BACKGROUND MATERIALS FOR SENATE COMMITTEE ON 

FINANCE ROUNDTABLE ON HEALTH CARE FINANCING

Before the

SENATE COMMITTEE ON FINANCE

on May 12, 2009

Prepared by the Staff

of the

JOINT COMMITTEE ON TAXATION

May 8, 2009

JCX-27-09
i

CONTENTS

Page

I. OVERVIEW ............................................................................................................................. 1

II. EMPLOYMENT RELATED TAX EXPENDITURES............................................................ 5

A. Employer-Provided Health Care......................................................................................... 5

B. Deduction for Health Insurance Premiums of Self-Employed Individuals...................... 19

III. OTHER PRESENT LAW HEALTH CARE TAX EXPENDITURES .................................. 21

A. Itemized Deduction for Medical Expenses....................................................................... 21

B. HSAs and Archer MSAs................................................................................................... 24

C. Refundable Credit for Health Insurance Expenses of Certain Classes of Individuals...... 28

1. Health insurance tax credit.......................................................................................... 28

2. COBRA continuation coverage premium reduction................................................... 29

IV. PRESIDENT’S FISCAL YEAR 2010 BUDGET PROPOSAL TO LIMIT THE RATES

AT WHICH TAXPAYERS MAY BENEFIT FROM ITEMIZED DEDUCTIONS.................... 31

V. THE VALUE OF TAX EXEMPTION FOR TAX-EXEMPT HOSPITALS......................... 39

APPENDIX A: COMPARISON OF PRESENT-LAW TAX BENEFITS FOR HEALTH 

EXPENSES................................................................................................................................... 43

APPENDIX B: COMPARISON OF VALUE OF HEALTH TAX BENEFITS: 

NON-HIGH-DEDUCTIBLE HEALTH PLAN............................................................................ 46

APPENDIX C: COMPARISON OF VALUE OF HEALTH TAX BENEFITS:

HIGH-DEDUCTIBLE HEALTH PLAN...................................................................................... 47
1

I. OVERVIEW

The Senate Committee on Finance has scheduled a roundtable on health care financing 

for May 12, 2009. As background for this roundtable, at the request of Chairman Baucus, the 

staff of the Joint Committee on Taxation has prepared background material relating to presentlaw tax expenditures related to health care and the Administration’s fiscal year 2010 budget

proposal to reduce the value of itemized deductions claimed by certain taxpayers. 1

The Internal Revenue Code

 The 

Administration’s proposal is intended to offset the cost of health care reforms. 

2 includes a number of significant tax expenditures for health 

expenses.3

1. Is the individual covered under an employer-provided health plan?

 The availability of these different benefits depends in part on the answers to the 

following questions:

2. Does the individual have self-employment income?

3. Does the individual itemize deductions and have medical expenses that exceed a 

certain threshold?

4. Is the individual covered by a high-deductible health plan?

Table 1 shows estimates of the tax expenditures for the health care sector in 2008. The 

largest tax expenditure is for employer-provided health care benefits. The remaining tax 

expenditures, such as the self-employment exclusion and the deduction for medical expenses 

greater than 7.5 percent of adjusted gross income, were each less than $11 billion, while the 

estimated tax expenditure for health savings accounts was less than $1 billion.

 1

 This document may be cited as follows: Joint Committee on Taxation, Background Materials 

for Senate Committee on Finance Roundtable on Health Care Financing, (JCX-27-09), May 8, 2009. 

This document is available at www.jct.gov. 

2

 Unless otherwise indicated, all section references are to the Internal Revenue Code of 1986, as 

amended (the “Code”). 

3

 Appendix A compares in tabular form the various tax provisions that mitigate the costs of 

health care under present law. 
2

Table 1.−Selected Tax Expenditures for Health, 2008

Billions

of

Value of Tax Expenditures Dollars

Exclusion of employer sponsored health care............................................................................ 226.2

Income .................................................................................................................. 132.7

FICA....................................................................................................................... 93.5

Exclusion of Medicare benefits from income .............................................................................. 41.8

Hospital Insurance (Part A).....................................................................................21.3

Supplemental Medical Insurance (Part B).............................................................. 14.9

Prescription Drug Insurance (Part D)........................................................................4.4

Exclusion of subsidies to employers who maintain prescription drug plans............ 1.1

Deduction for medical expenses above 7.5% of adjusted gross income...................................... 10.7

Self-employed health insurance deduction .................................................................................... 5.2

Exclusion of medical care and TRICARE insurance for military dependents and retirees not 

enrolled in Medicare................................................................................................................... 2.1

Exclusion of health insurance benefits for military retirees enrolled in Medicare ........................ 1.2

Health savings accounts................................................................................................................. 0.5

Health Coverage tax credit............................................................................................................. 0.1

Source: JCT Staff calculations.

The presentation in Table 1 differs from conventional estimates of tax expenditures in 

two respects. First, these estimates do not include the effects of “tax form behavior.” In 

particular, conventional expenditure estimates prepared by the Staff of the Joint Committee on 

Taxation (the “JCT Staff”) assume that when taxpayers are denied an exclusion for employer 

sponsored insurance, they can deduct premiums under section 213 to the extent that their 

expenses exceed 7.5 percent of adjusted gross income. By contrast, the estimates in Table 1 

assume that, if the exclusion for employer sponsored health insurance were repealed, employees 

would not be permitted to take into account the insurance premiums towards the section 213 

medical expense deduction. In addition, conventional tax expenditure estimates are calculated 

only with respect to their effect on income taxes, and thus do not include payroll tax under the 

Federal Insurance Contribution Act (“FICA”) effects. The estimate for the FICA effects of the 

employer exclusion in Table 1 does not reflect the effects of changes in current FICA liability on 

the present value of taxpayers’ future social security benefits. Finally, unlike revenue estimates, 

neither the estimates in Table 1 nor conventional tax expenditure estimates assume other 

behavioral responses by taxpayers. The expenditure for Health Coverage Tax Credit (“HCTC”) 

is expected to increase in 2009 due to the enactment of the TAA Health Coverage Improvement 

Act of 2009 (Pub. L. No. 111-5) that increased the coverage per eligible individual and the 

number of individuals eligible for the credit.4

 4

 Joint Committee on Taxation, Tax Expenditures for Health Care (JCX-66-08), July 31, 2008.

 
3

The exclusion of employer sponsored health care had a value of $226 billion with $133 

billion coming from exclusion from the income tax and $93 billion from excluding the value of 

health insurance from both the employer and employee portions of the Federal Insurance 

Contribution Act FICA tax.

The most favorable tax treatment under present law generally is provided to individuals 

who are in an employer plan where the employer pays the premium.5 Such individuals may 

exclude from income and wages employer-provided health insurance. Depending on the 

employer’s plan, they may also exclude from income some amounts expended for medical care 

not covered by insurance. Self-employed individuals receive the next most favorable treatment. 

They may deduct 100 percent of the cost of their health insurance from their income tax, but they 

may not deduct their health insurance premiums from their payroll tax base.6

There are significant non-tax advantages to operating through the employer-provided 

system. Providing health insurance coverage through a large group provides significant savings 

because of risk mitigation and lower administrative costs. Employers typically have superior 

negotiating power, compared to individual consumers, in negotiating the terms of insurance 

coverage with insurers. In addition, a group system mitigates the problems of adverse selection 

because the formation of employer groups is not highly correlated with health status. This 

results in a relatively even distribution of individuals who are high-risk and may have trouble 

finding affordable health insurance in the individual market. The combination of tax and 

economic advantages of employer-provided health care has resulted in the employer-provided 

system providing the vast majority of health care coverage, resulting in the large tax expenditure 

seen in Table 1 for employer-provided health care.

 In the case of the 

employer-provided exclusion and the self-employed deduction, there is no cap on the tax benefit 

that would limit the generosity of health plans that can be purchased with pre-tax dollars. The 

tax benefit is only subject to the limitation that the health benefits covered must fall under the 

definition of medical care in section 213(d). Present law also provides additional, less 

significant, tax expenditures for other health care benefits.

Nevertheless, the current system of providing a tax subsidy for employer-provided health 

care with no or little subsidy in the case of insurance purchased outside of the employer market 

distorts taxpayer and market behavior. The existence of the subsidy reduces the price of the 

consumption of health care, leading to overconsumption of health care relative to other goods 

 5

 The refundable HCTC provides a greater tax benefit than the exclusion. Fewer than one-half 

million taxpayers per year, however, are estimated to be eligible for the credit. Similarly, certain 

individuals are temporarily able to purchase health insurance at a reduced premium due to an employer 

tax credit for a portion of their COBRA eligibility period under the provision of the Consolidated 

Omnibus Reconciliation Act of 1985.

6

 In addition, where applicable, the deduction for self-employed individuals is taken after 

eligibility for the Earned Income Tax Credit (“EITC”) has been calculated. In contrast, an employee’s 

earned income for purposes of the EITC is determined after the exclusion of the value of employer 

provided health insurance. 
4

and services for those taxpayers with qualifying plans, and a comparative disadvantage for those 

purchasing health insurance in the individual market. 
5

II. EMPLOYMENT RELATED TAX EXPENDITURES

A. Employer-Provided Health Care

In general

The Code generally provides that an employee may exclude from his or her gross income 

the value of employer-provided health care. Income generally is defined to include 

compensation paid to a service provider in any form, whether in cash or in kind. The value of 

health insurance that an employer purchases for its employees constitutes compensation to each 

covered employee in this general sense. The exclusion therefore represents a departure from the 

Code’s general tax principle that compensation should be included in income; the exclusion for 

employer-provided health care is the largest tax expenditure under the current tax system. The 

tax expenditure for the exclusion for employer-provided health care is estimated to be $226.2 

billion for 2008, using the methodology described in connection with Table 1. This represents 

by far the largest portion of the total tax expenditures for health and is the third largest health 

expenditure if measured against direct Federal spending, exceeded only by direct expenditures 

for Medicare and Medicaid. 

Table 2.–Calendar Year Tax Benefit from Employer Exclusion by AGI,* 2008

Adjusted Gross Income

Total 

Savings

(millions)

Income Tax 

Savings

(millions)

FICA Tax 

Savings

(millions)

Total Tax 

Returns

(thousands)

Average 

Savings Per 

Return

(dollars)

< 10,000 3,620 (269**) 3,889 5,698 635

10,000 – 29,999 34,423 17,779 16,644 17,631 1,952 

30,000 – 49,999 42,667 22,697 19,970 17,369 2,457 

50,000 – 74,999 46,052 24,716 21,336 14,879 3,095 

75,000 – 99,999 37,055 22,110 14,945 9,502 3,900 

100,000 – 199,999 48,060 33,962 14,098 10,726 4,481 

200,000 – 499,999 11,645 9,549 2,096 2,463 4,728 

> 500,000 2,680 2,182 498 600 4,467 

Total 226,202 132,726 93,476 78,868 2,868

* See discussion immediately following Table 1 for the methodologies applied in calculating the value of this 

exclusion. Table 2 reflects both income and FICA tax distributional consequences. 

** Negative amounts reflect the fact that the exclusion reduces earned income for purposes of the earned income 

credit, resulting in a decrease in refundable credits for some recipients.

Source: JCT Staff calculations.

Table 2 shows the total savings from the employer exclusion for eight income brackets. 

