Understanding The Implications Of The Affordable Care Act
Understanding theImplications of theAffordable Care Act:Enrollment, Education and TaxesSummer 2013MONTH, DAY, YEAR 2013
ABOUT THE TAX INSTITUTE AT H&R BLOCKThe Tax Institute at H&R Block is the go-to source for objective insights on federal and state tax laws affecting theindividual. It provides nonpartisan information and analysis on the real world implications of tax policies and proposals topolicymakers, journalists, experts and tax preparers. The Institute’s experts include CPAs, Enrolled Agents, tax attorneysand former IRS agents. Building off more than 10 years of research and analysis from a specialized tax research group atH&R Block, the company launched The Tax Institute in 2007.ABOUT THIS REPORTFrom February through April of 2013, The Tax Institute at H&R Block conducted nationwide panel discussions on theimplications of the Patient Protection and Affordable Care Act (ACA). Focused on the intersection of taxes and healthcare created by the ACA, as well as on education, enrollment and outreach issues, we visited Washington, D.C.,Tallahassee, Florida, Sacramento, California and Springfield, Illinois. At each stop, a diverse panel of experts spoke ontheir areas of expertise, and on the unique challenges they foresaw for each state. Each panel was moderated by anexpert from Bloomberg Government, and questions were encouraged from audiences of local government officials,medical professionals, business leaders, non-profits and other associations, and other relevant stakeholders. This reportpresents the findings and conclusions from the tour, from each stop individually as well as collectively.ACKNOWLEDGEMENTSThis report, and the tour it has drawn from, would not have been possible without the support and participation of a widerange of groups and individuals. First thanks go to all who attended the panel discussions. Whether as a panelist oraudience member, the expertise, insights and questions you brought were truly the lifeblood of the tour and this report.We also thank all of the media organizations that promoted each event and amplified the conversations that came fromthem. Finally, we thank our partner Bloomberg Government, including all the analysts and staff who contributed to theproduction of these programs. This report would not have been possible without the help of each of these groups, andagain we thank you.Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes
Letter to our readers:The Patient Protection and Affordable Care Act (ACA) not only contains the most significantreforms the American health care system has seen in decades, but also some of the largestchanges to the tax code.At H&R Block our purpose is to look at life through tax and find ways to help. This groundbreakinglaw, and the new, inextricable link between health care and the tax code, has created manyunique and unprecedented issues for taxpayers and the uninsured. As a result we began to lookahead to the 2014 implementation and asked, “How is this going to affect taxpayers” and, “Howcan we help?” This is something H&R Block has done for our clients since 1955 – helping tonavigate complicated federal laws in a practical way.With an eye to the fall 2013 open enrollment season when some of the more broad-reachingparts of the ACA will be enacted, The Tax Institute at H&R Block conducted a wide-rangingconsumer opinion survey in September 2012. The survey, conducted by ORC International,found that three out of four taxpayers don’t know what it takes to become eligible for healthinsurance tax subsidies under the new law, including that their 2012 tax return could be used as abaseline for the credit. The study also found that while most people are familiar with therequirement to obtain insurance, 44 percent of respondents age 18-34 were not aware that theymay face a tax penalty if they fail to obtain insurance.While many of the current conversations about the ACA are focused on setting up the insurancemarketplaces for open enrollment in October, the survey told us that there’s also a real need toeducate consumers on the tax implications of this monumental law.This is why we launched a series of panel discussions. The nationwide conversations, whichwere conducted in partnership with and moderated by Bloomberg Government, brought togetherthought leaders from the government, the private sector, non-profit groups and academia to talkabout challenges and opportunities facing those who will navigate the new system.After the last discussion, The Tax Institute at H&R Block commissioned another ORC survey inApril 2013, which asked the same questions that were asked in September 2012 and tested forquestions raised during the discussions. The discussions and survey confirmed that individualawareness remains a challenge, outreach and enrollment efforts are still being developed andrefined, and small businesses are eager for information and support.The bottom line? Implementing the landmark ACA is still a work in progress and strongpartnerships among government officials, nonprofit groups, private industry and other keystakeholders will be essential in helping consumers navigate the system.We hope this report helps to draw attention to the key issues and challenges that consumersmust navigate. We at H&R Block look forward to continuing to be part of this importantconversation, and working with all stakeholders moving forward.Kathy PickeringExecutive DirectorThe Tax Institute at H&R BlockUnderstanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes
