January 18 update. The National Taxpayer Advocate has released their 2016 Annual Report to Congress. The report contains data regarding premium tax credit (PTC) and individual shared responsibility payment (ISRP) filings, but these data are not as up-to-date as recent data released by IRS Director Koskinen, reported earlier on Health Affairs Blog and are not reported here.

The report identifies a number of issues that the IRS has faced or is facing involving the ACA and makes a number of recommendations. These include:

  • The IRS seems to have largely addressed early problems with ISRP overpayments through outreach conducted to tax practitioners and software providers.
  • Reconciliation of PTCs with advance PTCs (APTCs) continues to cause problems, and has risen to the fourth highest category of Taxpayer Advocacy Service cases, accounting for nearly 11,000 cases in 2016. The primary problem seems to be the IRS holding up processing of returns when taxpayers fail to file a form 8962 and reconcile their advance PTC with their PTC.
  • Processing of tax filings is delayed when APTC recipients incorrectly file form 1040-E, which does not allow for APTC reconciliation.
  • The IRS is taking action to address “silent returns,” which do not either check the box indicating full-year coverage, claim an ISRP exemption, or pay the ISRP tax. The IRS will send a letter 12C requesting more information in these cases and assess the ISRP if no response is forthcoming.
  • The Taxpayer Advocate recommends that the IRS should ease the burden on individuals claiming the religious exemption by allowing individuals exempt from the Social Security and Medicare taxes to simply indicate this on their form 8965 rather than requiring them to apply separately for an ISRP religious exemption.
  • The Taxpayer Advocate recognizes that taxpayers who receive large Social Security Disability Payments may have to repay APTC received. There is no apparent administrative fix for this problem.
  • The IRS needs to provide specialized training to its newly established ACA Business Exam unit, which handles employer ACA returns.
  • The IRS may not be adequately prepared to handle ACA employer filings. It had expected 77 million 1095-Cs for 2016 and got 104 million, with 5.4 percent rejected.

Original Post. On January 17, 2017, the Congressional Budget Office—Congress’ nonpartisan scorekeeper—released a report on how the enactment of reconciliation legislation to repeal the Affordable Care Act (ACA) similar to that adopted by Congress in 2015 (and vetoed by President Obama) would affect health insurance coverage and premiums.

The report assumes that reconciliation legislation would repeal the individual mandate penalties and then, after a delay of two years, the premium tax credits and Medicaid expansions. The CBO further assumes that the legislation would leave intact the ACA’s insurance reforms, which presumably cannot be amended through reconciliation under the Senate’s reconciliation rules. These include the ACA’s essential health benefit and actuarial value requirements; its limitations on health status underwriting and pre-existing condition exclusions; and its rating requirements that allow premiums to vary only based on age, geographic locations, and tobacco use.

The CBO projects that the repeal legislation would not have an immediate dramatic effect in 2017 because premium increases would already be established and enrollment set for 2017. In 2018, however, 18 million people would become uninsured, including 10 million fewer enrollees in the nongroup (or individual) insurance market, 5 million fewer with Medicaid coverage, and 3 million fewer with employment coverage. These increases would be due to a combination of people dropping coverage because it was no longer mandated and to insurers abandoning the nongroup market and increasing premiums because of adverse selection concerns. As of 2018, insurers would increase premiums by 20 to 25 percent and about 10 percent of the population in areas where no insurers were available in the nongroup market.

In the year following the repeal of the Medicaid expansions and premium tax credits, the number of people without health insurance would grow to 27 million, further increasing to 32 million by 2026. If Congress repealed the insurance reforms as well, the number of uninsured people would only grow to 21 million in the year following repeal and to 23 million by 2026 (although coverage would be less comprehensive and individuals with pre-existing conditions may be unable to find coverage). The increase in the uninsured of 32 million would be the net result of 23 million fewer nongroup market enrollees, 19 million fewer covered by Medicaid, and 11 million more enrolled in employer coverage. In total, 59 million would be uninsured; 21 percent of the population.

CBO projects that the repeal of the individual mandate, premium tax credits, and Medicaid expansions would destabilize the nongroup market and that the destabilizing effects would worsen over time. In the first year after the repeal of the marketplace subsidies took place, nongroup market premiums would increase by 50 percent relative to current law projections and about half of the population would live in states with no insurer participation in the nongroup market. By 2026, nongroup market premiums would double and three-quarters of the population would live in states with no insurers in the nongroup market. Fewer than 2 million people would have nongroup market coverage.

Of course, if Congress replaces the ACA’s provisions with others—such as fixed-dollar tax credits, continuous coverage requirements, or high-risk pools–these numbers would change. If Congress moves forward on legislation including such replacement provisions (to the extent such provisions can be adopted under reconciliation rules or bipartisan agreement overcomes a filibuster) the CBO will project their consequences as well. But the January 17 CBO report is a sobering reminder that the nongroup insurance market is fragile, and ill-considered action can have devastating results.