This table shows that taxpayers with adjusted gross income (“AGI”) less than $50,000 obtain 

cash savings from the exclusion for employer-provided health care valued at between $600 and 

$2,500, while those earning more than $100,000 per year have average cash savings worth 

between $4,000 and $5,000.
6

As with other compensation, the amount paid by an employer for employer-provided 

health care of employees is deductible. Unlike other forms of compensation, however, if an 

employer contributes to a plan providing health coverage for an employee (and his or her spouse 

and dependents), the contribution and all benefits (including reimbursements) for medical care 

under the plan are excludable from the employee’s income for both income and payroll tax 

purposes.7

Active employees participating in a cafeteria plan

 The exclusion applies both in the case in which employers absorb the cost of their 

employees’ medical expenses not covered by insurance (i.e., a self-insured plan) as well as 

employer payments to purchase health insurance. There is no limit on the amount of employerprovided health coverage that is excludable.

8

The Employee Retirement Income Security Act of 1974 (“ERISA”) preempts State law 

relating to certain employee benefit plans, including employer-sponsored health plans.

may pay their share of premiums on a 

pre-tax basis through salary reduction. Such salary reduction contributions are treated as 

employer contributions and thus also are excluded from gross income and wages for payroll 

taxes. 

9

 7

 Secs. 104, 105, 106, 125, and 3121(a)(4). Health coverage provided to active members of the 

uniformed services, military retirees, and their dependents are excludable under section 134. That section 

provides an exclusion for “qualified military benefits,” defined as benefits received by reason of status or 

service as a member of the uniformed services and which was excludable from gross income on 

September 9, 1986, under any provision of law, regulation, or administrative practice then in effect. 

8

 If an employer offers employees a choice between taxable benefits (which include cash 

compensation) and qualified benefits (which include employer-provided accident and health coverage), 

the choice must generally be provided under a cafeteria plan that satisfies the requirements of section 125. 

Otherwise providing this choice may result in income inclusion even if the employee chooses an 

excludable benefit. See sec. 125 and proposed Treas. Reg. secs. 1.125-1 through -7 published in the 

Federal Register on August 6, 2007, 72 FR 43938.

A cafeteria plan must be in writing and must not provide for deferred compensation except as 

specifically provided in section 125(d). Certain excludable benefits are not permitted to be provided in a 

cafeteria plan, including long-term care benefits, contributions to Archer MSAs, qualified scholarships 

under section 117, benefits under educational assistance programs under section 127, and certain fringe 

benefits under section 132. HSA contributions are allowed through a cafeteria plan. If benefits provided 

under a cafeteria plan discriminate in favor of highly compensated participants, any exclusion from 

income for benefits under the plan may not apply to such highly compensated participants. Any qualified 

benefit must also satisfy any specific requirements under the section that allows its exclusion. 

9

 ERISA sec. 514.

 While 

ERISA specifically provides that its preemption rule does not exempt or relieve any person from 

any State law which regulates insurance, ERISA also provides that an employee benefit plan is 

not deemed to be engaged in the business of insurance for purposes of any State law regulating 

insurance companies or insurance contracts. As a result of this ERISA preemption, self-insured 

employer-sponsored health plans need not provide benefits that are mandated under State 
7

insurance law. Further, self-insured employer plans are not subject to State insurance taxes or 

regulation, such as premium taxes imposed on insurance companies under State law.

Unlike tax-qualified pension plans, present law includes few requirements or limitations 

on the design of employer-provided health care plans. In particular, and in contrast to most other 

Federal tax benefits, there is no limitation on the amount of health benefits that an employer can 

provide on a tax-free basis. This effectively allows taxpayers to control the amount of their tax 

benefit. Employer-provided health plans are not required to cover all employees or to provide 

the same benefits to all employees.10

While there are certain restrictions with which group health plans must abide, the Code 

imposes an excise tax on group health plans that fail to meet these requirements.

 In addition, the tax exclusion is not predicated on coverage 

of certain illnesses or conditions. 

11

In addition to offering health insurance (or self-insurance), employers often agree to 

allow employees to fund (or fund themselves) employer sponsored accounts to reimburse some 

of the remaining medical expenses of their employees (and their spouses and dependents). These 

arrangements are commonly used by employers to pay or reimburse employees for medical 

expenses that are not covered by health insurance. These arrangements include health flexible 

spending arrangements (“FSAs”) and health reimbursement arrangements (“HRAs”). 

 The excise 

tax is generally equal to $100 per day during the period of noncompliance and is imposed on the 

employer sponsoring the plan if the plan fails to meet the requirements. 

Health FSAs typically are funded on a salary reduction basis under a cafeteria plan, 

meaning that employees are given the option to reduce their current cash compensation and 

instead have the amount made available for use in reimbursing the employee for his or her 

medical expenses. Health FSAs that are funded on a salary reduction basis are subject to the 

Code’s requirements for cafeteria plans, including a requirement that amounts remaining in a 

health FSA under a cafeteria plan as of the end of a plan year must be forfeited by the employee 

(referred to as the “use-it-or-lose-it-rule”).12

 10 An exception to this general rule applies in the case of self-insured group health plans, which 

must satisfy certain nondiscrimination rules in order for the benefits of highly compensated individuals to 

be excludable. Sec. 105(h). As previously discussed, benefits provided under a cafeteria plan are subject 

to certain nondiscrimination requirements.

11 Secs. 4980B; 4980D.

12 Sec. 125(d)(2). See proposed Treas. Reg. secs. 1.125-1 through -7. However, if a plan 

chooses, a grace period not to exceed two and one-half months immediately following the end of the plan 

year during which unused amounts may be used is allowed. Notice 2005-42, 2005-1 C.B. 1204. Health 

FSAs are subject to certain other requirements, including rules that require that the FSA have certain 

characteristics similar to insurance. 

 If the health FSA under a cafeteria plan meets 

certain requirements, the compensation that is forgone is not includible in gross income or 

wages. Health reimbursement arrangements (“HRAs”) operate in a manner similar to health 

FSAs, in that they are an employer-maintained arrangement that reimburses employees for 
8

medical expenses. Some of the rules applicable to HRAs and health FSAs are similar (e.g., the 

amounts in the arrangements can only be used to reimburse medical expenses and not for other 

purposes), but the rules are not identical. In particular, HRAs cannot be funded on a salary 

reduction basis and the use-it-or-lose-it rule does not apply. Thus, amounts remaining at the end 

of the year may be carried forward to be used to reimburse medical expenses in the next year.13

Unlike the section 213 itemized deduction for medical expenses which (as discussed 

below), in the case of drugs, is limited to prescribed drugs,

 

Unlike a health FSA, an HRA is permitted to reimburse an employee for health insurance 

premiums.

14

 13 Guidance with respect to HRAs, including the interaction of FSAs and HRAs in the case of an 

individual covered under both, is provided in Notice 2002-45, 2002-2 C.B. 93.

14 Under section 213(b), in the case of medicine or drugs, an expenditure is taken into account 

only if it is incurred for a prescribed drug or insulin. 

tax-free reimbursement for nonprescription drugs is permitted in the case of an employer-provided health plan. Thus, for 

example, amounts paid from an FSA, HRA, or health savings account (described later in the 

pamphlet) to reimburse the employee for nonprescription medicines, such as sunscreen, 

nonprescription aspirin, allergy medicine, antacids, or pain relievers, are excludable from 

income. This creates an even greater tax preference for employer-provided health care 

arrangements. 
9

Coverage under employer-sponsored health care 

The vast majority of Americans finance health care through employment-based insurance 

coverage. 

Figure 1.–Health Insurance Coverage Source for the Nonelderly Population, 

2008

[millions of persons]

Employer Sponsored 

Insurance, 163.8

Non-group, 8.4

Self Employed, 6.6

Medicaid and SCHIP, 42.1

Medicare (disability), 5.8

TRICARE, 11.5

Uninsured, 44.2

16.7%

4.3%

2.2%

15.9%

61.8%

2.5%

3.2%

* Total exceeds 100% because individuals may have multiple sources of health insurance coverage.

Source: JCT Staff calculations based on Medical Expenditure Panel Surveys (2001-3), and Internal Revenue 

Service Statistics of Income 2005 data; Congressional Budget Office March 2008 baseline.

All employers do not provide equal access to health insurance. Historically, small 

businesses are far less likely than large businesses to offer health insurance.15

 15 Forty-nine percent of workers in firms with fewer than 10 employees held employment-based 

health insurance while more than 77 percent of employees in firms with more than 100 employees held 

employment-based coverage. Based on Employee Benefit Research Institute analysis of Current 

Population Survey, March, 2008; Paul Fronstin, “Sources of Health Insurance and Characteristics of the 

Uninsured: Analysis of the March 2008 Current Population Survey,” Vol. 321; September, 2008. 

Subsidies for Employment-Related Health Insurance: Estimates for 2006,” Health Affairs Vol. 25 Issue 

6, November/December, 2006 pp. 1568-1579.

 Small businesses 

are more sensitive to price than are large businesses when considering offering health insurance. 

Therefore, if the price of health insurance changes due to a change in the tax treatment of health 
10

insurance, the greatest impact will be seen in the rates at which health insurance is offered by 

small businesses. 

Employer involvement in the purchase of health insurance has both advantages and 

disadvantages in the market. The primary advantage is that health insurance costs less when 

purchased through an employer as compared with the non-group market; non-group insurance is 

more expensive.

The principal reason for the price advantage of group over individual health insurance is 

that insuring a group has less per capita risk than insuring an individual; therefore, the risk 

premium paid to the insurance company is lower. Employer-sponsored health plans provide a 

pooling mechanism that is unrelated to the health status of the insured, which minimizes 

problems with adverse selection into health plans. (Adverse selection refers to the fact that those 

who are most likely to use health care services are the most likely to purchase health insurance.) 

Economies of scale also reduce the administrative costs for group plans, and therefore health 

insurance premiums are lower to this extent for employer plans relative to premiums in the nongroup market.16

Finally, employers generally have superior negotiating power with an insurance company 

than does an individual consumer. Employers may have more experience and sophistication in 

evaluating insurance proposals, can offer much larger blocks of business by virtue of the group 

nature of employer-provided insurance, and may have other business relationships with the 

insurer. 

 As a result, insurance purchased through the group market is less expensive, 

because it is less costly to sell to and maintain one group of several hundred people than to sell 

and maintain hundreds of groups of one to two people. 

There is some recent evidence from the financial services sector that shifting people into 

the individual market would increase the time and effort required to purchase health insurance. 

This may lead to procrastination in obtaining insurance and a temporary or even a permanent rise 

in the rate of uninsurance. Complexity of choice, paired with the absence of a deadline for 

acquiring insurance, will likely lead to delays in the purchase of insurance. 17

 16 A Congressional Research Service Report from 1988 found that insurance in small groups 

(fewer than five members) cost 40 percent more than in large groups (more than 10,000 members). 

Congressional Research Service, Costs and Effects of Extending Health Insurance Coverage, 1988.

17 Research on retirement plans finds that as the number of investment options increased by 10, 

participation declined by 1.5 to 2 percentage points. S.S. Iyengar, G. Huberman, and W. Jiang. “How 

Much Choice Is Too Much?: Contributions to 401(k) Retirement Plans,” in Olivia Mitchell and Stephen 

Utkus, eds., Pension Design and Structure: New Lessons from Behavioral Finance (Oxford, UK: Oxford 

University Press, 2004): pp. 83-96.

