One of these Ryan budget proposals—as yet little noticed by pundits or politicians—is almost an exact copy of its equivalent in the Affordable Care Act. It would repeal the current exclusion from employees’ income of employer contributions to their health insurance premiums, thus terminating the subsidized employer-sponsored group health regime that covers nearly 60 percent of all Americans. In its place, the Republican plan would substitute a refundable tax credit, to be provided to individuals who purchase health insurance (or to employers who purchase health insurance for their employees). When this new arrangement takes effect in 2022, the tax credit would be set at $2,300 per adult and $1,700 per child, not to exceed $5,700 per family.
Like this Ryancare tax incentive, the “individual mandate” section of the ACA, which the White House calls the “individual responsibility” provision, constitutes a pay-or-play option. Beginning Jan. 1, 2014, when the ACA provision takes effect, individuals who do not qualify for exemption on hardship or other specified grounds, must either carry health insurance or pay a tax penalty as part of their annual income tax filing. The ACA caps individuals’ penalty liability at 2.5 percent of household income above the filing threshold, or a flat dollar amount ranging from $695 to $2,085, depending on family size.Under both provisions, the result is the same: People who choose to carry health insurance have a lower tax bill than they would if they chose not to. In terms of their respective potential impact on individuals’ bank accounts and tax liability, the manner in which they affect individuals’ financial incentives, and hence the constraining effect on individuals’ financial choices to either buy or forgo health insurance, the two “mandate” provisions are identical. (Indeed, in most cases, the financial difference for the individual taxpayer made by the Republican tax credit would be greater—i.e., more “coercive”—than the ACA tax penalty.)
In addition to cloning the ACA’s framework for coverage of adults under 65, the Ryan budget would also apply a similar approach to Americans currently covered by Medicare. Beginning in 2021, former Medicare-eligibles would receive a voucher they can apply to the purchase of private insurance. According to the Congressional Budget Office, the vouchers would be worth approximately $6,000 for recipients age 65, and would be greater for older recipients, averaging $11,000 across the entire Medicare population. Of course, Americans would be required to continue to pay their annual Medicare tax throughout their working lives. Hence, the Republicans’ proposal to replace Medicare with partially subsidized private insurance also operates to “compel” people to pay for private health insurance policies. Moreover, this mandate is not even a pay-or-play option; Medicare taxes are mandatory, whether workers want to buy eligibility for old-age vouchers or not.