ACA and Taxes

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA and Households >> ACA and Taxes (last updated 2.12.17)

Topic Outline


Taxes originally were designed to cover about half the total cost of the ACA. These came in the form of 21 new tax provisions designed specifically for the purpose of raising revenues under the ACA. Seven of these provisions represented direct taxes on families, some in the form of new levies and others in the form of reducing the generosity of previous tax benefits (e.g., tighter limits on FSA contributions). Another four were taxes imposed on employers, but generally expected to be passed onto households (e.g., lower worker wages). Three taxes were levied on the health insurance industry, but again the ultimate incidence of such taxes was expected to fall on households in the form of higher prices. Likewise, five provisions affecting health insurers were expected to ultimately be borne by households, along with three other taxes on industries outside the health sector.  Following the 2012 Supreme Court decision upholding the Affordable Care Act, the House Ways and Means Committee recalculated the net impact of all taxes in the new law, concluding that the 21 new taxes imposed under the act would cost taxpayers more than $675 billion over its first 10 years.

Only two of the taxes specifically target high income taxpayers–that is, households making at least $250,000 ($200,000 single): the surtax on investment income and 0.9 percent Medicare payroll tax. Other taxes hit families directly regardless of income. In the case of taxes targeting industries, the Congressional Budget Office (CBO) advised Congress that the health insurance tax “would be largely passed through to consumers in the form of higher premiums for private coverage.” This observation has been confirmed by statements from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) and by the Joint Committee on Taxation (JCT) of Congress. It is likely that other industries likewise would pass along tax increases imposed on them onto consumers.

The following summarizes the various taxes, the date they are scheduled to begin, and the dollar estimates of expected revenues from 2010-2019 and the updated estimates for the years 2013-2022. Within each category, the taxes are listed in chronological order of their effective dates.

Direct Taxes on Families

Tax on Over-the-Counter Medications (“Medicine Cabinet Tax”) (2011)

  • Summary. This tax limits on use of HSAs/FSAs/HRAs/MSAs to purchase non-prescription medications. Effective 1.1.11, the cost of an over-the-counter medicine or drug cannot be reimbursed from Flexible Spending Arrangements or health reimbursement arrangements unless a prescription is obtained. The change does not affect insulin, even if purchased without a prescription, or other health care expenses such as medical devices, eye glasses, contact lenses, co-pays and deductibles. The new standard applies only to purchases made on or after 1.1.11, so claims for medicines or drugs purchased without a prescription in 2010 can still be reimbursed in 2011, if allowed by the employer’s plan. A similar rule goes into effect on 1.1.11 for Health Savings Accounts (HSAs), and Archer Medical Savings Accounts (Archer MSAs). For more information, see IRS news release IR-2010-95,Notice 2010-59Revenue Ruling 2010-23 and questions and answers.
  • Details. PPACA Section 9003, pp. 1957-1959. Effective 1.1.11.
  • Revenue. From 2010-2019: $5B.; from 2013-2022: $4.0B.

Increased Penalties On Nonqualified HSA Withdrawals (2011)

Limits On FSA Contributions (“Special Needs Kids Tax”) (2011)

Taxes Targeting High-Income Individuals (2013)

Together these taxes are expected to produce the following revenue from 2010-2019: $210.2B./2013-2022: $317.7B.. No break-down provided for update: for original 10-year projection, surtax on investment income accounts for 58.6% of joint revenues.

Medicare Surtax on Investment Income (2013)

Medicare Surtax on Higher-Income Individuals (2013)

