House Republicans on the evening of March 6 unveiled their much anticipated Patient Protection and Affordable Care Act (ACA) repeal and replacement legislation. A markup of The American Health Care Act is scheduled in the Ways and Means Committee for Wednesday, March 8. “It is going to be a big week”, House Speaker Paul Ryan’s, R-Wis., press secretary AshLee Strong said on March 6.

The ACA repeal and replacement legislation will repeal most of the ACA-related taxes, as well as eliminate the individual and employer mandate penalties. It will, however, retain the controversial Cadillac Tax, though delaying it until 2025. Additionally, the measure would provide a monthly tax credit between $2,000 and $4,000 a year (per individual and capped at $14,000 per family) to assist certain individuals to purchase coverage.

“This is a plan we are all working on together – the House, Senate, White House – so there aren’t rival plans here. We are all working on this together with the administration,” Ryan said on March 6 before release of the bill. Senate Finance Committee ranking member Ron Wyden, D-Ore., however, criticized the legislation minutes after it was released, saying, “We will fight this.”

Four Senate Republicans sent a March 6 letter to Senate Majority Leader Mitch McConnell, R-Ky., saying they would not support an ACA replacement bill that did not offer key protections for Medicaid expansions. The senators, including Sens. Rob Portman, R-Ohio and Shelley Moore Capito, R-W.V., wrote that while they support efforts to repeal and replace the ACA, they would not support a bill that mirrored the leaked draft healthcare bill. The potential loss of at least two of these four Republican votes could prevent an ACA repeal and replacement bill’s passage, pulling from the requisite 51 votes in the Senate.

Specific Provisions

House Republicans, in a summary released with the bill, explained that the bill would:

  • -Dismantle ACA taxes, including taxes on prescription drugs, over-the-counter medications, health-insurance premiums, and medical devices.
  • -Eliminate the individual and employer mandate penalties
  • -Prohibit health insurers from denying coverage or charging more for pre-existing conditions. Allow dependents to continue staying on their parents’ plan until they are 26.
  • -Establish a Patient and State Stability Fund.
  • -Revise Medicaid by transitioning to a “per capita allotment.”
  • -Enhance and expand Health Savings Accounts (HSAs)
  • -Provide a monthly tax credit, between $2,000 and $14,000 a year, for low- and middle-income individuals and families not insured through work or a government program.
  • Ways and Means Chairman Brady, in a more detailed summary of the tax provisions within the bill, subtitled “Repeal and Replace of Health-Related Tax Policy,” covered the following:
  • Section 1: Recapture Excess Advance Payments of Premium Tax Credits. For tax years 2018 and 2019, any individual who was overpaid in premium tax credits would be required to repay the entire excess amount, regardless of income.
  • Section 2: Additional Modifications to Premium Tax Credit. The bill would make available premium tax credits for the purchase of “catastrophic-only” qualified health plans and certain qualified plans not offered through an Exchange.
  • Section 3: Premium Tax Credit. The bill would repeal the premium tax credit beginning in 2020.
  • Section 4: Small Business Tax Credit. The bill would repeal the small business tax credit beginning in 2020.
  • Section 5: Individual Mandate. The bill would effectively repeal the individual mandate, for months beginning after December 31, 2015.
  • Section 6: Employer Mandate. The bill would effectively repeal the employer mandate for months beginning after December 31, 2015.
  • Section 7: Repeal of Tax on Employee Health Insurance Premiums and Health Plan Benefits. The tax on “Cadillac” plans would apply only for tax periods beginning after December 31, 2024.
  • Section 8: Repeal of Tax on Over-the-Counter Medications. Tax-advantaged health savings accounts may help pay or be reimbursed for over-the-counter medications, effective beginning in 2018.
  • Section 9: Repeal of Tax Increase on Health Savings Accounts. The bill would lower the penalty rate on distributions from an HSA or Archer MSA that are not used for qualified medical expenses.
  • Section 10: Repeal of Limitations on Contributions to Flexible Savings Accounts. The $2,500 annual limitation on health FSA contributions would be repealed for tax years beginning after December 31, 2017
  • Section 11: Repeal of Medical Device Tax. The 2.3 percent excise tax on the sale of certain medical devices would be repealed for tax beginning after December 31, 2017.
  • Section 12: Repeal of Elimination of Deduction for Expenses Allocable to Medicare Part D Subsidy. The bill would reinstate the business-expense deduction for retiree prescription drug costs for tax years beginning after December 31, 2017.
  • Section 13: Repeal of Increase in Income Threshold For Medical Expense Deduction. The bill would rollback the AGI percentage threshold for the itemized medical expense deduction to 7.5 percent from 10 percent, starting in 2018, but would be applicable to taxpayers aged 65 or older immediately.
  • Section 14: Repeal of Medicare Tax Increase. The bill would repeal the Medicare Hospital Insurance (HI) surtax based on higher income at a rate equal to 0.9 percent of an employee’s wages or a self-employed individual’s self-employment income, beginning in 2018.
  • Section 15: Refundable Tax Credit for Health Insurance. This section creates an advanced, refundable tax credit for the purchase of state-approved, major medical health insurance and unsubsidized COBRA coverage. To be eligible, generally, an individual must not have access to government health insurance programs or an offer from any employer. The credit ranges from $2,000 for those under age 30 to $4,000 for those over 60. The credit is additive for a family and capped at $14,000.
  • Section 16: Maximum Contribution Limit to Health Savings Account Increased to Deductible and Out-of-Pocket Limitation. The basic limit for HSA contributions would be at least $6,550 in the case of self-only coverage and $13,100 in the case of family coverage, beginning in 2018.
  • Section 17: Allow Both Spouses to Make Catch-Up Contributions. This section would effectively allow both spouses to make catchup contributions to one HSA, beginning in 2018.
  • Section 18: Special Rule For Certain Medical Expenses Incurred Before Establishment Of HSA. The bill sets forth certain circumstances under which HSA withdrawals can be used to pay qualified medical expenses incurred before the HSA was established. Starting in 2018, if an HSA is established during the 60-day period beginning on the date that an individual’s coverage under a high deductible health plan begins, then the HSA is treated as having been established on the date coverage under the high deductible health plan begins for purposes of determining if an expense incurred is a qualified medical expense.

Repeal of Tanning Tax

The bill would repeal the 10 percent sales tax on indoor tanning services, starting in 2018.

Repeal of Net Investment Tax

The bill would repeal the 3.8 percent net investment tax, applied to higher-income individuals, estates, and trusts, starting in 2018.

Remuneration From Certain Insurers

The bill would repeal the $500,000 limit on the deduction of a covered health insurance provider for compensation attributable to services performed by an applicable individual starting in 2018.