TABLE OF CONTENTS1. Executive Summary12. The Intersection of Health Care & Taxes33. Awareness44. Outreach & Enrollment75. Small Businesses116. Technology137. Conclusion158. Appendix16a.Tour Locations and Participants16b. Health Care Reform: What it Means for Your TaxesInfographic & Scenarios26a.27EndnotesUnderstanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes
EXECUTIVE SUMMARYMore than three years after the passage of the landmark Patient Protection and Affordable Care1Act (ACA) aimed at overhauling the 2.7 trillion U.S. health care system, implementation has2begun in earnest to provide 30 million uninsured Americans with coverage. As the federalgovernment and states work to expand the health care system, there no doubt will be confusion,uncertainty and the occasional setback along the way.Since implementation relies in part on the U.S. tax code, The Tax Institute at H&R Blockpartnered with Bloomberg Government to host panels around the country to discuss thechallenges, opportunities and potential solutions related to ACA implementation. In early 2013,we traveled to Washington, D.C., Tallahassee, Fla., Sacramento, Calif. and Springfield, Ill. tobetter understand the road ahead for implementing the ACA and how these key states’ differingapproaches will affect the uninsured.The discussions focused on topics such as how to best make large and diverse populationsaware of the coming changes; innovative ways to reach audiences and drive enrollment; howthese changes affect the way companies provide health care to their employees; and how statesare preparing to assist the uninsured in the enrollment process. We found that: Awareness of the implications of the ACA remains low. People have receivedinformation that is inaccurate, incomplete or haven’t received any information at all.Frustrations are already elevated, and the appetite for knowledge is low.Outreach and enrollment efforts are still being developed and refined. The peoplewho will guide consumers through this process have not been fully identified, the scopeof their roles has not been solidified, and the tools and techniques they will use have notbeen finalized.Small businesses are eager for information and support. Most of these companieslack the capability or resources to manage all their options and responsibilities, and arelooking for assistance from the government and the private sector.Technology is an open question. Whether or not requisite data will be seamlessly andsufficiently integrated will be a critical factor in preventing confusion and delays.To understand what’s ahead for consumers, it is essential to learn what they do or do not know.Despite all the media attention, political discourse and public debate about the forthcomingchanges and deadlines for implementing the law, many remain unaware of its benefits and theirresponsibilities going forward. A survey conducted by The Tax Institute at H&R Block and ORC International inSeptember 2012 found that 77 percent of Americans were unaware that their 2012 taxreturn may be used as a baseline for their income if they choose to take advantage of atax credit to help subsidize the cost of health insurance. That number remainedconsistent, at about 73 percent, based on a similar survey conducted in April 2013.Approximately 44 percent of 18-34-year-olds were also unaware that they could face atax penalty if they do not have insurance, which would be imposed in April 2015. On apositive note, the April 2013 survey showed a shift for these respondents. Unawarenessamong 18-34-year-olds was at 35 percent, some 9 points below the September survey.Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes1
The September figures added urgency during our panel discussions. Collectively, the discussionsshowed the great obstacles that the government, health care providers, insurers, tax preparersand other organizations must overcome in the approaching months and years to educate a largecross-section of the country on their obligations to secure health care coverage and the taxconsequences of remaining uninsured. They also highlighted the level of collaboration that willbe necessary between the public and private sectors to successfully launch and sustain the newhealth care system.In addition to the critical issue of how to raise awareness, participants discussed the challengesof reaching a diverse American population and potential solutions, including