  • Summary. This increases the Medicare payroll tax by 0.9 percentage points for households making at least $250,000 ($200,000 single).  Unlike other payroll taxes, the Additional Medicare Tax is levied on the household level, not the individual level. Joint filers are required to pay the tax on labor income above $250,000, while single filers are taxed on labor income above $200,000 (p. 104).
  • Details. PPACA Section 9015, pp. 2000-2003. Effective 1.1.13.
  • Revenue. From 2010-2019: $86.8B.; no separate update for 2013-2022 reported. Tax Foundation calculates (p. 104) that repealing the Additional Medicare Tax would reduce federal revenue by $87 billion from 2016-2025, on a static basis. However, it would also encourage additional work among high-income households, which would generate 73,000 full-time equivalent jobs and grow the economy by 0.1 percent over the long run. Taking these economic effects into account, repealing the tax would only reduce federal revenue by $63 billion over 10 years, on a dynamic basis. TaxBrain can be used to calculate the expected revenue from this tax and distributional effects for any year starting in 2016.
  • Impact. Tax Foundation reports (p. 104)  that in 2013, 2.8 million households were subject to the Additional Medicare Tax. Most of the households subject to the tax had adjusted gross incomes between $200,000 and $500,000. All in all, the tax raised $6.27 billion in 2013.
    • Jobs. Tax Foundation calculates (p. 104) that repealing the surtax would increase the number of FTE jobs in the economy by 73,000.
    • Distributional Effects. Tax Foundation calculates (p. 32) that repealing the surtax would lead to lower taxes for high-income Americans, and would increase the after-tax incomes of the top 1 percent of taxpayers by 0.3 percent, on a static basis. However, when accounting for the positive economic effects of repealing the Additional Medicare Tax, income groups across the board would see their incomes rise (full table at p. 104).

Raise “Haircut” for Medical Itemized Deduction from 7.5% to 10% of AGI (2013)

  • Summary. The 7.5% remains in effect through 2016 for who attained age 65 prior to the end of the tax year.
  • Details. PPACA Section 9013, pp. 1994-1995. Effective 1.1.13.
  • Revenue. From 2010-2019: $15.2B.; from 2013-2022: $18.7BTaxBrain can be used to calculate the expected revenue from this tax and distributional effects for any year starting in 2016.
  • Impact. The latest available IRS data show that 10 million families used this tax deduction in 2009; nearly all were middle class, with the average taxpayer claiming this deduction earning just over $53,000 annually. ATR has further details on this tax.

Individual Mandate Excise Tax (2014)

Taxes on Employers Ultimately Borne by Families

Reporting of Employer Cost of Employer-sponsored Health Coverage on W-2 (2011)

Elimination of Tax Deduction for Medicare Part D Subsidy  (2011)

  • Summary. Employers that provide Medicare-eligible retirees with prescription drug coverage are eligible for a tax-exempt federal subsidy to encourage them to maintain that coverage. Prior to the ACA, employers deducted retiree prescription drug costs from their income taxes without regard to the subsidies they received. The ACA amended the tax code requiring employers to reduce the allowable deduction for retiree prescription drug costs by the amount of any subsidy received (Table 3). Additional details.
  • Details. PPACA Section 9012, p. 1994. Effective 1.1.11.
  • Revenue. From 2010-2019: $4.5B.; from 2013-2022: $3.1B.

1099 Reporting Requirements (repealed)

  • Summary. Expands IRS form 1099 reporting requirements of payments more than $600 to include payments to corporations, not just individuals;
  • Details. PPACA Section 9006, pp. 1960-1961. Repealed prior to effective date of 1.1.12.
  • Revenue. From 2010-2019: $17.1B.; repealed by P.L. 112-9 prior to any revenue gains.
  • Impact. This would have substantially increased the number of 1099 forms filed, but was repealed April 14, 2011 before it became effective.

Large Employer Mandate Tax (“Pay or Play”) (2015)


  • Compliance Costs. According to the New York Times (11.18.15), “Starting this year, all companies with 50 or more full-time workers — even those not yet required to offer health benefits — must file new tax forms with the Internal Revenue Service that provide details on employee head count and any health insurance offered. Gathering the data requires meticulous record-keeping. “These are some of the most complex informational returns we’ve ever seen,” said Roger Prince, a tax lawyer with the consulting firm Berry Dunnin Portland, Me. Some of his clients, even small ones, have spent months reconfiguring their human resources and financial systems to track the information that the new forms demand. The health care law defines a full-time-equivalent employee as someone who works an average of 30 or more hours a week — and the hours worked by some part-time employees count toward the calculation. For businesses that use many seasonal, variable-hour or temporary workers, like those in the hospitality industry, simply figuring out how many qualifying employees they have can be a challenge.”
  • Employment. As a very rough approximation, the mandate alone might result in a net job loss of 700,000 (NFIB Research Foundation 2009). Evidence from Hawaii and Massachusetts, the only states having experience with an employer mandate, show limited adverse effects on the total number employed but potentially larger effects on shifting more workers to part-time work (Evidence from States).
Research and Analysis
  • NFIB Research Foundation (January 2009). Chow MJ and Phillips BDSmall Business Effects of a National Employer Healthcare Mandate. Nashville, TN: NFIB Research Foundation, January 26, 2009. This study projected a 1.6 million job loss under a hypothetical employer mandate, along with 890,000 new jobs created in the health sector, for a net loss of about 700,000 jobs.  However, because the authors never scored the ACA as enacted, this estimate provides limited insight.
  • Evidence from States with Employer Mandates. See also Evidence from States for empirical evidence regarding the impact of employer mandates. There are ample studies listed at ACA Impact on Employment/Economy on the ACA’s potential net impact on national employment, but such studies do not typically break down how much any adverse effect on employment is specifically attributable to the employer mandate.

