provision enabling them to stay on their parents’ plans until age 26. From the baseline period through the start of open enrollment in October 2013, the uninsured rate for young adults declined from 34.1 percent to 26.7 percent, which translates to 2.3 million young adults gaining coverage.

● Since October 2013, an additional 3.2 million young adults aged 19 to 25 gained coverage.

Continued on page 32

32 Congressional Digest ■■■■■ www.CongressionalDigest.com ■■■■■ March 2016

Impact of Obamacare on Coverage Continued from page 7

s● In total, an estimated 5.5 million young adults gained coverage from 2010 through September 12, 2015, which is statistically unchanged from March 4, 2015.

■ Uninsured Rates by Gender

The uninsured rate declined for both males and females since the baseline period. There was a greater decline in the uninsured rate among females than among males.

● Males experienced a decline in their uninsured rate of 7.3 percentage points, from an average baseline rate of 21.8 percent to 14.5 percent, resulting in 7.3 million adult males gaining coverage.

● Females experienced a decline in their uninsured rate of 8.1 percentage points, from an average baseline rate of 18.9 percent to 10.8 percent, resulting in nearly 8.2 million adult women gaining coverage.

of fairer rules and stronger consumer protections that have made health care coverage more afford- able, more attainable, and more patient centered. And it is working. About 17.6 million Americans have gained health care coverage as the law’s cover- age provisions have taken effect. The Nation’s un- insured rate now stands at its lowest level ever, and demand for Marketplace coverage during Decem- ber 2015 was at an all-time high. Health care costs are lower than expected when the law was passed, and health care quality is higher — with improve- ments in patient safety saving an estimated 87,000 lives. Health care has changed for the better, setting this country on a smarter, stronger course.

The Reconciliation Act would reverse that course. The Congressional Budget Office estimates that the legislation would increase the number of uninsured Americans by 22 million after 2017. The Council of Economic Advisers estimates that this reduction in health care coverage could mean, each year, more than 900,000 fewer people getting all their needed care, more than 1.2 million additional

people having trouble paying other bills due to higher medical costs, and potentially more than 10,000 additional deaths. This legislation would cost millions of hard-working middle-class families the security of affordable health coverage they de- serve. Reliable health care coverage would no longer be a right for everyone: it would return to being a privilege for a few.

The legislation’s implications extend far beyond those who would become uninsured. For example, about 150 million Americans with employer-based insurance would be at risk of higher premiums and lower wages. And it would cause the cost of health coverage for people buying it on their own to sky- rocket.

The Reconciliation Act would also effectively defund Planned Parenthood. Planned Parenthood uses both Federal and non-Federal funds to provide a range of important preventive care and health ser- vices, including health screenings, vaccinations, and check-ups to millions of men and women who visit their health centers annually. Longstanding Federal policy already prohibits the use of Federal funds for abortions, except in cases of rape or incest or when the life of the woman would be endangered. By eliminating Federal Medicaid funding for a major provider of health care, H.R. 3762 would limit ac- cess to health care for men, women, and families across the Nation, and would disproportionately impact low-income individuals.

Republicans in the Congress have attempted to repeal or undermine the Affordable Care Act over 50 times. Rather than refighting old political battles by once again voting to repeal basic protections that provide security for the middle class, Members of Congress should be working together to grow the economy, strengthen middle-class families, and cre- ate new jobs. Because of the harm this bill would cause to the health and financial security of millions of Americans, it has earned my veto.

Outlook. The House failed, by a vote of 241 to 186, to sustain the President’s veto. Opponents of the law have vowed to continue to work for repeal. “The idea that Obamacare is the law of the land for good is a myth,” stated Speaker of the House Paul Ryan. “This law will collapse under its own weight, or it will be repealed.”

Legislative Background Continued from page 9

■

■

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National Tax Journal, December 2016,69(4), 883-904 https://doi.O rg/10 .1 7310 /n tj.2 0 1 6.4.08

W H A T C A N TA X DATA TELL US A B O U T T H E U N IN S U R E D ? E V ID E N C E F R O M 2 0 1 4

Ithai Z. Lurie and Janet McCubbin

About 14 percent o f fam ilies that file d tax returns fo r 2014 reported a spell o f uninsurance fo r at least one fam ily member. Uninsurance rates were higher fo r young adults, unmarried persons, low-income families, and fam ilies in states that did not expand eligibility fo r Medicaid. These results are generally consistent with estimates from survey data. M any fam ilies who were uninsured in 2014 appear eligible fo r M edicaid or Premium Tax Credits. Outreach to these fam ilies coidd ef­ fectively reduce the number o f uninsured. Better data fo r 2015 and later years will allow fo r more comprehensive and detailed estimates about uninsured Americans.