lessons learned fromthe implementation of the federal prescription drug program known as Medicare Part D and theState Children’s Health Insurance Program (SCHIP). Questions were also raised about who isbest suited to provide that information to consumers and what will happen to one of the largestsegments affected by the new law – small business owners and their employees.Participants in the forums universally agreed that despite the inevitable setbacks, public andprivate entities must work together to create innovative ways to educate taxpayers and theuninsured about their obligations and opportunities under the ACA. Unique solutions proposedincluded the use of emerging technology as a way to assist enrollment and provide information,guidance and assistance to small businesses and their employees who are expected to face themost challenges when trying to explain and implement the changes.Sister Carol Keehan, President and CEO of the Catholic Health Association of the United Statesand a panelist at the Washington, D.C. panel discussion, put it best: In order to make the systemwork, we must all “have faith, go forward, fix problems.”Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes2
The Intersection of Health Care & TaxesThe Requirement to Obtain InsurancePerhaps the ACA’s most widely known feature is the requirement to obtain health insurancecoverage. Beginning in 2014, almost all Americans will be required to enroll in a qualified healthplan, or be forced to pay a tax penalty. The amount of the tax penalty will be phased in between2013 and 2016, and will vary based on filing status and income.Traditionally, the majority of Americans have secured health insurance coverage through their3employer . The ACA seeks to maintain the primacy of that system by requiring businesses toprovide insurance if they employ more than 50 full-time equivalent workers. Companies at thissize that do not offer coverage could face a penalty of up to 2,000 per employee. Somecompanies will be eligible for tax credits to help buy employee insurance, which again vary basedon workforce size and average wages.Exemptions from the RequirementIndividuals who earn less than 9,750 per year are not subject to the requirement to obtaininsurance and the penalty. In addition, recent regulations list the individuals who are exempt fromthe requirement to obtain insurance and therefore the tax penalty and how such exemptions areto be claimed. In sum, there are eight exemptions, divisible into three categories: those whichrequire an individual to obtain a certificate from an exchange, those which an exchange certificateis available but not required, and those which may only be claimed when filing a tax return. Thefollowing is a list of exempt individuals. Exchange certificate requiredo A member of a recognized religious secto An individual experiencing hardshipExchange certificate or claim when filing tax returno A member of a health care sharing ministryo An incarcerated individualo A member of a federally recognized Indian tribeClaim only when filing tax returno An individual not lawfully presento An individual offered coverage by an employer that is unaffordableo An individual experiencing the first short-term coverage gap of the calendar yearTax Credits to Obtain InsuranceThe Congressional Budget Office estimates that 22 million Americans will receive tax credits, also4known as premium subsidies, to purchase insurance through the exchanges by 2017 . Thosecredits move along a sliding scale depending on a variety of factors.Families and individuals with incomes ranging between 133 percent and 400 percent of thefederal poverty level may be eligible for advance tax credits to help them purchase healthinsurance. However, these tax credits are only available if the insurance is purchased throughone of the new insurance marketplaces, also known as exchanges.Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes3
Insurance Marketplaces (Exchanges)At the time of this report, 17 states and the District of Columbia are planning to open their ownstate-controlled health insurance marketplaces this October. Just over half the states, 26, willrely on the federal health exchange. Another seven states will offer a hybrid model, working inpartnership with the federal program. Each of these approaches provides unique opportunitiesand challenges for their residents. The states examined in this report are as follows:CaliforniaFloridaIllinoisType of ExchangeUninsuredTotal Medicaid Enrollment (FY 0,858Hybrid1,885,8002,698,787Eligible for the tax credit2.6 million1.7 million957,000Small businesses 3,600159,900(78.5%)Small businesses eligible for subsidy6National48,611,60062,692,69326 million (Families USA)22 million by 2017 (CBO)4,798,3004,015,300 (83.7%)AWARENESSBy far, the most talked about issue during the discussions was the level of awareness about theforthcoming changes to health care insurance and what stakeholders are doing, and must do, tohelp educate Americans about their obligations to have coverage and dispel any confusion ormisinformation.