 These complexity 

problems were seen by some American seniors after the release of the Medicare Part D plans in 

2004, which required many seniors to choose a prescription drug plan in order to optimize 
11

prescription drug benefits. There were reports that, with so many complicated options, many 

seniors had difficulty choosing a plan.18

Some have argued that employers are good agents for their employees and provide 

invaluable research into the appropriate health plans to offer. The employer acts as an agent to 

limit and guide choice. The open enrollment period, which is a limited time window when 

insurance can be chosen, prevents excessive procrastination before purchase. 

Although the individual market is at a cost disadvantage relative to the employer market 

for health insurance, it provides greater choice for health insurance coverage. This said, only one 

percent of those offered employer insurance decline it and purchase insurance in the individual 

market.19

Some employees may feel locked into their current jobs because switching to a different 

employer could result in a loss of their current health coverage. Despite the protection provided 

by the Health Insurance Portability and Accountability Act (“HIPAA”) for pre-existing 

conditions,

 

20 an employee who has insurance with a certain level of coverage for a specific 

condition through his or her current employer may nevertheless lose that level of coverage if the 

employee were to move to a new job because the new employer’s health plan does not cover that 

condition or does not provide the same level of coverage for the condition. Even if the health 

plan is substantially identical, the employee might be concerned that the new job might not work 

out, and the employee might become unemployed resulting in a loss of coverage or the potential 

for significantly higher premium costs. The resulting labor market inefficiency is commonly 

referred to as “job lock,” where individuals remain with employers to maintain their current 

health insurance when their preference is to leave the workforce or find new work.21

 18 John Leland, “73 Options for Medicare Plan Fuel Chaos, Not Prescriptions,” New York Times, 

May 14, 2004. Jack Hoadley, “Medicare Part D: Simplifying the Program and Improving the Value of 

Information for Beneficiaries,” The Commonwealth Fund: May, 2008.

19 Congressional Budget Office, “CBO’s Health Insurance Simulation Model: A Technical 

Description,” October 2007. 

20 Although a group health plan sponsored by an employer is limited by HIPAA in its ability to 

impose a pre-existing condition exclusion on a plan participant, a plan is permitted to exclude conditions 

diagnosed within the six-month period ending on enrollment in the plan, provided that the exclusion 

generally may not extend for longer than 12 months (18 months in the case of certain late enrollees in the 

plan) and the maximum exclusion period must be reduced by the participant’s aggregate periods of 

“creditable coverage.” Creditable coverage includes a participant’s coverage under a group health of a 

prior employer provided that there is no more than a 63 day gap in coverage between the new plan and the 

old plan. Sec. 9801.

21 Evidence of job lock in the literature is mixed, with some papers finding health insurance 

decreasing mobility, some papers finding no effect and some papers finding an effect only under certain 

specifications. Brigitte C. Madrian, “The U.S. Health Care System and Labor Markets,” National Bureau 

of Economic Research, Working Paper # 11980, January 2006.

 There are 

other examples of job lock. Job lock may prevent an individual from leaving a large employer 
12

that offers insurance and starting a new independent business due to increased health insurance 

premiums that may be charged with respect to an individual health insurance policy.22

Market distortions from employer-provided health care

 Job lock 

also may prevent an employee who is sick or has a sick dependent from switching to an 

employer with another health plan for fear of disrupting the patient-physician relationship. 

The tax treatment of health care affects the health care market and can distort consumer 

choices. Reduced taxation of income spent on health insurance is an implicit subsidy by the 

Federal government to eligible consumers. This “discount” on the employer purchase of health 

insurance provides an incentive for the purchase of more generous health insurance benefits than 

would otherwise be purchased without the discount. Increased health insurance benefits 

generally include some combination of reduced copayments, lower deductibles and expanded 

benefits. Because consumers are responsive to changes in the cost of health care,23

The distortion in the market caused by the tax preference afforded health insurance arises 

from a two-part market response: 1) demand for medical care increases, increasing the price of 

health care services; and 2) increased prices draw additional resources into the medical services 

sector, and away from other less tax-favored sectors. These market mechanisms affect the price 

for all health care services. The market inefficiency arising from the tax-induced spending on 

health care versus other goods generates a loss to the economy referred to as “dead weight 

loss,”

increased 

health insurance benefits lead to an increase in the use of health care services. Therefore, the tax 

exclusion for health insurance and other medical services increases the demand for health care 

services. 

24

There is substantial evidence that the tax preference for health care does indeed increase 

demand; however, estimates of the size of the increase span an extremely wide range, indicating 

because it results in a net loss of consumer welfare. Therefore, the impact on the 

economy materially exceeds the loss of tax revenues from subsidizing health care expenditures. 

The elimination of this distortion could lead the economy to function more efficiently and 

increase overall societal welfare.

 22 While HIPAA contains rules that generally require that an individual who loses employerprovided health coverage have access to an individual health insurance policy without being subject to 

pre-existing condition exclusions, such rules are subject to a number of exceptions (including rules that 

permit a State to implement alternative individual health insurance protections) and the rules do not 

provide protections with respect to the premium that may be charged for the policy. See 42 U.S.C. 

300gg-41, 44.

23 Joseph P. Newhouse, Free For All?: Lessons From the RAND Health Insurance Experiment,

Harvard University Press, 1996.

24 Martin S. Feldstein, “The Welfare Loss of Excess Health Insurance,” Journal of Political 

Economy Vol. 81 Issue 2, (Mar-April 1973): pp. 251-280.
13

considerable uncertainty among economists on the true size of the increase in the volume and 

price of health care due to the tax exclusion.25

On the other hand, some observers argue that tax subsidies for health insurance and other 

medical expenditures may correct an existing market failure where people have the tendency to 

spend below the optimal level of health insurance and health services due to underestimation of 

their likelihood of needing medical care in the future. Under this view, the tax subsidy might 

make the health care market more efficient and may improve welfare.26

Equity issues relating to employer-provided health care

The current tax treatment of health care expenditures is criticized as inequitable because 

it provides an inconsistent tax benefit based on how health coverage is provided.27

Some critics assert that the tax exclusion for employer-provided health care is inherently 

regressive, and thus unfair − those with the greatest income are in the highest tax brackets, and 

therefore receive the greatest tax benefit from the exclusion from income. For example, a single 

individual with no dependents and $100,000 of taxable income per year has a marginal income 

tax rate of 28 percent, excluding the effects of Social Security and Medicare taxes. If that person 

purchases a health plan through an employer that costs $5,000, the Federal income tax value of 

the tax exclusion (the income tax not paid) is $1,400. A single individual with no dependents 

and taxable income of $30,000 is in the 15 percent bracket and would therefore receive a 15 

percent, or $750, subsidy for the same health plan. 

 Generally, 

those who obtain their health insurance through their employer are afforded the most favorable 

tax treatment. Those who must obtain health insurance in the individual market receive the 

worst tax treatment. Many observers believe that this inequity combined with the lack of group 

rates in the individual market may lead to some persons remaining uninsured. 

The argument that the exclusion (or a similar deduction) for employer-provided health 

care is unfair because it is regressive is somewhat incomplete, in that the asserted unfairness of 

the exclusion follows directly from the tax rate structure being progressive. For example, under a 

single tax rate system (a flat tax), the tax benefit in the example above would be identical for the 

$100,000 earner and the $30,000 earner. 

 25 Joseph P. Newhouse, Free For All?: Lessons From the RAND Health Insurance Experiment,

Harvard University Press, 1996.

26 For example, one study found that 25 percent of patients took zero or one drug after a heart 

attack rather than two or more drugs due to the drugs’ copayment costs even though the extra drugs cost 

only $1,855 per year, while they provided $35,000 in health care benefits (not including savings from 

decreases in future medical costs). This study indicated that costs greatly impact the purchase of these 

drugs and they are often underutilized. Niteesh K. Choudhry, et. al., “Cost-Effectiveness of Providing 

Full Drug Coverage to Increase Medication Adherence in Post Myocardial Infarction Medicare 

Beneficiaries,” Circulation Vol. 117 (2008) pp. 1261-1268.

27 See Appendix B and Appendix C for illustrations of the tax benefits for an individual 

depending on the source and type of coverage. 
14

Any exclusion from income or deduction will be regressive given a progressive rate 

structure, but the appropriateness of a deduction in defining the tax base arguably should be 

determined independently of the rate structure.28

Additionally, it must be recognized that policies with respect to permitted deductions and 

the marginal rate structure are set concomitantly to achieve the desired level of progressivity of 

the tax code overall. If a deduction were not permitted, the rate structure, including the bracket 

widths, might have evolved differently. That is, the same overall degree of progressivity of the 

tax code can be achieved with or without a given deduction, through the alteration of the rate 

structure. In the example above, it would be possible to permit the exclusions for employerprovided health care but alter the rate structure to raise taxes on the employee with $100,000 of 

income by $1,400, and the employee with $30,000 of income by $750, thus negating the tax 

advantage of the exclusion and preserving the progressivity of the tax code in the absence of the 

tax exclusion.

 If the tax base is intended to reflect ability to 

pay, then a deduction for an expenditure that reduces ability to pay may be appropriate, 

notwithstanding that the decision to have a progressive rate structure means that a given 

deduction will have more value the greater is the taxpayer’s marginal tax rate. 

Geographic Variation In Health Spending

Markets for medical care are largely local and health spending varies greatly across 

regions even after controlling for both a health plan’s benefits and the risk of the local population 

(a measure called actuarial value).29

Currently, both individuals may exclude their entire premium from all taxation regardless 

of premium cost because the tax exclusion for employer sponsored premiums is unlimited; every 

dollar of insurance purchased is subsidized through the tax code. Therefore, the greater the 

premium, the greater the tax subsidy. Currently, if two people purchase the same health plan 

benefits and one lives in a high premium region and one lives in a low premium region, the 

individual in the high premium region receives a greater tax benefit than a person living in the 

low premium region. 

 The higher costs are rooted in a combination of greater use 

of health care services and higher cost per service with little explicit evidence of greater resultant 

health outcomes in these regions. Because health insurance premiums are largely made up of 

health spending, health insurance premiums vary greatly by local markets. The person living in 

the low premium region pays a lower total cost (premium) for the same quality health care as the 

person in the high premium region. 

A uniform dollar cap on the tax exclusion would impact a greater portion of the 

population in regions with high premiums than in regions with low premiums. In regions with 

low premiums, a family could purchase a plan with greater actuarial value tax free than could the 

 28 For related discussion, see William D. Andrews, “Personal Deductions in an Ideal Income 

Tax,” 86 Harvard Law Reveiw 309, 1972.

29 Peter Orszag, “Health Care and Behavioral Economics,” Presentation to the National Academy 

of Social Insurance, May 28, 2008.
15

same family living in a high premium region. If there were no behavioral response to a cap on 

the exclusion, much of the incidence of the tax would be felt in high premium regions.

Generally, the tax code does not adjust for variation in cost of living between regions and 

some types of variation may be considered unconstitutional. In 2009 the marginal tax rate for a 

married couple filing jointly increases from 15 percent to 25 percent at $67,900 across the entire 

United States, even though $67,900 can purchase many more goods and services in a low cost 

region than it can in a high cost region. Economic theory holds that wages adjust in regions to 

account for these variations. In other words, even though cost of living is higher, pay is higher to 

appropriately compensate workers. 

Although the tax code typically does not adjust for regional variation, the federal 

government often takes regional variation into account in other situations, particularly in health 

care. Most broadly, the Department of Labor calculates the Consumer Price Index by launching 

surveys in dozens of regions across the country to estimate cost of living in different regions. 