Keywords: ISRP, exemption, uninsured

JEL Codes: H22, H24,113

I. INTRODUCTION

he Affordable Care Act o f 2010 (ACA) intersects with the tax system in several ways. Most importantly, the ACA created subsidies, including the Premium Tax

Credit (PTC), to help low- and moderate-income people obtain affordable health insur­ ance. The AC A also requires individuals to obtain health insurance coverage, receive an exemption from the coverage requirement, or pay a penalty. In addition, large employers that do not provide affordable coverage to full-time employees may owe an assessable payment if one or more full-time employees receive the PTC.

In this paper we use tax return data to learn about the characteristics of the uninsured in 2014. Data on the insured and uninsured can help us understand the efficacy of subsidies and penalties in inducing health insurance coverage. In addition, information about the reporting of insurance status will help the Internal Revenue Service (IRS) improve tax forms and instructions. Information about the characteristics and behavior of the uninsured will also help IRS and others to improve outreach efforts aimed at

Ithai Z. Lurie: O ffice o f Tax Analysis, U.S. D e p a rtm e n t o f theTreasury, W ashington, DC, USA ([email protected] treasury.gov)

Janet M cC ubbin: O ffice o f Tax Analysis, U.S. D e p a rtm e n t o f th e Treasury, W ashington, DC, USA (Janet. M cC [email protected] treasury.gov)

884 National Tax Journal

encouraging coverage. Finally, tax data on the uninsured can corroborate and supple­ ment survey data about health insurance coverage — data that are widely used for tax expenditure modeling and myriad other purposes.

We find that 14.5 percent of families that filed tax returns for 2014 reported a spell of uninsurance for at least one family member. Uninsurance rates were higher for young adults, unmarried persons, low-income families, and families in states that did not expand eligibility for Medicaid. These results are generally consistent with estimates from survey data. Many families who remained uninsured in 2014 appear to be eligible for Medicaid or PTC. Outreach to these families could effectively reduce the number o f uninsured. Our findings to date are tentative, because information about insurance status on 2014 returns is limited. Better data for 2015 and later years will allow for more comprehensive and detailed estimates about uninsured Americans.

II. DATA

Taxpayers who have full-year coverage for all of the individuals on their tax returns report this by checking a box on Form 1040. Tax return filers who are uninsured any part o f the year, or who have a dependent who is uninsured for any part of the year, may claim exemptions from the health coverage requirement on Form 8965. Taxpayers who do not have coverage for themselves or for a dependent for at least one month, and who do not claim an exemption, report the individual shared responsibility payment (i.e., the penalty) on Form 1040. In this paper we use tax year 2014 data to examine the characteristics o f tax return filers in 2014. Specifically, we analyze the population o f tax year 2014 returns processed by IRS through March 2016. We define uninsured families or persons as those who claim an exemption from the health care coverage requirement or who pay a penalty for failure to have coverage or both for at least one month.

Taxpayers are responsible for providing coverage, claiming exemptions, and receiving PTCs for themselves and for any person they may claim as a dependent. Dependents generally do not report on their own health insurance status, even if they file tax returns. Thus, we exclude returns filed by dependents from our analysis and define a tax family as a non-dependent return, including the primary and secondary filers and all dependents.

Relying on tax return data creates analytical challenges and important limitations to our findings. First, because insurance status was not reported on tax returns before 2014, we cannot show the effect o f the AC A on coverage.1 Second, the 2014 data are largely self-reported, and taxpayers face incentives to over-report coverage. However, we find several indications that the self-reported data are largely accurate. Third, our data are limited to families that file tax returns, and exclude the approximately 10 percent

1 Data from the Current Population Survey and other sources find that rates o f uninsurance fell significantly between 2013 and 2014, in a manner that is consistent with the intent of the ACA (Smith and Medalia, 2015).

What Can Tax Data Tell Us about the Uninsured? Evidence from 2014 885

of the U S. population (including 7 percent o f the non-elderly population) that does not appear on an income tax return. Lastly, the tax return data do not provide insur­ ance status for each person or the duration of any spell of uninsurance; in many cases we know only that at least one family member was uninsured for at least part of the year.2

III. EXEMPTIONS FROM THE COVERAGE REQUIREMENT

Exemptions from the coverage requirement are available for several specific cir­ cumstances provided under the statute and for general hardship, as determined by the Marketplaces (under the purview o f the Department o f Health and Human Services).3 Some exemptions are granted only by the Marketplaces, some are claimed only on the tax return, and some can be taken in either way.