Taxes on Health Industry Ultimately Borne by Families

Excise Tax on Charitable Hospitals (2010)

  • Summary. Requires tax-exempt charitable hospitals to conduct a needs assessment every two years; to adopt a written financial assistance policy for patients requiring such assistance; and refrain from taking extraordinary collection against against a patient until determining whether the patient needs financial assistance. The penalty tax is imposed only on hospitals that fail to comply with these requirements.
  • Details. PPACA Section 9007, pp. 1961-1971, as modified by Section 10903, p. 2389. Effective immediately. 
  • Revenue. Minimal revenue expected.

Drug Manufacturers/Importers Tax (Tax on Prescription Medications) (2010)

Medical Device Fee (2013)


Research and Analysis

Items are in reverse chronological order.

  • Congressional Research Service (January 2015). Gravelle, Jane G. and Sean Lowry. The Medical Device Excise Tax: Economic Analysis. Congressional Research Service (1.9.15).
    • This tax, which took effect in January 2013, is projected to collect approximately $38 billion of excise tax revenues over the next 10 years, resulting in $29 billion of net revenues, after accounting for offsets from other taxes.
    • The tax was justified partly because the medical device industry was among the commercial interests that stood to benefit from unanticipated profits as more individuals enroll in health care insurance, post-ACA. Viewed from the perspective of traditional economic and tax theory, however, the tax is challenging to justify. In general, tax policy is more efficient when differential excise taxes are not imposed. It is generally more efficient to raise revenue from a broad tax base. Therefore excise taxes are usually based on specific objectives such as discouraging undesirable activities (e.g., tobacco taxes) or funding closely related government spending (e.g., gasoline taxes to finance highway construction). These justifications do not apply, other than weakly, to the medical device case.
    • The tax also imposes administrative and compliance costs that may be disproportionate to revenue.
    • Opponents of the tax claim that the medical device tax could have significant, negative consequences for the U.S. medical device industry and on jobs. The estimates in this report
      suggest fairly minor effects, with output and employment in the industry falling by no more than two-tenths of 1%. This limited effect is due to the small tax rate, the exemption of approximately half of output, and the relatively insensitive demand for health services. The analysis suggests that most of the tax will fall on consumer prices, and not on profits of medical device companies. The effect on the price of health care, however, will most likely be negligible because of the small size of the tax and small share of health care spending attributable to medical devices.
  • Tax Foundation (August 2014)Kyle PomerleauThe Obamacare Medical Device Tax is Not Working as Planned (8.21.14). This report reviews the Treasury Inspector (TIGTA) report. TIGTA found that there was a high amount of error both on the part of businesses and the IRS. This kind of error isn’t that surprising for the medical device tax. The tax is surprisingly complex with a number of “specific exemptions, other safe harbors, and retail exemptions,” so not all businesses that sell, or manufacture devices need to pay the tax. This reasonably leads to confusion on both the IRS’s and the business’ side over who should be paying the tax. High compliance and administration costs, low revenues coupled with a gross receipts tax base does not make for good tax policy.
  • Treasury Inspector General for Tax Administration (July 2014). The Affordable Care Act: An Improved Strategy Is Needed to Ensure Accurate Reporting and Payment
    of the Medical Device Excise Tax 