“I just think it’s really criticalThe numbers paint a vivid picture about just how muchthat we all know that we haveAmericans know about the ACA, according to twoa tremendous amount to gainsurveys conducted by The Tax Institute at H&R Blockif we get it right as we comeand ORC International. The surveys found that manythrough these changes, andknew about the risk of a tax penalty for not havingthat’s going to take every oneinsurance coverage: 71 percent in April 2013 (up fromof us to deploy that68 percent in September 2012). Yet, in April 2013 aninformation.”even greater number of respondents, 73 percent, didFormer Sen. Blanche Lincolnnot know that their 2012 tax return could be used as(D-Ark.)the baseline for determining their eligibility to receiveFebruary 15, 2013,financial support to pay for health care coverage.Washington, D.C. discussionThe surveys also reinforced the fact that Americans donot plan to change the way that they do their taxes, despite knowing now that their income willdictate how much of a tax credit they could be eligible to receive as a result of the ACA. Some 84percent said in April that they would prepare their taxes the same way, up from 78 percent whosaid the same last year.“I think the issue of awareness is the single most important issue right now facing this law. Andone of the dangers of everybody being responsible is that nobody is responsible,” Peter Gosselin,an analyst at Bloomberg Government, said during the Tallahassee, Fla. event.Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes4
That could have significantimplications for the millions ofuninsured Americans who will beaffected by the ACA. The populationof uninsured in just the three statesthat The Tax Institute andBloomberg Government visited –California, Florida and Illinois – ismore than 13 million, nearly 3 millionof whom are expected to join thehealth care marketplaces during the7first year of open enrollment , whichbegins in October 2013.The surveys conducted by The Tax Institute at H&RBlock and ORC International found that there was highawareness of the tax penalty associated with failing toobtain health coverage by 2014. The largest increase inawareness during this seven-month period was in youngAmericans (age 18-34) whose awareness levels increasedby 21 percent.April 2013September 2012Yes (Nationwide)71%68%No (Nationwide)29%32%Age 18-3465%44%“Communication is going to be, as itnormally is, the biggest challenge,” former Sen. Blanche Lincoln (D-Ark.), who was a key playerduring negotiations for the ACA, said during the Washington, D.C. forum. “There is so muchmisinformation that people may not even seek out information because they’re so angry or upsetor so confused by the misinformation that they’ve already gotten.”And of course the central question is: where will consumers get this information?According to the April and September surveys, 54percent of respondents said that they were most likelyto ask friends and family. That was followed by 49percent who said that they would ask an insurancecompany, 45 percent who said a doctor and 44 percentwho said their employer.“There is no average American family when it comes tohealth reform because what the program means is verydifferent for different people, depending on theircircumstances,” Professor Mark Paul, of University ofPennsylvania Wharton School of Health CareManagement Department, said during the forum inWashington, D.C.Panelists discussed the awareness gap of someAmericans, noting that sometimes it is hard for theinformation to penetrate.“I think we all shareresponsibility in that[awareness and education],and I think starting with thefederal government, movingdown to the health plans,moving over to the taxprofessionals, we’re all goingto play a part in this”Dr. Michael W. Garner,President and CEO, FloridaAssociation of Health PlansFebruary 28, 2013,Tallahassee, Fla. discussionUnderstanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes5
“They’re either in low-wage jobs or the cost of health care greatly exceeds the price ofemployment or they have a preexisting condition where the cost of health care is just much toogreat for them to be able to afford it or it isn’t even offered because it’s too expensive,” AllanZaremberg, president and CEO of the California Chamber of Commerce, said at the forum inSacramento.“For many of the people who don'thave access today, it isn't justabout: Now you have insurance. Itis to be able to show them that thisis going to result in better healthcare for them, that there are clinics
Feb 15, 2013 · Understanding the Implications of the Affordable Care Act: Enrollment, Education and Taxes The Intersection of Health Care & Taxes The Requirement to Obtain Insurance Perhaps the ACA’s most widely known feature is the requirement to obtain health insurance coverage. Beginning in 2014,
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