Exemptions granted by the Marketplace are reported to IRS by the Marketplace and reported by tax return filers on Part I of Form 8965. The data reported to IRS by the Marketplace include the specific individual and months for which each exemption applies and the type o f exemption. In 2014, nearly all Marketplace exemptions reported to IRS were applicable for the full year. Exemptions that may be granted by the Marketplace include those for: general hardship (e.g., bankruptcy, fire, homelessness, death of a family member); unaffordable coverage based on projected income;4 membership in a religious sect that objects to accepting insurance benefits; individuals unable to renew 2013 coverage; and certain other exceptions available only for 2014.

Exemptions that may be claimed only on the tax return are reported in Parts II or III of Form 8965. These include exemptions for. income below the filing requirement (but nevertheless filing a tax return);5 unaffordable coverage, based on actual income or

2 More complete information will be available for future years. To facilitate IR S’s administration o f the ACA tax provisions and to help taxpayers correctly report on their coverage status, insurers and employ­ ers provide information about health coverage to enrollees and to IRS. This information includes the type o f coverage and months o f coverage for each person enrolled in insurance that meets the ACA coverage requirement. Coverage through a health insurance Marketplace (which is required in order to obtain the PTC) is reported by the Marketplaces on Form 1095-A. Large employers report offers o f coverage and enrollment in self-insured plans on Form 1095-C. Other insurers, government health programs, and small employers providing self-insured coverage report monthly enrollment for each person on Form 1095-B. While Marketplace data are available for 2014, employer and insurer reporting on Forms 1095-B and C did not begin until this year, for coverage in tax year 2015.

3 See Internal Revenue Code §5000A, 45 CFR 155.605 and 26 CFR 1,5000Afor the health insurance cover­ age requirement, penalty calculation, and exemptions.

4 The exemption for coverage unaffordable based on projected income is allowed: (1) if an individual is eligible for employer-sponsored coverage but the required employee contribution for the coverage exceeds 8 percent o f projected household income for the year; or (2) if the required contribution (after accounting for PTC) for the lowest-cost bronze Marketplace plan that would cover all family members who are not eligible to purchase employer-sponsored coverage or have not received another exemption exceeds 8 percent of projected household income.

5 Families who do not file tax returns do not need to claim exemptions.

886 N a t io n a l T a x J o u r n a l

based on aggregate self-only coverage;6 citizens living abroad or certain non-citizens; short gaps in coverage o f three months or less; and a few other exceptions that apply in 2014 only.

Some exemptions may be granted by the Marketplace (in which case they may be reported in Part I of Form 8965) or claimed on the tax return (in which case they are reported in Part III of Form 8965). These include exemptions for: income below 138 percent of the Federal poverty level (FPL) and resident of a state that did not expand Medicaid; member of a health care sharing ministry; member of an Indian Tribe or recipient o f Indian Flealth Services care; and incarceration.

Exemptions are generally reported for each person and each month, and we provide results for both families and individuals below. However, the exemption for having income below the filing requirement applies to the entire tax family for the entire year, and uninsurance for specific family members or months is not reported. Therefore, we categorize every person on a tax return with this exemption as exempt and uninsured for the entire year when analyzing the data at a person-level. Interpreting every person who qualifies for this exemption as uninsured will overstate the number o f uninsured persons.

Individuals may be eligible for more than one type of exemption for a given month, and in some cases are instructed to report all of the exemptions for which they qualify. However, taxpayers are not required to determine or report all of the exemptions for which they qualify. Therefore, we use an ordering rule to place individuals in mutually exclusive categories o f the type o f exemption used. We first identify who claims the exemption for having income below the filing requirement, followed by those who have low incomes and reside in a state that did not expand Medicaid, citizens abroad and certain non-citizens, persons with a short-coverage gap, persons with unaffordable coverage, and other exemptions. Placing persons in mutually exclusive categories sim­ plifies the analysis. But as a result, the exemption for having income below the filing requirement will appear more frequently and the exemption for unaffordable coverage less frequently than would be the case if we used a different ordering rule or none at all.