The Department of Health and Human Services uses Geographic Practice Cost Index (“GPCI”) 

to vary Medicare payments to physicians by local practice conditions including wages of 

individuals who would make comparable earnings to physicians, as well as practice expenses, 

such as office rents and other labor costs of running a physicians’ office. The Department of 

Health and Human Services also creates separate Federal poverty lines for Alaska and Hawaii 

due to a higher cost of living than in the contiguous states. The Federal Poverty Level for a 

family of four in the continental U.S. is $22,050, while it is $27,570 in Alaska and $25,360 in 

Hawaii.30 This measure is often used to determine eligibility for Medicaid which although state 

run, is largely funded by the Federal government. Lastly, the Federal Medical Assistance 

Percentage legislation varies its funding of state Medicaid programs by state largely using an 

average measure of per capita income from the Bureau of Economic Analysis at the Department 

of Commerce. The share of Medicaid expenses paid for by the Federal government ranges from 

50 percent in the states that have the highest per capita incomes to 75 percent in states with the 

lowest per capita incomes.31

Alternative tax policies subsidizing insurance coverage

Because of the efficiency and equity concerns associated with subsidizing health 

insurance through the exclusion for employer-sponsored health care, those considering options 

for financing health reform often consider capping the employer exclusion as a potential source 

of funding. On the other hand, removal or reduction of the exclusion of employer-provided 

health care from an employee’s taxable income and wages could reduce the number of firms 

offering health insurance, possibly increasing the number of uninsured.

For example, one study estimated that the total number of employees offered health 

insurance would drop by 15.5 percent if all of the exclusions were repealed and by 9.7 percent if 

 30 Notice, 74 Fed. Reg. 4199, 4200 (Jan. 23, 2009).

31 Christie Provost Peters, National Health Policy Forum, Issue Brief No. 828, Medicaid 

Financing: How the FMAP Formula Works and Why It Falls Short 4-5 (2008).
16

the income tax exclusion were repealed, but the payroll and State tax exclusions remained.32

However, the unlimited exposure of the Federal budget created by the exclusion could be 

reduced by capping the dollar amount of the exclusion per person or per tax return. A cap would 

also reduce the incentive for individuals to over-consume health insurance. To the extent that the 

cap is lower than the total cost of a policy the marginal cost of the policy would be paid with 

after-tax dollars. If the cap is not indexed, or is indexed to a measure that grows more slowly 

than medical costs, the subsidy for employer-provided health care would decline relative to the 

cost of care over time. In this event, the economic distortion effects of the exclusion would be 

reduced gradually over time.

 

Proposals to eliminate the tax exclusion for health insurance would need to consider any increase 

in the total number of uninsured. 

One alternative to a tax exclusion for health insurance is a tax deduction available 

contingent on the purchase of health insurance. A set deduction would maintain the Federal 

subsidy for employer-sponsored health insurance, but would reduce the marginal incentive to 

purchase more expensive insurance because the deduction’s value does not increase with the cost 

of insurance.33

If such a deduction were provided for the purchase of insurance in the individual market 

in addition to employer-sponsored insurance, individuals who do not have the option of 

obtaining employer-sponsored health insurance would be able to use the deduction to help 

purchase insurance in the individual market, thus reducing the number of uninsured. However, 

the advantage of obtaining insurance through one’s employer would also be reduced, possibly 

leading to a reduction in the number of firms offering health insurance benefits and therefore, the 

total number of individuals eligible to receive employer sponsored health insurance coverage. 

 Under this approach, the tax subsidy would be large enough to enable people to 

continue insurance coverage, but there would be no tax advantage to purchase insurance that 

costs more than the cap. A tax credit would behave in much the same way, except its value 

would not vary with the marginal tax rate of the individual. 

The net effect of this policy on the number of uninsured individuals would depend on the 

size of the fixed deduction relative to the cost of a typical insurance policy.34

 32 Jonathan Gruber and Michael Lettau, “How elastic is the firm’s demand for health insurance?” 

Journal of Public Economics, Vol. 88 (2004), pp. 1273-1293. 

33 See, for example, the proposal included in the Administration’s Fiscal Year 2009 Revenue 

Proposals. 

34 For example, the Congressional Budget Office finds that removing the exclusion and replacing 

it with flat deductions of $7,000 for single policies and $15,000 for family policies would reduce the 

number of uninsured people by about five million in the first several years after enactment. 

Congressional Budget Office, “An Analysis of the Presidents Budgetary Proposals for Fiscal Year 2009,” 

March 2008, p.10.

 The amount of the 

deduction could be chosen to limit Federal budget exposure, and, like the cap, it could be 
17

indexed to grow more slowly than medical expenditures, thus reducing the Federal budget 

impact and the tax subsidy for health insurance over time. 

An additional consideration in the setting of subsidy levels for employer and non-group 

insurance is the interaction of these changing subsidies with adverse selection. Non-group 

insurance is generally more attractive to individuals with low medical costs. To the extent that 

there is a substantial re-alignment between the attractiveness of employer-sponsored insurance 

and non-group insurance, younger, healthier individuals may decline employer coverage to such 

an extent that the advantages of risk pooling by employers are lost, resulting in significant 

declines in the offer of employer-sponsored insurance. To the extent that this occurs without 

some alternate risk pooling mechanism being made available, this could result in a significant 

increase in the number of uninsured individuals and/or the cost of employer-sponsored 

insurance.

None of the approaches described above addresses the limitations of the exclusion or 

deduction in providing subsidies for the purchase of health insurance to those who are least able 

to afford it: to people who have little income and thus little or no tax liability. To address this 

problem, the exclusion or deduction could be converted to a refundable credit.35 In contrast to an 

exclusion or deduction (even a deduction of a fixed amount), a refundable credit will provide the 

same benefit or subsidy to all taxpayers regardless of their income levels. While a nonrefundable credit for an expenditure would generally be as easy to administer as a deduction for 

the same expenditure. A refundable tax credit poses significant difficulties in administration for 

several reasons.36 It brings into the income tax system people who otherwise would not be part 

of the tax system, and thus the IRS may not have easily verifiable information about their income

and other information necessary to monitor compliance with the credit. Additionally, some have 

proposed that refundable tax credits be made available on an advance basis, so that they could be 

used directly to purchase health insurance. Such a system could require timely verification of 

insurance status and credit eligibility by the IRS. Some believe refundable credits, particularly 

advanceable refundable credits, may encourage fraud. Existing refundable credits in the Code 

that have been paid in error have proven difficult for the IRS to recoup.37

Exclusion from income, in contrast to either deductions or credits, has the administrative 

advantage of not requiring valuation or verification of the excluded item, at least when the 

 

 35 Lily L. Batchelder, Fred T. Goldberg Jr., Peter R. Orszag, “Efficiency and Tax Incentives: The 

Case for Refundable Tax Credits,” 59 Stanford. Law Review Vol. 23 (2006).

36 See, for example, the following papers regarding the administration of the earned income tax 

credit: Janet McCubbin, “Non-compliance with the Earned Income Tax Credit” pp. 237-273; and Jennifer 

Romich and Thomas Weisner, “How Families View and Use the Earned Income Tax Credit: Advance 

Payments Versus Lump-Sum Delivery,” pp. 366-391, in Making Work Pay, Bruce Meyr and Douglas 

Holtz-Eakin, eds, New York: Russell Sage Foundation, 2001.

37 Government Accountability Office, “Advanced Earned Income Tax Credit: Low Use and 

Small Dollars Paid Impede IRS’s Efforts to Reduce High Noncompliance,” Report to the Joint Committee 

on Taxation, GAO-07-1110, August 2007.
18

exclusion is not capped. Providing a tax benefit through an exclusion has limited application, 

however, as it requires that the subsidized item be provided to the taxpayer in the form of 

compensation, or other form of income. 
19

B. Deduction for Health Insurance Premiums

of Self-Employed Individuals

Under present law, self-employed individuals may deduct from self-employment the cost 

of health insurance for themselves and their spouses and dependents.38

The deduction is not available for any month in which the self-employed individual is 

eligible to participate in an employer-subsidized health plan. Moreover, the deduction may not 

exceed the individual’s self-employment income and is taken from earned income after the 

Earned Income Tax Credit “EITC” has been calculated. The deduction applies only to the cost 

of insurance, i.e., it does not apply to out-of-pocket expenses that are not reimbursed by 

insurance.

 The tax expenditure for 

the deduction for health insurance premiums for self-employed individuals was $5.2 billion for 

2008. 

39 The deduction does not apply for self-employment tax purposes. For purposes of 

the deduction, a more than two percent shareholder-employee of an S corporation is treated the 

same as a self-employed individual.40

This deduction has the effect of putting a self-employed individual in a similar position to 

an employee by allowing the self-employed individual to receive the equivalent of an income tax 

exclusion for health insurance coverage provided by the business for which the self-employed 

individual performs services. In fact, however, the two regimes differ in several important 

respects. First, as described above, a deduction from income for self-employment tax purposes 

is not provided in the case of a self-employed individual. For this reason, a self-employed 

individual receives less favorable tax treatment than does an employee with the same coverage 

provided by their employer. The employer-provided exclusion retains another significant 

advantage because the exclusion for self-employed individuals does not apply in the case of noninsurance arrangements, such as an HRA. 

 Thus, the exclusion for employer-provided health care 

does not apply to such individuals, but they are entitled to the deduction for health insurance 

costs as if they were self-employed.

 38 Sec. 162(l).

39 Premiums for a self-insured plan are eligible for the deduction if the self-insured plan actually 

constitutes an insurance arrangement, which generally means that the arrangement must result in adequate 

risk-shifting and not merely reimburse the individual for health expenses. For example, the IRS has ruled 

that a self-insured health plan of a law firm covering 200 self-employed partners and 800 employees 

demonstrated adequate risk shifting where the plan charged premiums that were determined on the basis 

of the actuarial costs of the plan and each partner was liable for a pro-rata share of plan experience losses. 

Pvt. L. Rul. 200007025. Self-employed individuals are not eligible to participate in HRAs. See Notice 

2002-45, 2002-2 C.B. 93. In addition, self-employed individuals are not eligible to participate in a 

cafeteria plan, including a health FSA funded by elective contributions, because cafeteria plan 

participation is limited to employees. See sec. 125(d)(1)(A).

40 Sec. 1372.
20

On the other hand, a self-employed individual, particularly a partner or a self-employed 

individual with a minority interest in a business, may be at an advantage over an employee 

because the self-employed individual may unilaterally decide to purchase health insurance 

regardless of whether the business offers health coverage to its employees. A significant cost 

differential may exist, however, because the self-employed individual may have to purchase 

coverage on the individual market because only some states will count self-employed individuals 

as an employer for health insurance purposes and thus not have the benefit of administrative 

savings and risk pooling from the group market unless the business has other self-employed 

individuals or common-law employees under the same plan.41

Table 3 shows the tax savings by self-employed health deduction by income bracket for 

2008.

Table 3.–Self Employed Deduction Tax Savings, 2008

Adjusted Gross

Income

Total Income Tax 

Savings

(millions)

Self Employed 

Deduction Number

of Returns

(thousands)

Average Savings

Per Return

(Dollars)

< 10,000 13 485 27

10,000 – 29,999 306 863 355

30,000 – 49,999 428 612 699

50,000 – 74,999 529 579 914

75,000 – 99,999 496 425 1,167

100,000 – 199,999 1,427 735 1,941

200,000 – 499,999 1,267 410 3,090

> 500,000 691 189 3,656

Total 5,157 4,298 1,200

Source: JCT Staff calculations.