    • Revenue 23% Lower Than Expected. The IRS estimated between 9,000 and 15,600 quarterly Forms 720 tax returns with excise tax revenue of $1.2 billion for the first 2 quarters of 2013. However, during the same period, a total of only 5,107 returns were filed, yielding only $913.4 million in revenues.
    • Processing Controls Do Not Ensure the Accuracy of Medical Device Excise Tax Figures Reported. An analysis of all 5,107 returns found 225 returns on which the amount of taxed owed potentially overstated by $41.6 million; another 51 returns found the amount of taxed owed potentially understated by $76.2 million.
    • Taxpayers Were Erroneously Assessed Failure to Deposit Penalties. 219 penalties were erroneously assessed for an amount totalling more than $700,000.
  • Graham, John (August 2014)Repealing The Medical-Device Excise Tax: Next Steps. (8.1.14).
  • Tax Foundation (August 2014)Kyle Pomerleau. The ACA Medical Device Tax: Bad Policy in Need of Repeal (8.21.14)
    • The tax will adversely affect innovation, employment, and competition in the same way the windfall profits tax of the 1980s depressed domestic oil production.
    • Adverse Effect on Innovation. One concern is that the tax could reduce the incentive for medical manufacturers to innovate. As was suggested above, an excise tax is levied on a business whether it makes profits or not. As a result, firms will take on fewer risks and less research and development [David I. Meiselman, The Oil Excise Tax: Another Government Windfall, Tax Foundation Tax Review, Vol. XL, No. 9 (Oct. 1979)]. Take the example by Henry I. Miller of the Hoover Institute: a small company with total sales of medical devices of $2 million is liable for a $46,000 tax. However, after accounting for R&D and other expenses, total profit on those sales may only be $75,000. This is the same as an effective corporate income tax of 60 percent [Henry I. Miller, ObamaCare’s Medical Device Tax Will Cost Innovation and Jobs, Forbes, Dec. 17, 2012]. Since firms are profit maximizing, they will undertake less R&D on the margin to remain profitable, likely having an industry-wide effect on innovation.
    • Complexity. One issue regarding complexity is how firms calculate the actual sales price of taxable medical devices. There are cases in which vertically integrated manufacturers sell directly to hospitals rather than through wholesalers. This requires them to create an artificial wholesale price upon which to apply the tax.
    • Disproportionate Burden on Small Firms. Ultimately, the complexity of the tax places an additional, disproportionate administrative burden on smaller firms. Smaller firms, in the process of compliance, need to expend a greater percentage of their resources on administration than a bigger company [J. Scott Moody, The Impact of Tax Complexity on Small Businesses, Tax Foundation Special Brief (Sept. 2000)]. For many medical device firms, adding one more person in the tax department likely means not adding one more scientist in the R&D laboratory.

Taxes on Health Insurance Ultimately Borne by Families

Annual Fee on Health Insurers (Health Insurance Tax -“HIT”) (2014)


Research and Analysis
Government Estimates
  • Joint Committee on Taxation (June 2011). Barthold, Thomas A. Letter to Senator Jon Kyl. Joint Committee on Taxation, Washington, DC (6.3.11).
    • 2-2.5% Higher Premiums. “We estimate that repealing the health insurance industry fee would reduce the premium prices of plans offered by covered entities by 2.0 to 2.5 percent.”
    • Cost per Family. “We estimate that eliminating this fee could decrease the average family premiun in 2016 by $350 to $400.”
    • Mostly Borne by Consumers. “While uncertainty exists, we assume that a very large portion of the fee on purchased health insurance premiums will be borne by consumers in most markets, including in some markets with a high level of concentration among market participants covered by the fee.”
    • May Result in Lower Quality Plans. “While consumers (or employers) may respond by changing their health insurance coverage from more expensive plans to less expensive plans to offset any potential price increase, this behavior is properly characterized as the consumers bearing the burden ofthe excise tax by accepting lower quality (for example, a more restricted physician network) for the same price rather than paying a higher price for the same quality of insurance that they would prefer if there were no tax.”
    • Incentives for Self-Insurance. “To the extent that firms can avoid the fee by switching from full insurance to self-insurance, this may suggest that insurers are unable to pass on the full cost of the insurance industry fee on purchased health insurance. To the extent that health insurers maintain some pricing power in the administrative services that they provide self-insurers, the self-insurance market may bear some of the burden of the fee as well. “
    • Distributional Consequences Unknown. “Regardless of any determination of the economic incidence of the insurance industry fee, at the present time the staff ofthe Joint Committee on Taxation is not able to distribute the effects by income of individuals.”
  • Congressional Budget Office (November 2009).
    • In a November 30, 2009 letter, the Congressional Budget Office stated that “New fees would be imposed on providers of health insurance and on manufacturers and importers of medical devices.  Both of those fees would be largely passed through to consumers in the form of higher premiums for private coverage.” The letter provided aggregate impacts on premiums based on the net effect of a large number of various provisions that would have affected premiums, including the HIT, but no breakdown was provided of the impact of the HIT alone.
Other Estimates