In addition, some codes used on Form 8965 may refer to more than one type of exemption. In particular, code “G” may indicate that coverage is unaffordable based on aggregate self-only coverage that the individual has low income and resides in a state that did not expand eligibility for Medicaid, or that other special cases for 2014 apply. We assume that a code G on a return with income below 138 percent of the poverty level filed from a state that did not expand Medicaid is explicitly for that exemption and that the remaining code G entries indicate that coverage was unaffordable.

6 The exemption allowed because coverage is unaffordable based on actual income is similar to that de­ scribed in footnote 4 above, but is based on actual household income rather than projected income. The exemption for unaffordable aggregate self-only coverage is allowed for the year if for any month: (1) the cost of employer-sponsored self-only coverage for two or more members is affordable when tested individually, (2) the cost of employer-sponsored family coverage is unaffordable, and (3) the combined cost of employer-sponsored individual coverage is unaffordable.

W h a t Can Tax D ata Tell Us a b o u t th e U n in s u re d ? E v id e n c e fr o m 2 0 1 4 887

IV. CALCULATION OF THE INDIVIDUAL PAYMENT RESPONSIBILITY

Taxpayers who are uninsured for all or part of the year (or who have an uninsured dependent) and who do not qualify for an exemption from the coverage requirement must make an individual responsibility payment. The amount of this payment, or pen­ alty, depends on the number o f persons without qualifying health insurance coverage per month, income, and the family’s filing threshold. Specifically, for 2014 the penalty for each month is

(1) (l/12)xm ax|m in[95x(A ?<i +0.5A?J,95×3],

0.01 x( household income – filing threshold} } ,

where AMs the number o f uninsured adults for the month, JV is the number of uninsured children under age 18, and household income is adjusted gross income (AGI) plus tax exempt interest and amounts o f foreign earned income or foreign housing excluded from AGI.

The penalty for the year is the sum of the monthly amounts, limited to the cost of the national average bronze plan that could cover the uninsured, non-exempt family members for all months of uninsurance, up to a maximum of five persons. For 2014, the national average bronze plan is $204 per person per month, for a maximum of $1,020 per family per month.7 In 2014, the average annual penalty per return with a penalty was about $210 (Internal Revenue Service, 2016).

Only the total penalty for the year is reported by the taxpayer on the tax return. In some cases, the number o f uninsured persons by month can be inferred from the pen­ alty amount. In other cases, we know only that at least one person was uninsured for at least part of the year. For the analysis in this paper, we present information about tax families who pay any amount o f penalty. In addition, we present information about families who pay the maximum amount of penalty conditional on their income and family size. If a family is paying the maximum amount, we know that the family paid some penalty every month, meaning that at least one person was uninsured each month. For a single person, this amounts to being fully uninsured. In addition, for most families who are paying a maximum penalty that exactly equals $95x(Na + 0.5A ), we know that the family is fully uninsured. Flowever, for families o f two or more people who are paying 1 percent o f income over the filing threshold, we cannot discern the number of uninsured persons. Thus, paying the maximum amount might best be thought of as correlated with fully uninsured status or as indicating a greater intensity o f uninsurance.

7 The $95 amount is increased to $325 for 2015 and $695 for 2016, and indexed to inflation thereafter. The 1 percent of income is increased to 2 percent for 2015 and 2.5 percent for 2016 and thereafter. The national average bronze plan premium is based on the average o f the median premium for a 21-year old non-tobacco user in each county, weighted by county populations. Internal Revenue Service (2014) provides more details.

888 N ational Tax Journal

In the next section, we examine rates o f uninsurance among different types o f families and the distribution of uninsured families by filing status, age, income relative to the poverty level, and other characteristics. Specifically, we tabulate the number o f families paying a penalty, claiming an exemption, or both. Then we look more closely at the types of exemptions claimed, at the individual (rather than family) level.

V. RESULTS

We find that of tax year 2014 returns processed through the end of March 2016,11.7 million claimed an exemption only, 7.2 million paid a penalty only, and 0.8 million reported both for tax year 2014 (Figure 1). Thus, in total, 19.7 million families reported at least one month o f uninsurance for at least one family member. This amounts to 14.5 percent of the 135.5 million families who filed 2014 returns.8

It is difficult to interpret this rate o f uninsurance, because it may reflect spells as short as one month or as long as a year, and it may reflect uninsurance for only some family members or for the whole family. Thus, our measure is expected to overstate the share of individuals who are uninsured all year or at any point in time. On the other hand, because our data exclude very low-income families who do not file tax returns,

F ig u re 1

N u m b e r o f R eturns w ith P enalty, E x e m p tio n , o r Both

Penalty Only Exemption Only Category

Both

8 This is nearly identical to tabulations reported by IRS for tax year 2014 returns processed through October 2015 (Internal Revenue Service, 2016).