 41 Even if a self-employed individual’s business does not employ and cover enough employees to 

generate the advantage of risk pooling, state law may provide assistance. Under HIPAA, an employer 

with two to fifty employees is generally guaranteed access to insurance in the small group market, and 

States are permitted to allow sole proprietors with no employees to purchase health insurance on the small 

group market rather than being limited to the individual market. 42 U.S.C. sec. 300gg-11, 91(e). While 

HIPAA does not require the States to provide protections as to the amount of premiums charged in the 

small group market, many States do provide for premium protection rules for this market.
21

III. OTHER PRESENT LAW HEALTH CARE TAX EXPENDITURES

A. Itemized Deduction for Medical Expenses

Individuals may claim an itemized deduction for unreimbursed medical expenses, but 

only to the extent that such expenses exceed 7.5 percent of AGI.42

Table 4 shows the medical expense deduction by income bracket for 2008. The greatest 

total tax expenditure is in the middle of the income distribution.

 As a result, the deduction is 

beneficial only if two conditions are met: the taxpayer’s medical expenses must exceed the 7.5-

percent of AGI threshold, and the taxpayer must have sufficient personal deductions in general to 

claim an itemized deduction. The tax expenditure for the itemized deduction for medical 

expenses was $10.7 billion for 2008. 

Table 4.–Calendar Year Medical Expense Deduction, 2008

Adjusted Gross

Income

Total Income Tax 

Savings

(millions)

Medical Expense 

Deduction Number

of Returns

(thousands)

Average Savings

Per Return

(Dollars)

< 10,000 7 987 7

10,000 – 29,999 754 3,272 230

30,000 – 49,999 1,853 3,135 591

50,000 – 74,999 2,612 2,606 1,002

75,000 – 99,999 1,958 1,340 1,461

100,000 – 199,999 2,658 1,022 2,601

200,000 – 499,999 680 86 7,907

> 500,000 162 7 23,143

Total 10,684 12,455 858

Source: JCT Staff calculations.

This deduction is available both to insured and uninsured individuals, thus, an individual 

with employer-provided health insurance (or another form of tax-subsidized health benefits, as 

summarized in this section) may also claim the itemized deduction for the individual’s medical 

expenses not covered by that insurance if the 7.5-percent AGI threshold is met. Moreover, an 

individual’s nonsubsidized health insurance premiums can be counted towards the 7.5-percent 

threshold. In practice, however, it is very unusual for an individual who purchases insurance with 

after-tax dollars to meet the income threshold solely through the premiums that the individual 

has paid. 

There are a few common ways that individuals use this deduction. For those who are 

insured, it mainly consists of payments for expensive medical items that are not covered by an 

 42 For alternative minimum tax purposes, the itemized deduction is calculated using a floor of 10 

percent of adjusted gross income. Sec. 56(b)(1)(B).
22

individual’s insurance, often including mental health care, dental care, and long-term care. 

Mental health care can consist of either frequent use of outpatient services, such as 

psychotherapy, or the use of inpatient services such as an inpatient rehabilitation facility for 

substance abuse or other mental illness. Dental care is only insured in a subset of those who 

have health insurance and frequently dental insurance is insufficient to cover expenses. People 

may reach the 7.5-percent limitation due to use of acute dental services such as root canal 

surgery. Lastly, the need for nursing home care, particularly in the elderly population, is another 

reason for the use of the medical deduction. While Medicare covers up to 100 days of nursing 

home care, Medicaid coverage is only available once an individual can show he or she is 

impoverished, and long-term care insurance is rare and frequently insufficient to cover the cost 

of nursing home care. Therefore, the cost of a nursing home frequently is paid directly by the 

taxpayers. In addition, someone in a nursing home is likely to be too sick to work and therefore, 

may have sufficiently limited income to more easily qualify for the deduction for medical 

expenses in excess of 7.5 percent of income.

Health insurance is designed to spread the risk of expensive health care over time and 

across people through the payment of insurance premiums. The 7.5-percent of AGI threshold, 

however, arguably distorts the decision whether to buy insurance or to self insure. Thus, if an 

individual without access to any tax-advantaged health insurance has a major medical event 

costing 50 percent of income every 10 years, that person can pay for 42.5 percent (50 - 7.5) of 

that event tax-free through the section 213 medical expense deduction if they self insure. If, 

however, that person pays an actuarially fair premium in the individual market every year, his or 

her annual medical expenses are below the threshold and therefore, he or she cannot deduct any 

of it. (In practice, however, it is unlikely that those individuals who do not purchase health 

insurance will have the liquidity to pay medical expenses that are such a large portion of their 

annual income.) 

The deduction for medical expenses above 7.5 percent of AGI, like other deductions for 

expenses not directly incurred to earn income, might be criticized on the grounds that the 

deduction is inconsistent with the Code’s general measure of taxable income, and (more 

importantly) might at the margin distort taxpayer behavior by encouraging taxpayers to view the 

U.S. Treasury as a partial co-insurer of major medical expenses (through the tax benefits of the 

deduction), thereby crowding out the private insurance market.43

 43 Moreover, not all medical expenses are involuntary. To this extent the deduction for medical 

expenses creates additional efficiency costs in that it encourages excessive consumption of some medical 

services since the government subsidizes the cost of these discretionary services. Thus, while the 

deduction is not likely to encourage excess consumption of some services, such as critical need surgeries, 

it could cause excessive consumption of ancillary services, such as private hospital rooms, etc. Similarly, 

other medical expenditures have a strong personal consumption component, such as the quality or variety 

of one’s eye glass frames, and a deduction or exclusion that includes these types of medical expenses is 

more likely to create economic distortions in consumption.

 On the other hand, there is a 

longstanding consensus that a personal income tax should account for an individual’s ability to 

pay tax, and that large medical expenses are generally involuntary nature, have a direct impact 
23

on the taxpayer’s ability to pay tax.44

However, a floor on such a deduction may be justified on economic grounds. Small 

health expenditures are predictable and part of consumption, however, very large medical 

expenditures are unpredictable and more likely impact the ability to pay taxes.

 It therefore is argued that, for the income tax to be 

horizontally equitable— that is, to tax equally those with equal ability to pay— a deduction for 

medical expenses should be provided. 

A floor on the deductibility of medical expenses can be argued to be appropriate for 

administrative reasons, to eliminate the need for the Internal Revenue Service to audit millions of 

returns each claiming deductions for minor medical expenses. 

Medical expenses that qualify for deduction are narrower than medical expenses for 

which an FSA or HSA can be used. For example, non-prescription medicines such as aspirin are 

not deductible under the medical deduction, but could be purchased using dollars set aside in an 

HSA, HRA or an FSA. 

 44 See William D. Andrews, “Personal Deductions in an Ideal Income Tax,” 86 Harvard Law 

Review, 309, 1972; William J. Turnier, “Personal Tax Deductions and Tax Reform: The High Road and 

the Low Road,” 31 Villanova Law Review, 1703, 1986. Andrews argues that the main point of the HaigSimons definition of income (Income = Consumption + Change in Wealth) is to focus on the uses of 

income and not its sources, and that an ideal income tax would not treat income differently based on its 

source. He argues that an ideal income tax should focus on elaborating the notion of taxable consumption 

embodied in the Haig-Simons definition of income in order to arrive at a fairer definition of taxable 

income. He concludes that a medical expense deduction is necessary in an ideal income tax, i.e., that 

consumption of medical care should not be taxable consumption. Turnier rejects some of Andrews’ 

reasoning, but ultimately arrives at the same conclusion that a deduction for medical expenses is 

necessary for an income tax to accurately base tax on ability to pay.
24

B. HSAs and Archer MSAs

Present law provides that individuals with a high deductible health plan (and no other 

health plan except for a plan that provides permitted coverage)45

Like opening an individual retirement account (“IRA”), the decision to create and fund an 

HSA is made on an individual-by-individual basis, but unlike the case of an IRA, an HSA is 

subject to the condition that the individual is covered under a high deductible health plan 

(purchased either through the individual market or through an employer). Subject to certain 

limitations, contributions made to an HSA by an individual are deductible for income tax 

purposes, regardless of whether the individual itemizes personal deductions. Moreover, the 

individual can exclude from income (and from taxable wages) contributions that the individual’s 

employer (including contributions made through a cafeteria plan through salary reduction) makes 

to the individual’s HSA. 

may establish and make taxdeductible contributions to a health savings account (“HSA”). The tax expenditure for HSAs 

was $0.5 billion for 2008. HSAs are one of the lowest cost tax expenditure in the health care 

sector. 

A high deductible health plan is a health plan that has an annual deductible that is at least 

$1,150 for self-only coverage or $2,300 for family coverage (for 2009) and that limits the sum of 

the annual deductible and other payments that the individual must make in respect of covered 

benefits to no more than $5,800 in the case of self-only coverage and $11,600 in the case of 

family coverage (for 2009).46

Earnings on amounts in an HSA accumulate on a tax-free basis. Distributions from an 

HSA that are used for qualified medical expenses are excludable from gross income regardless of 

the taxpayer’s age and regardless of whether treated as paid out of the account’s contributions or 

its earnings. 

 

Distributions from an HSA that are not used for qualified medical expenses are includible 

in gross income and are subject to an additional tax of 10 percent. The additional 10-percent tax 

does not apply, however, if the distribution is made after death, disability, or the individual 

attains the age of Medicare eligibility (i.e., age 65). 

 45 An individual with other coverage in addition to a high deductible health plan is still eligible 

for an HSA if such other coverage is “permitted insurance” or “permitted coverage.” Permitted insurance 

is: (1) insurance if substantially all of the coverage provided under such insurance relates to (a) liabilities 

incurred under worker’s compensation law, (b) tort liabilities, (c) liabilities relating to ownership or use of 

property (e.g., auto insurance), or (d) such other similar liabilities as the Secretary may prescribe by 

regulations; (2) insurance for a specified disease or illness; and (3) insurance that provides a fixed 

payment for hospitalization. Permitted coverage is coverage (whether provided through insurance or 

otherwise) for accidents, disability, dental care, vision care, or long-term care. Effective after December 

20, 2006, with respect to coverage for years beginning after December 31, 2006, certain coverage under a 

health FSA is disregarded in determining eligibility for an HSA.

46 These amounts are indexed for inflation. 
25

In sum, HSAs provide the opportunity to pay for current out-of-pocket medical expenses 

on a tax-favored basis, as well as the ability to save for future medical (and after age 65, 

nonmedical) on a tax-favored basis. To the extent that amounts in an HSA are not used for 

qualified expenses, an HSA provides tax benefits similar to an IRA,47

In contrast to an FSA or HRA, both of which require substantiation for tax-free 

reimbursement of a medical expense, an individual is not required to provide substantiation to 

the trustee or custodian of an HSA that a distribution is for a qualified expense to be entitled to 

the exclusion.

including the same tax 

deferral of contributions and earnings ultimately used to fund general living expenses after age 

64 and the same 10-percent additional tax for nonqualified distributions before age 65. 

48

For 2009, the maximum aggregate annual contribution that can be made to an HSA is 

$3,000 in the case of self-only coverage and $5,950 in the case of family coverage.

Instead, the individual simply maintains his or her own books and records with 

respect to the expense and claims the exclusion for a distribution from the HSA on his or her 

return if it is used for a qualified expense. This may result in certain nonqualified distributions 

not being reported as subject to tax, including the 10-percent additional tax.