Items listed in reverse chronological order.

  • Oliver Wyman (December 2015). “AHIP has asked that Oliver Wyman prepare this letter to address the implications of the elimination of the HIT for 2017-2020. Specifically, we estimate the impact of the suspension of the health insurance tax on premiums across all lines of business, as compared to a scenario where the tax remains in place. We find that suspending the HIT would significantly reduce premiums in the marketplace, reducing premiums by over 3 percent or by more than $200 per member per year in 2017 across all fully-insured major medical plans.” (Oliver Wyman, 12.16.15)
  • Who’s Paying the New Obamacare Tax? You. “When Congress passed the Affordable Care Act, it required health insurers, hospitals, device makers and pharmaceutical companies to share in the cost because they would get a windfall of new, paying customers. But with an $8 billion tax on insurers due Sept. 30 — the first time the new tax is being collected — the industry is getting help from an unlikely source: taxpayers. States and the federal government will spend at least $700 million this year to pay the tax for their Medicaid health plans.” (Kaiser Health News, 8.30.14)
  • Book, Robert and Sang Kim (July 2014). Recycling the Health Insurance Tax. American Action Forum. 7.25.14. This analysis shows that of $8 billion to be collected in 2014 by HIT, $3.029 billion will be “recycled” i.e., indirectly paid by the federal government back to itself due to various subsidies provided for the purchase of health insurance, including a) tax exclusion for employer-provided health insurance; b) subsidized Exchange coverage; c) Medicaid managed care organizations; d) Medicare Part D drug plans; and e) Medicare Advantage plans. For example, for every $1 increase in premiums for employer-sponsored HI, the federal government will implicitly pay 31.5 cents due to the tax exclusion). This means that $3 billion in other general tax revenues will be needed to offset these revenues needed to cover ACA costs.
  • Book, Robert (February 2014)Impact of the Health Insurance “Annual Fee” Tax (2.20.14)The “annual fee” tax on health insurers will result in a premium increase of $60 to $160 per person in 2014, rising to $100-$300 by 2018, for the average insured individual — and over $260 per family in 2014, rising to over $450 in 2018, for families with employer-sponsored, fully-insured coverage. This amount will increase over time with the amount of the tax, even before taking into account the increased incentives for employers to switch to self-insurance, and the possibility that the higher premiums will induce some customers to forgo insurance. Both of these factors will increase the average tax paid by those who remain insured.
  • Meerschaert, John D. and Mathieu Doucet. ACA Health Insurer Fee: Estimated Impact on State Medicaid Programs and Medicaid Health Plans. Milliman, Inc., January 2014. We estimate the ACA health insurer fee will increase Medicaid managed care payments by about 1.2% in 2014 and increasing to about 1.6% thereafter on a nationwide basis, with some states expected to see increased payments of up to 2.8% in a particular year. Given Medicaid managed care profit margins were less than 2% in CY 20121, increases of this magnitude are meaningful. We project the state and federal government funding for the increase in Medicaid managed care payments related to the ACA health insurer fee will be between $36.4 billion and $39.3 billion over ten years, with between $13.3 billion and $13.9 billion of the total funding paid by state governments.
  • The Business Council (December 2013). 12.2.13. The Health Insurers Tax (HIT) becomes effective on Jan. 1, 2014.  The final rule sets explicit revenues that the tax must generate each year, beginning with $8 billion in 2014. The government will collect $11.3 billion from the HIT in 2015 and 2016; $13.9 billion in 2017; and $14.3 billion in 2018, a total of $58.8 billion over five years. Thereafter, the tax will be increased subject to premium growth. For the average family, the tax will add $270 to premiums in 2014, $400 in 2016 and $5,080 over the next decade.
  • Chow, Michael (March 2013).  Effects of the PPACA Health Insurance Premium Tax on Small Businesses and Their Employees: An Update. 3.19.13. Estimates predict the tax will raise the cost of employer-sponsored insurance by 2% – 3%, imposing a cumulative cost of nearly $5,000 per family by 2020. The NFIB Research Foundation’s BSIM model suggests that such price increases will reduce private sector employment by 146,000 to 262,000 jobs in 2022, with 59 percent of those losses falling on small business.
  • Oliver Wyman (November 2012).  Annual Tax on Insurers Allocated by State (November 2012).  This new analysis shows that averaged over 10 years, the annual cost of the premium tax will be:
    • $514 per year (individual), $688 per year (small group), and $719 per year (large group) for family coverage;
    • $360 per year for each senior with Medicare Advantage; and
    • $152 per year for each Medicaid enrollee.
  • Oliver Wyman (October 2011). Chris Carlson. Estimated Premium Impacts of Annual Fees Assessed on Health Insurance Plans (10.31.11).
    • This analysis estimates that HIT tax “will increase premiums in fully insured coverage markets on average by 1.9% to 2.3% in 2014,” and by 2023 “will increase premiums 2.8% to 3.7%.”
    • In the individual (nongroup) market, the tax will increase premiums by $2150 (individual) and $5080 (family) over 10 years starting in 2014.
    • In the small group market, the tax will increase premiums by $2760 (individual) and $6830 (family) over 10 years starting in 2014.
    • In the large group market, the tax will increase premiums by $2610 (individual) and $7130 (family) over 10 years starting in 2014.
    • Medicare Part C premiums will rise $220 in 2014, reaching $450 by 2023 and $3590 over 10 years. Medicare Part D premiums will rise $9 in 2014 and $20 by 2023 for a total increase of $161 over 10 years.
    • Medicaid managed care premiums will increase by $80 in 2014, $200 by 2023, $1,530 over 10 years.
  • AHIP (October 2011).  AHIP Issue Brief:  Premium Tax—Ending the Sales Tax on Health Insurance That Raises Costs for Families, Small Businesses, Seniors, State Governments, and Taxpayers (October 2011).
  • Holtz-Eakin, Douglas (March 2011). Higher Costs and the Affordable Care Act: The Case of the Premium Tax. American Action Forum. 3.9.11. This short paper examines in detail the likely insurance and economic impact of the fees levied on U.S. health insurance companies. They conclude that the structure of the fees will substantially raise premiums for small businesses and households. Between 2014-2019 tax will increase premiums by 2.4% to over 3%. A 3% increase would amount to nearly $5,000 per family over a decade.
  • Haislmaier, Edmund (December 2009).  Cost of the Insurance Premium Tax to Individuals and Families. Heritage Foundation. 12.9.09.