W h a t Can Tax D ata Tell Us a b o u t t h e U n in s u re d ? E v id e n c e fr o m 2 0 1 4 889

our measure could understate the true rate of uninsurance, at least among the non- elderly. The Bureau of the Census reports that for 2014 an estimated 10.4 percent o f individuals were uninsured all year and nearly 12 percent were uninsured at the time they were surveyed.5 * * * 9 While our measure is conceptually different and excludes very low-income persons, it is o f the same order of magnitude and suggests that taxpayers accurately reported their status on their tax returns, in a manner similar to what they report in survey data.

Figure 2A shows that unmarried taxpayers are more likely to be uninsured. This is consistent with Census tabulations. Somewhat surprising to us, families with children are more likely than those without children to report a spell of uninsurance. About 20 percent o f head of household filers, that is, unmarried persons with children, report a spell of uninsurance, compared to 17 percent of single filers without children, 12 percent of married couples filing jointly with children and only 7 percent o f joint filers without children. The higher rate of uninsurance among filers with children may be due to the age composition o f the family. It does not necessarily mean the children were uninsured, and may indicate that a parent was uninsured. Figure 2B shows that single taxpayers without children account for about half o f all tax returns reporting a spell of uninsurance.

The rate of uninsurance was highest for families in which the primary taxpayer was under age 25 (22 percent) or age 25 to 29 (22.5 percent), and declined steadily after age 29. Families in the under-30 age group account for about one-third o f uninsured families. As expected, the rate of uninsurance drops markedly, tojust 3 percent, when the primary taxpayer reaches age 65 and becomes eligible for Medicare (Figures 3A and 3B).

Lower-income families are more likely to be uninsured, and are more likely to claim an exemption than to pay a penalty (Figure 4A).10 About 28 percent of families with incomes below 100 percent of the federal poverty level (FPL) claimed an exemption only, 4 percent paid a penalty only, and 1 percent did both. Among those with incomes between 100 and 138 percent of the poverty level, about 18 percent claimed an exemp­ tion only, 11 percent reported a penalty only, and 2 percent did both. While taxpayers with income below the filing threshold are exempt from the coverage requirement, it is nonetheless possible for poor families to be subject to the penalty. This can occur because the filing threshold is below the FPL for single and head of household filers, and for married couples with two or more children." Thus, some poor families may indeed be subject to a penalty. However, it also appears that some families paid a penalty when they could have claimed an exemption. In fact, IRS has contacted about 400,000 families to notify them that they might have paid too much for tax year 2014.

Families with incomes below the poverty level account for 37 percent of uninsured families, and those between 100 and 13 8 percent of the poverty level account for another 16 percent (Figure 4B).

5 See Smith and Medalia (2015) for the Census data cited in this paper. 10 For all figures showing income as a percentage o f FPL, income is defined as AGI plus tax-exempt interest,

foreign earned income and housing, and Social Security income that is otherwise excluded from AGI. This is the definition used to determine eligibility for Medicaid and PTC.

11 For example, for a single person in 2014, the filing threshold was $10,150 and the poverty level was $11,490.

890 National Tax Journal

Figure 2A

■ Penalty Only Exemption Only "B oth

Figure 2B

Distribution of Uninsured Returns by Family Type

C/)c CDO'

■ O0) 3

c ’ c 3 o 0l_ 03

SZ i f )

0.60

0.50

0.40

0.30

0.20

0.10

0

Family Type

W hat Can Tax Data Tell Us a b o u t th e U ninsured? Evidence fro m 2014 891

Figure 3A Share o f Families that is Uninsured by Age

Age

■ Penalty Only Exemption Only ■ Both

Figure 3B D istribution o f Uninsured Families by Age

Age

892 NationalTax Journal

Figure 4A

Share o f Families that is Uninsured by FPL

0.35 ■

« 0.25

1 0.20 – LL

O <u 0.15

Income as a Share of FPL (l/FPL)

■ Penalty Only Exemption Only a* Both

Figure 4B

D istribution of Uninsured Families by FPL

Income as a Share of FPL (l/FPL)

W h a t Can Tax D ata Tell Us a b o u t t h e U n in s u re d ? E v id e n c e fr o m 2 0 1 4 893

Prior to 2014, most states did not provide Medicaid to non-disabled adults without children. The ACA provides incentives for states to extend eligibility for Medicaid to all persons with incomes below 138

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