49

If an employer makes contributions to employees’ HSAs, the employer must make 

available comparable contributions on behalf of all employees who have comparable coverage 

 The annual 

contribution limits are increased for individuals who have attained age 55 by the end of the 

taxable year (referred to as “catch-up contributions”). In the case of policyholders and covered 

spouses who are age 55 or older, the HSA annual contribution limit is greater than the otherwise 

applicable limit by $1,000 in 2009 and thereafter. Contributions, including catch-up 

contributions, cannot be made once an individual is enrolled in Medicare.

 47 Other tax-favored vehicles may also be used to save for future medical expenses, but they are 

not specific to use for medical expenses and they do not provide the same tax benefits. For example, 

funds in a traditional IRA may be used to pay medical expenses, but distributions for medical expenses 

are includible in gross income in the same manner as are other traditional IRA distributions. 

48 Qualified medical expenses include expenses for diagnosis, cure, mitigation, treatment, or 

prevention of disease, including prescription drugs, transportation primarily for and essential to such care, 

and qualified long-term care expenses. Qualified medical expenses do not include expenses for insurance 

other than for (1) long-term care insurance, (2) premiums for health coverage during any period of 

continuation coverage required by Federal law, (3) premiums for health care coverage while an individual 

is receiving unemployment compensation under Federal or State law, and (4) premiums for individuals 

who have attained the age of Medicare eligibility, other than premiums for policies that provide 

supplemental coverage for individuals whose primary insurance is Medicare. 

49 These amounts are the same as the maximum deductible amounts permitted under a high 

deductible plan for purposes of Archer Medical Savings Accounts (“MSAs”) and are indexed for 

inflation. In the case of individuals who are married to each other, if either spouse has family coverage, 

both spouses are treated as only having the family coverage with the lowest deductible and the 

contribution limit is divided equally between them unless they agree on a different division. Limitations 

exist based on the amount of the deductible under the high deductible health plan apply to years 

beginning before January 1, 2007.
26

during the same period. Employer contributions are not includable in employees’ incomes or 

taxable wages. Contributions are considered comparable if they are either of the same amount or 

the same percentage of the deductible under the plan. If employer contributions do not satisfy 

the comparability rule during a period, then the employer is subject to an excise tax equal to 35 

percent of the aggregate amount contributed by the employer to HSAs for that period. The 

comparability rule does not apply to contributions made through a cafeteria plan.

A taxpayer may not combine the benefits of an HSA with those of an Archer MSA. 

Amounts can be rolled over, however, into an HSA from another HSA or from an Archer MSA. 

One-time rollovers are permitted from IRAs to HSAs.

Like an HSA, an Archer MSA is a tax-exempt trust or custodial account to which taxdeductible contributions may be made by individuals with a high deductible health plan.50 

Archer MSAs provide tax benefits similar to, but generally not as favorable as, those provided by 

HSAs for individuals covered by high deductible health plans. The main differences include: 

(1) only self-employed individuals and employees of small employers are eligible to have an 

Archer MSA; (2) for Archer MSA purposes, a high deductible health plan is a health plan with 

(for 2009) (a) an annual deductible of at least $2,000 and no more than $3,000 in the case of selfonly coverage and at least $4,000 and no more than $6,500 in the case of family coverage and (b) 

maximum out-of pocket expenses of no more than $4,000 in the case of self-only coverage and 

no more than $7,350 in the case of family coverage;51

After 2007, no new contributions can be made to Archer MSAs except by or on behalf of 

individuals who previously had made Archer MSA contributions and employees who are 

employed by a participating employer. In light of this fact, the fact that HSAs are more generous 

than Archer MSAs, and the fact that an individual can roll over an Archer MSA into an HSA, 

one can expect Archer MSA to soon be replaced by HSAs. 

and (3) the additional tax on distributions 

not used for medical expenses is 15 percent rather than 10 percent. 

Proponents of high deductible health plans believe that such plans help to alleviate the 

distortion in the health insurance market caused by the exclusion for employer-sponsored health 

insurance. Some proponents of HSAs believe that many current health insurance policies cover 

routine medical expenses and that the tax laws should provide a subsidy only for insurance for 

substantial and unpredictable medical expenses.

The creation of HSAs was intended to encourage high deductible health plans and to 

control the growth of health care spending. Proponents of HSAs believe that if consumers 

personally pay for a greater portion of their health care purchases (because of the large 

deductible) out of a fund that can be used for savings (and therefore ultimately is the consumer’s 

money to use as they wish), they will be more prudent in their health spending. In theory, this 

 50 Sec. 220.

51 These deductible and out-of-pocket expenses dollar amounts are for 2009. These amounts are 

indexed for inflation.
27

would result in lower volume of services and potentially consumer pressure to drive down prices 

of health care services.52

Prior to the introduction of HSAs, there was a clear tax advantage to structuring 

employer-sponsored health insurance to have a low deductible. The tax exclusion for premiums 

meant that purchasing a more generous plan with no deductible, essentially paying the deductible 

through the increased premium, was tax-advantaged because any deductible had to be paid out of 

after-tax dollars, but the premium could be paid with pre-tax dollars. HSAs were meant to 

equalize health spending through premiums and through out of pocket spending while creating a 

financial incentive for individuals to be economical in their health expenditures. Concerns exist 

that HSAs and high deductible health plans are likely to be more attractive to healthier 

individuals, with the result that adverse selection will occur. If correct, this could erode the 

group market and result in higher premiums for individuals with greater health risks. When 

insurance is priced on a group basis, individuals with lower health risks in effect subsidize higher 

risk individuals. If the healthy, low risk individuals leave the pool to seek cheaper, high 

deductible insurance, the average cost will increase for those remaining. This in turn may cause 

the next-lowest risk individuals to leave the pool, with a concomitant rise in cost for those still 

remaining, resulting in a spiral that could drive a plan with generous benefits to price itself out of 

the market. 

To the extent that amounts in HSAs are not used for current medical expenses, HSAs 

provide a tax benefit similar to that of a deductible IRA, in that HSAs allow tax-free 

compounding of earnings. HSA proponents argue that this feature may help contribute to 

lowering medical costs by in effect rewarding lower spending on medical care. Because HSAs 

operate similarly to deductible IRAs, there is concern that they will be used as an additional tax 

shelter for retirement income for wealthy individuals. Critics argue that HSAs are primarily 

attractive to higher income individuals who can afford to self insure on a current basis for the 

higher deductible under the high deductible plan and who are primarily interested in a long-term 

tax-favored savings vehicle. In this regard, critics observe that a taxpayer can fund both an HSA 

and a deductible IRA, thereby substantially increasing the individual’s annual contributions for 

tax-preferred savings. In response, proponents of HSAs argue that the additional tax of 10 

percent for uses other than health care before age 65 (the age of Medicare eligibility) may 

mitigate this issue. 

 52 Evidence from the RAND Health Insurance experiment indicates that health expenditures are 

elastic; those who can access health care for free used 20 percent more hospital visits than those who paid 

a 25 percent coinsurance payment or higher for medical care. See Robert H. Brook, et. al. “The Health 

Insurance Experiment: A Classic RAND Study Speaks to the Current Health Reform Debate,” RAND 

Corporation. 2006. http://www.rand.org/pubs/research_briefs/2006/RAND_RB9174.pdf Accessed 24 

July 2008.
28

C. Refundable Credit for Health Insurance Expenses

of Certain Classes of Individuals

1. Health insurance tax credit 

Under the Trade Adjustment Assistance Reform Act of 2002,53 certain individuals are 

eligible for the Health Coverage Tax Credit (“HCTC”).54 The HCTC is a refundable tax credit 

equal to 80 percent of the cost of qualified health coverage paid by an eligible individual. 55

In general, eligible individuals are individuals who receive a trade adjustment allowance 

(and individuals who would be eligible to receive such an allowance but for the fact that they had 

not exhausted their regular unemployment benefits), individuals eligible for the alternative trade 

adjustment assistance program, and individuals over age 55 who receive pension benefits from 

the Pension Benefit Guaranty Corporation. The credit is available for “qualified health 

insurance,” which includes certain employer-based insurance, certain State-based insurance, and 

in some cases, insurance purchased in the individual market. The credit is available on an 

advance basis through a program established and administered by the Treasury Department. 

Persons entitled to Medicare and certain other governmental health programs, covered under 

certain employer-subsidized plans, or with certain other specified coverage are not eligible for 

the credit.56

The HCTC is often cited as an example of how a broad-based refundable tax credit for 

health insurance (or health expenses) could operate. However, the size of the population eligible 

for the HCTC is not representative of the population at large. In addition, the costs of 

administering the credit were significant in the first several years of implementation. The credit 

generally is delivered as follows: the eligible individual sends his or her portion of the premium 

to the Treasury. The Treasury pays the full premium (the individual’s portion and the amount of 

the refundable tax credit) to the insurer. Alternatively, an eligible individual is also permitted to 

pay the entire premium during the year and claim the credit on his or her income tax return.57

 53 Pub. L. No. 107-210, secs. 201(a), 202 and 203 (2002).

54 Sec. 35.

55 The amount of the credit was increased from 65 percent to 80 percent by the TAA Health 

Coverage Improvement Act of 2009, Pub. L. No. 111-5, effective May 2009. The credit returns to 65 

percent for months after December 31, 2010.

56 Sec. 35(f).

57 See Internal Revenue Service Publication 4181. 
29

2. COBRA continuation coverage premium reduction 

The Consolidated Omnibus Reconciliation Act of 1985 (“COBRA”) requires that a group 

health plan58 must offer continuation coverage to qualified beneficiaries with respect to a 

covered employee59 in the case of a qualifying event (such as a loss of employment). A plan may 

require payment of a premium for any period of continuation coverage. The amount of such 

premium generally may not exceed 102 percent60 of the “applicable premium” 61

Section 3001 of the American Recovery and Reinvestment Act of 2009

for such period 

and the premium must be payable, at the election of the payor, in monthly installments. 

62

The premium subsidy also applies to temporary continuation coverage elected under the 

Federal Employees Health Benefits Program (“FEHBP”) and to continuation health coverage 

provides that, 

for a period not exceeding nine months, an assistance eligible individual is treated as having paid 

any premium required for COBRA continuation coverage under a group health plan if the 

individual pays 35 percent of the premium. Thus, if the assistance eligible individual pays 35 

percent of the premium, the group health plan must treat the individual as having paid the full 

premium required for COBRA continuation coverage, and the individual is entitled to a subsidy 

for 65 percent of the premium. An assistance eligible individual generally is any qualified 

beneficiary who elects COBRA continuation coverage and the qualifying event with respect to 

the covered employee for that qualified beneficiary is a loss of group health plan coverage on 

account of an involuntary termination of the covered employee’s employment (for other than 

gross misconduct). In addition, the qualifying event must occur during the period beginning 

September 1, 2008 and ending with December 31, 2009. 

 58 A group health plan is defined as a plan (including a self-insured plan) of, or contributed to by, 

an employer (including a self-employed person) or employee organization to provide health care (directly 

or otherwise) to the employees, former employees, the employer, others associated or formerly associated 

with the employer in a business relationship, or their families.

59 A “covered employee” is an individual who is (or was) provided coverage under the group 

health plan on account of the performance of services by the individual for one or more persons 

maintaining the plan and includes a self-employed individual. A “qualified beneficiary” means, with 

respect to a covered employee, any individual who on the day before the qualifying event for the 

employee is a beneficiary under the group health plan as the spouse or dependent child of the employee. 