Excise Tax on Comprehensive Health Insurance Plans (Cadillac Tax) (2018)

Patient-Centered Outcomes Research Trust Fund Fee (2012-2019)

Blue Cross/Blue Shield Tax (2010)

Limitation of Excessive Remuneration Paid By Certain Health Insurance Providers (2010)

Taxes on Non-health Industries Ultimately Borne by Families

Elimination of Cellulosic Biofuel Producer Credit for “Black Liquor” (2010)

Codify Economic Substance Doctrine (2010)

Excise Tax on Indoor Tanning Services (2010)

  • Summary. This 10% excise tax replaced the PPACA Section 9017 tax of 5% on elective cosmetic surgery procedures (pp. 2004-2006). A 10-percent excise tax on indoor UV tanning services went into effect on July 1, 2010.  The tax doesn’t apply to phototherapy services performed by a licensed medical professional on his or her premises. There’s also an exception for certain physical fitness facilities that offer tanning as an incidental service to members without a separately identifiable fee.
  • Details.  PPACA Section 9017 as modified by Section 10907, pp. 2397-2399Effective 7.1.10. For more information on the tax and how it will be administered, see IRS news releasevideoquestions and answers and legal guidance.
  • Revenue. From 2010-2019: $2.7B.; from 2013-2022: $1.4B.

Research and Analysis (Multiple Taxes)



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