Comments
for the Record
United
States House of Representative
Committee on Ways and Means
Protecting
Americans with Pre-Existing Conditions
Tuesday, January 29, 2019 - 10:00am
By Michael G. Bindner
Center for Fiscal Equity
Chairman Neal and Ranking Member Brady, thank you for the
opportunity to submit these comments for the record to the Committee. As usual,
let us preface our remarks in the context of our four part tax reform proposal.
•
A Value Added Tax (VAT) to fund domestic military
spending and domestic discretionary spending with a rate between 10% and 13%,
which makes sure very American pays something.
•
Personal income surtaxes on joint and widowed
filers with net annual incomes of $100,000 and single filers earning $50,000
per year to fund net interest payments, debt retirement and overseas and
strategic military spending and other international spending, with graduated
rates between 5% and 25%.
•
Employee contributions to Old Age and Survivors
Insurance (OASI) with a lower income cap, which allows for lower payment levels
to wealthier retirees without making bend points more progressive.
•
A VAT-like Net Business Receipts Tax (NBRT), which
is essentially a subtraction VAT with additional tax expenditures for family
support, health care and the private
delivery of governmental services, to fund entitlement spending and replace
income tax filing for most people (including people who file without paying),
the corporate income tax, business tax filing through individual income taxes
and the employer contribution to OASI, all payroll taxes for hospital
insurance, disability insurance, unemployment insurance and survivors under age
60.
The key issue for patients is the impact of pre-existing
condition reforms on the market for health insurance. If people start dropping
insurance until they get sick – which is rational given the repeal of mandates
– and Congress does nothing private sector health insurance will be lost. This
will require a bailout.
Resorting to catastrophic insurance with health savings
accounts (another Republican proposal) would not work as advertised, as health
care is not a normal good. While mandates could be replaced with a single payer
catastrophic system, it will work.
People will obtain health care upon doctor recommendations,
regardless of their ability to pay. Providers will then shoulder the burden of
waiting for health savings account balances to accumulate – further encouraging
provider consolidation. Existing trends toward provider consolidation will
exacerbate these problems, because patients will lack options once they are in
a network, giving funders little option other than paying up as demanded.
In what seems counter-intuitive, with the repeal of mandates,
should coverage for the poor decline, the best option is to also repeal pre-existing condition reforms. The only way
to stop this from happening is to enact a subsidized public option for those
with pre-existing conditions. I could end here except that enacting a public
option opens wide the issue of funding.
Shifting to more public funding of health care in response to
future events is neither good nor bad. Rather, the success of such funding
depends upon its adequacy and its impact on the quality of care – with
inadequate funding and quality being related.
Ultimately, fixing health care reform will require more
funding, probably some kind of employer payroll or net business receipts tax –
which would also fund the shortfall in Medicare and Medicaid (and take over
most of their public revenue funding). We will now move to an analysis of
funding options and their impact on patient care and cost control.
The committee well understands the ins and outs of increasing
the payroll tax, so I will confine my remarks to a fuller explanation of Net
Business Receipts Taxes (NBRT). Its base is similar to a Value Added Tax (VAT),
but not identical.
Unlike a VAT, an NBRT would not be visible on receipts and
should not be zero rated at the border – nor should it be applied to imports.
While both collect from consumers, the unit of analysis for the NBRT should be
the business rather than the transaction. As such, its application should be
universal – covering both public companies who currently file business income
taxes and private companies who currently file their business expenses on
individual returns.
The key difference between the two taxes is that the NBRT would
be the vehicle for distributing tax benefits for families, particularly the
Child Tax Credit, the Dependent Care Credit and the Health Insurance Exclusion,
as well as any recently enacted credits or subsidies under the ACA. In the
event the ACA is reformed, any additional subsidies or taxes should be taken
against this tax (to pay for a public option or provide for catastrophic care
and Health Savings Accounts and/or Flexible Spending Accounts).
The NBRT would replace corporate income taxes and proprietary
and pass through taxes and treat all business income the same. It would provide
for a public option, the health insurance exclusion or fund single payer
insurance.
The NBRT would replace disability insurance, hospital
insurance, the corporate income tax, business income taxation through the
personal income tax and the mid-range of personal income tax collection.
Collection of this tax would lead to a reduction of gross
wages, but not necessarily net wages – although larger families would receive a
large wage bump, while wealthier families and childless families would likely
receive a somewhat lower net wage due to loss of some tax subsidies and because
reductions in income to make up for an increased tax benefit for families will
likely be skewed to higher incomes. For this reason, a higher minimum wage is
necessary so that lower wage workers are compensated with more than just their
child tax benefits.
For further cost
savings under an NBRT, allow companies to offer services privately to both
employees and retirees in exchange for a substantial tax benefit. Employers who
fund catastrophic care would get an even higher benefit, with the proviso that
any care so provided be superior to the care available through the public
option.
Companies who hire their own doctors and pharmacists and buy
their own drugs would get a tax exclusion from single payer (third party
insurance would be discouraged), and would negotiate with drug makers for lower
prices, although this would leave small firms at a distinct disadvantage and
would discourage such practices as franchising and 1099 employment. Still, on
the whole, it would decrease cost while not discouraging innovation. Expanding
the Uniformed Public Health Service into the Medicare and Medicaid markets
(edging out HMOs) would also lead to cost cutting on drugs.
This proposal is probably the most promising way to decrease
health care costs from their current upward spiral – as employers who would be
financially responsible for this care through taxes would have a real incentive
to limit spending in a way that individual taxpayers simply do not have the
means or incentive to exercise. While not all employers would participate,
those who do would dramatically alter the market. In addition, a kind of
beneficiary exchange could be established so that participating employers might
trade credits for the funding of former employees who retired elsewhere, so
that no one must pay unduly for the medical costs of workers who spent the
majority of their careers in the service of other employers.
Employer provided health care will also reverse the trend
toward market consolidation among providers. The extent to which firms hire
doctors as staff and seek provider relationships with providers of hospital and
specialty care is the extent to which the forces of consolidation are overcome
by buyers with enough market power to insist on alternatives, with better care
among the criteria for provider selection.