The term qualified beneficiary also includes the covered employee in the case of a qualifying event that is 

a termination of employment or reduction in hours. 

60 In the case of a qualified beneficiary whose minimum coverage period is extended to 29 

months on account of a disability determination, the premium for the period of the disability extension 

may not exceed 150 percent of the applicable premium for the period.

61 The applicable premium for any period of continuation coverage means the cost to the plan for 

such period of coverage for similarly situated non-COBRA beneficiaries with respect to whom a 

qualifying event has not occurred, and is determined without regard to whether the cost is paid by the 

employer or employee. 

62 Pub. L. No. 111-5.
30

under State programs that provide coverage comparable to continuation coverage. The subsidy is 

generally delivered by requiring employers to pay the subsidized portion of the premium for 

assistance eligible individuals. The employer then treats the payment of the subsidized portion 

as a payment of employment taxes and offsets its employment tax liability by the amount of the 

premium subsidy.63

There is an income limit on entitlement to the premium reduction and subsidy, and it is 

conditioned on the individual not being eligible for certain other health coverage. To the extent 

that an eligible individual receives a subsidy during a taxable year to which the individual was 

not entitled due to income or being eligible for other health coverage, the subsidy overpayment is 

repaid on the individual’s income tax return as additional tax. However, in contrast to the 

HCTC, the subsidy for COBRA continuation coverage may only be claimed through the 

employer and cannot be claimed on an individual’s tax return. 

 To the extent that the aggregate amount of subsidy for all assistance eligible 

individuals for which the employer is entitled to a credit for a quarter exceeds the employer’s 

employment tax liability for the quarter, the employer can request a tax refund or can claim the 

credit against future employment tax liability. 

 63 In the case of a multiemployer group health maintained by a multiemployer or a plan subject to 

a State program, the person to whom the reimbursement is payable is either the multiemployer group 

health plan or the insurer providing coverage under an insured plan. 
31

IV. PRESIDENT’S FISCAL YEAR 2010 BUDGET PROPOSAL TO LIMIT

THE RATES AT WHICH TAXPAYERS MAY BENEFIT

FROM ITEMIZED DEDUCTIONS

As described in greater detail below, the President’s Fiscal Year 2010 budget proposals 

contain a proposal to limit the tax rates at which taxpayers may benefit from itemized 

deductions, such as the charitable contribution deduction, the mortgage interest deduction, and 

the deduction for State and local income taxes. The proposal is designed in part to fund a new 

reserve fund for health care reform.

Present Law

General structure of the individual income tax

Under the Code, gross income means “income from whatever source derived” except for 

certain items specifically exempt or excluded by statute. An individual’s AGI is determined by 

subtracting certain “above-the-line” deductions from gross income. These deductions include, 

among other things, contributions to a tax-qualified retirement plan by a self-employed 

individual, contributions to certain IRAs, one-half of self-employment taxes, certain moving 

expenses, and alimony payments.

In order to determine taxable income, an individual reduces AGI by any personal 

exemption deductions and either the applicable standard deduction or his or her itemized 

deductions. Personal exemptions generally are allowed for the taxpayer, his or her spouse, and 

any dependents. For 2009, the amount deductible for each personal exemption is $3,650. This 

amount is indexed annually for inflation. The deduction for personal exemptions is reduced or 

eliminated for taxpayers with incomes over certain thresholds, which are indexed annually for 

inflation. The applicable thresholds for 2009 are $166,800 for single individuals, $250,200 for 

married individuals filing a joint return and surviving spouses, $199,950 for heads of households, 

and $125,100 for married individuals filing separate returns.

Standard and itemized deductions

A taxpayer also may reduce AGI by the amount of the applicable standard deduction. 

The basic standard deduction varies depending upon a taxpayer’s filing status. For 2009, the 

amount of the standard deduction is $5,700 for single individuals and married individuals filing 

separate returns, $8,350 for heads of households, and $11,400 for married individuals filing a 

joint return and surviving spouses. An additional standard deduction is allowed with respect to 

any individual who is elderly or blind.64

 64 For 2009, the additional amount is $1,100 for married taxpayers (for each spouse meeting the 

applicable criterion) and surviving spouses. The additional amount for single individuals and heads of 

households is $1,400. If an individual is both blind and aged, the individual is entitled to two additional 

standard deductions, for a total additional amount (for 2009) of $2,200 or $2,800, as applicable.

 The amounts of the basic standard deduction and the 

additional standard deductions are indexed annually for inflation. Finally, a taxpayer may reduce 
32

AGI by an additional standard deduction for State and local property taxes paid of $500 ($1,000 

for joint filers) and for qualified motor vehicle taxes.

In lieu of taking the applicable standard deductions, an individual may elect to itemize 

deductions. The deductions that may be itemized include State and local income taxes (or, in 

lieu of income, sales taxes), real property and certain personal property taxes, home mortgage 

interest, charitable contributions, certain investment interest, medical expenses (in excess of 7.5 

percent of AGI), casualty and theft losses (in excess of $500 per loss and in excess of 10 percent 

of AGI), and certain miscellaneous expenses (in excess of two percent of AGI). 

Under present law, the total amount of otherwise allowable itemized deductions (other 

than medical expenses, investment interest, and casualty, theft, or wagering losses) is reduced by 

three percent of the amount of the taxpayer’s 2009 adjusted gross income in excess of $166,800 

($83,400 for married couples filing separate returns). These amounts are adjusted annually for 

inflation. In computing this reduction of total itemized deductions, all present law limitations 

applicable to such deductions (such as the separate floors) are first applied and, then, the 

otherwise allowable total amount of itemized deductions is reduced in accordance with this 

provision. Under present law, the otherwise allowable itemized deductions may not be reduced 

by more than 80 percent.

Individual income tax rates

A taxpayer’s net income tax liability is the greater of (1) regular individual income tax 

liability reduced by credits allowed against the regular tax, or (2) tentative minimum tax reduced 

by credits allowed against the minimum tax. The amount of income subject to tax is determined 

differently under the regular tax and the alternative minimum tax, and separate rate schedules 

apply. Lower rates apply for long-term capital gains; those rates apply for both the regular tax 

and the alternative minimum tax.

To determine regular tax liability, a taxpayer generally must apply the tax rate schedules 

(or the tax tables) to his or her regular taxable income. The rate schedules are broken into 

several ranges of income, known as income brackets, and the marginal tax rate increases as a 

taxpayer’s income increases. Separate rate schedules apply based on an individual’s filing 

status. For 2009, the regular individual income tax rate schedules are as follows in Table 5:
33

Table 5.–Federal Individual Income Tax Rates for 2009

If taxable income is: Then income tax equals:

Single Individuals

Not over $8,350 10% of the taxable income

Over $8,350 but not over $33,950 $835 plus 15% of the excess over $8,350

Over $33,950 but not over $82,250 $4,675 plus 25% of the excess over $33,950

Over $82,250 but not over $171,550 $16,750 plus 28% of the excess over $82,250

Over $171,550 but not over $372,950 $41,754 plus 33% of the excess over $171,550

Over $372,950 $108,216 plus 35% of the excess over $372,950

Heads of Households

Not over $11,950 10% of the taxable income

Over $11,950 but not over $45,500 $1,195 plus 15% of the excess over $11,950

Over $45,500 but not over $117,450 $6,227.50 plus 25% of the excess over $45,500

Over $117,450 but not over $190,200 $24,215 plus 28% of the excess over $117,450

Over $190,200 but not over $372,950 $44,585 plus 33% of the excess over $190,200

Over $372,950 $104,892.5 plus 35% of the excess over $372,950

Married Individuals Filing Joint Returns and Surviving Spouses

Not over $16,700 10% of the taxable income

Over $16,700 but not over $67,900 $1,670 plus 15% of the excess over $67,900

Over $67,900 but not over $137,050 $9,350 plus 25% of the excess over $67,900

Over $137,050 but not over $208,850 $26,637.50 plus 28% of the excess over $137,050

Over $208,850 but not over $372,950 $46,741.50 plus 33% of the excess over $208,850

Over $372,950 $100,894.50 plus 35% of the excess over $372,950

Married Individuals Filing Separate Returns

Not over $8,350 10% of the taxable income

Over $8,350 but not over $33,950 $835 plus 15% of the excess over $8,350

Over $33,950 but not over $68,525 $4,675 plus 25% of the excess over $33,950

Over $68,525 but not over $104,425 $13,318.75 plus 28% of the excess over $68,525

Over $104,425 but not over $186,475 $23,310.75 plus 33% of the excess over $104,425

Over $186,475 $50,447.25 plus 35% of the excess over $186,475

Alternative minimum tax liability

An alternative minimum tax is imposed on an individual, estate, or trust in an amount by 

which the tentative minimum tax exceeds the regular income tax for the taxable year. The 

tentative minimum tax is the sum of (1) 26 percent of so much of the taxable excess as does not 

exceed $175,000 ($87,500 in the case of a married individual filing a separate return) and (2) 28 

percent of the remaining taxable excess. The taxable excess is so much of the alternative 

minimum taxable income (“AMTI”) as exceeds the exemption amount. The maximum tax rates 

on net capital gain and dividends used in computing the regular tax are also used in computing 
34

the tentative minimum tax. AMTI is the taxpayer’s taxable income increased by the taxpayer’s 

“tax preference items” and adjusted by redetermining the tax treatment of certain items in a 

manner that negates the deferral of income resulting from the regular tax treatment of those 

items.

The exemption amounts for 2009 are: (1) $70,950 in the case of married individuals 

filing a joint return and surviving spouses; (2) $46,700 in the case of other unmarried 

individuals; (3) $35,475 in the case of married individuals filing separate returns; and 

(4) $22,500 in the case of an estate or trust. The exemption amounts are phased out by an 

amount equal to 25 percent of the amount by which the individual’s AMTI exceeds (1) $150,000 

in the case of married individuals filing a joint return and surviving spouses, (2) $112,500 in the 

case of other unmarried individuals, and (3) $75,000 in the case of married individuals filing 

separate returns or an estate or a trust. These amounts are not indexed for inflation.

Among the preferences and adjustments applicable to the individual alternative minimum 

tax are accelerated depreciation on certain property used in a trade or business, circulation 

expenditures, research and experimental expenditures, certain expenses and allowances related to 

oil and gas and mining exploration and development, certain tax-exempt interest income, and a 

portion of the amount of gain excluded with respect to the sale or disposition of certain small 

business stock. In addition, personal exemptions, the standard deduction, and certain itemized 

deductions, such as State and local taxes and miscellaneous deductions items, are not allowed to 

reduce alternative minimum taxable income.

Description of President’s Budget Proposal

The proposal limits the rate at which taxpayers with taxable income in excess of a 

threshold amount benefit from itemized deductions. In general, the proposal limits the benefit of 

itemized deductions for individuals with taxable income in excess of $200,000 and married 

couples with taxable income in excess of $250,000 to 28 percent.

For example, assume that a taxpayer in the 35-percent income tax bracket makes a $1,000 

charitable contribution. Under present law, the $1,000 contribution would result in a $350 tax 

savings, or 35 percent of $1,000 (disregarding any other limitations that may apply to reduce the 

taxpayer’s itemized deductions). Under the proposal, the same $1,000 contribution by the same 

35-percent65

Effective date.−The proposal is effective for tax years beginning after December 31, 

2010.

bracket taxpayer would result in a tax savings of only $280 (28 percent of $1,000).

 65 Under a separate budget proposal, the President would increase the top marginal tax rates for 

higher-bracket taxpayers. For the sake of simplicity, however, the examples in this section assume a top 

marginal income tax rate of 35 percent, as under present law.
35

Analysis

The proposal has been the subject of considerable debate, much of which centers on the 

likely effect of the proposal on charitable giving and housing (discussed below), although the 

proposal applies more broadly to all itemized deductions. Some proponents have argued that 

limiting the benefit of itemized deductions in this manner will reduce the incentive to undertake 

certain activities. Some opponents have argued that such a limitation is inappropriate to the 

extent that the deductions, such as those for medical expenses, casualty or theft losses, or local 

taxes, are designed to reflect more accurately a taxpayer’s ability to pay. If this is the case, then 

no adjustment should be made to the deductions, and any concern about fairness or progressivity 

should be addressed through the marginal tax rate structure. Furthermore the extent to which the 

proposal impacts progressivity is unclear given the interaction with other budget proposals such 

as the so-called Pease limitation on itemized deductions and provisions of the alternative 

minimum tax.

Charitable deduction

Some argue, for example, that the proposed limit on itemized deductions diminishes a 

taxpayer’s incentive to make charitable contributions by increasing the cost of charitable 

giving66; such commentators argue that the proposal therefore will result in a decrease in 

charitable giving.67

Others, however, argue that the proposed limit will result in little if any reduction in 

overall charitable giving.

 For example, disregarding any other limitations that may apply to limit 

itemized deductions, under present law a 35-percent bracket taxpayer who makes a $1,000 

charitable contribution will save $350 (35 percent of $1,000). In other words, the after tax cost 

to the taxpayer is only $650 to give $1,000 to charity ($1,000 - $350 savings). Under the 

proposal, the same $1,000 charitable contribution would cost the same taxpayer $720 ($1,000 -

(28 percent of $1,000)). This represents a cost increase of more than 10 percent.

68

 66 For a recent literature review of the responsiveness of charitable giving to its price, see John 

Peloza and Piers Steele, “The Price Elasticities of Charitable Contributions: A Meta Analysis,” Journal of 

Public Policy & Marketing 24(2): 260‐272, 2005. See also Charles T. Clotfelter, Federal Tax Policy and 

Charitable Giving (Chicago: University of Chicago Press), 1985; and Jon Bakija and Bradley Heim “How 

Does Charitable Giving Respond To Incentives And Income? Dynamic Panel Estimates Accounting For 

Predictable Changes In Taxation,” National Bureau of Economic Research Working Paper 14237, August 

2008. 

 Some argue, for example, that charitable giving is motivated in 

67 See Independent Sector, Statement on Changes to Tax Incentives for Charitable Giving and 

Health Care Reform, 

http://www.independentsector.org/media/20090326_giving_healthcare_statement.html (March 26, 2009) 

(arguing that changing in tax benefits affect charitable giving levels and that the President’s budget 

proposal will result in a decrease in charitable giving).

68 For example, the Center on Philanthropy at Indiana University performed a study to determine 

how the President’s proposal would affect charitable giving. See The Center on Philanthropy at Indiana 

University, white paper, “How Changes in Tax Rates Might Affect Itemized Charitable Deductions,” 

available at http://www.philanthropy.iupui.edu/docs/2009/2009_TaxChangeProposal_WhitePaper.pdf
36

significant part by factors other than tax rules, such as altruism and the overall state of the 

economy;69

Furthermore, some argue that the proposal improves fairness and equity to the tax 

treatment of itemized deductions by partially leveling the tax benefit to higher- and lowerincome taxpayers resulting from identical gifts. For example, assume that a taxpayer in the 35-

percent bracket and a taxpayer in the 25-percent bracket each make identical $1,000 

contributions to charity. As a result of the $1,000 contribution, the higher-income taxpayer will 

have a tax savings of $350 (35 percent of $1,000), such that his cost of making the $1,000 

contribution is $650 ($1,000 - $650). The taxpayer in the 25-percent bracket, however, will 

achieve a tax savings of only $250 (25 percent of $1,000), such that his cost of making the 

$1,000 contribution is $750 ($1,000 - $250). In other words, under present law, an identical 

charitable contribution results in a greater benefit (in this example, $100) to the higher-bracket 

taxpayer, even though the lower-bracket taxpayer arguably has been more generous by 

contributing a higher percentage of his taxable income to charity. The proposal limits (but does 

not eliminate) this disparate treatment by limiting the rate at which the higher-bracket taxpayer 

may benefit from itemized deductions to 28 percent.

most taxpayers, therefore would not eliminate or significantly reduce charitable 

giving under the proposal. Indeed, under the proposal, each additional dollar given to charity by 

a taxpayer subject to the proposal will continue to result in a tax savings, although at a rate of 28 

percent rather than the higher 33- or 35-percent rates.

On the other hand, such a fairness argument rests on an implicit assumption that, when a 

taxpayer makes a charitable contribution, he or she is buying something. If, however, one’s 

initial view is that a gift to charity reduces a taxpayer’s resources available for private 

consumption, then the proposed modification to the marginal rates at which taxpayers may 

benefit from deductions should not be undertaken, else taxpayers similarly situated with respect 

to resources available for private consumption would face differential tax burdens.

Mortgage interest and property tax deductions

The deductions for home mortgage interest and property taxes reduce the after-tax cost of 

financing and maintaining a home. The benefit generally rises as the marginal tax rate of the 

taxpayer rises. However, research suggests that the benefits of the home mortgage interest 

deduction, and thus the costs of any limitation, are distributed heterogeneously among taxpayers, 

 

(March 2009) (hereafter “Indiana University White Paper). Using a simplified model and 2006 itemized 

deduction data, the Center estimated that, if the budget proposal had been in effect in 2006, “the impact 

on itemized giving would have been a relatively small reduction when measured as a percentage of total 

itemized charitable giving by individuals (a decrease of 2.1 percent).” Looking only at the highest 

income households, the Center estimated a slightly larger drop (approximately 4.8 percent). The Center 

concluded that “[t]he larger economy plays a more important role in changes in giving than do tax rate 

changes.”

69 See, e.g., Indiana University White Paper, supra.
37

even among those with more than $250,000 in income.70

Limiting itemized deductions would raise the after-tax cost of financing and maintaining 

a home for affected taxpayers. One study estimates that completely repealing the mortgage 

interest deduction would raise the cost of capital for owner-occupied housing by seven percent.

 Within this group, the largest benefits 

accrue to younger homeowners, who tend to have higher loan-to-value ratios, and to those 

taxpayers purchasing more expensive homes. 

71 

Smaller cost increases would be associated with limiting the deduction. However, if taxpayers 

adjusted their portfolios to reduce their loan-to-value ratios, changing the tax treatment of 

mortgage interest might have little impact on the user cost.72

Some argue that the proposal would have a detrimental effect on the U.S. economy, 

because it would lead to a decline in home prices at a time when many homeowners have seen 

the value of their residences decline to an amount below their mortgage balances. Areas with 

relatively large numbers of affected taxpayers and relatively inelastic housing supply would be 

expected to face the greatest price declines. This, they argue, could lead to deterioration in bank 

balance sheets as the value of their mortgage loans and mortgage-backed securities also decline.

 As with the benefits of the 

deduction, the largest increases in the cost of housing would occur for younger, high-income 

homeowners with relatively higher loan-to-value ratios and relatively fewer non-housing assets 

with which to reduce those ratios. Demand for housing by affected taxpayers would be expected 

to decline in response to the increased cost. 

Others argue that limiting the home mortgage interest deduction is unlikely to have a 

detrimental effect on the U.S. economy. They argue that the limitation will affect too few 

taxpayers to reduce incentives for the marginal homebuyer. Still others question whether the 

mortgage interest deduction does much to encourage homeownership and thus the positive 

spillover benefits that might entail.73

 70 James Poterba and Todd Sinai, “Tax Expenditures for Owner-Occupied Housing: Deductions 

for Property Taxes and Mortgage Interest and the Exclusion of Imputed Rental Income” American 

Economic Review Papers and Proceedings, vol. 96, number 2 (May 2008).

71 Id.

72 See Martin Gervais and Manish Pandey, “Who Cares about Mortgage Interest Deductibility?” 

Canadian Public Policy, University of Toronto Press, vol. 34, number 1 (March 2008). Wealthier 

households are more likely to alter their balance sheets to reduce their loan-to-value ratios. To the extent 

that non-housing assets generate income derived subject to tax, such portfolio shifting will reduce taxable 

income for these households, partially offsetting the increase in tax due to limitation of the deduction. 

Indeed, the benefits of deductibility do not increase with income as fast as taxes paid. Accordingly, 

Gervais and Pandey (2008) find “mortgage interest deductibility makes the tax code less progressive at 

relatively low levels of income and more progressive for relatively high levels of income.”

73 Edward L. Glaeser and Jesse M. Shapiro, “The Benefits of the Home Mortgage Interest 

Deduction” Harvard Institute of Economic Research, Discussion Paper Number 1979, (October 2002).

 On the contrary, to the extent that the mortgage interest 

deduction creates economic distortions−increasing the size and cost of housing, increasing the 

allocation of capital to owner-occupied housing away from potentially higher pre-tax return 
38

investments in other sectors, increasing the amount of leverage used to purchase homes--limiting 

the deduction could be beneficial to the economy as a whole. 
39

V. THE VALUE OF TAX EXEMPTION FOR TAX-EXEMPT HOSPITALS

Present Law

Tax exemption

Charitable organizations, i.e., organizations described in section 501(c)(3), generally are 

exempt from Federal income tax, are eligible to receive tax deductible contributions,74 have 

access to tax-exempt financing through State and local governments (described in more detail 

below),75 and generally are exempt from State and local taxes. A charitable organization must 

operate primarily in pursuance of one or more tax-exempt purposes constituting the basis of its 

tax exemption.76 The Code specifies such purposes as religious, charitable, scientific, 

educational, literary, testing for public safety, or to foster international amateur sports 

competition, or for the prevention of cruelty to children or animals. In general, an organization 

is organized and operated for charitable purposes if it provides relief for the poor and distressed 

or the underprivileged.77

The Code does not provide a per se exemption for hospitals. Rather, a hospital qualifies 

for exemption if it is organized and operated for a charitable purpose and meets additional 

requirements of section 501(c)(3).

 

78 The promotion of health has been recognized by the IRS as 

a charitable purpose that is beneficial to the community as a whole.79

Although section 501(c)(3) hospitals generally are exempt from Federal tax on their net 

income, such organizations are subject to the unrelated business income tax on income derived 

from a trade or business regularly carried on by the organization that is not substantially related 

to the performance of the organization’s tax-exempt functions.

 It includes not only the 

establishment or maintenance of charitable hospitals, but clinics, homes for the aged, and other 

providers of health care. 

80

 74 Sec. 170.

75 Sec. 145.

76 Treas. Reg. sec. 1.501(c)(3)-1(c)(1).

77 Treas. Reg. sec. 1.501(c)(3)-1(d)(2).

78 Although nonprofit hospitals generally are recognized as tax-exempt by virtue of being 

“charitable” organizations, some may qualify for exemption as educational or scientific organizations 

because they are organized and operated primarily for medical education and research purposes.

79 Rev. Rul. 69-545, 1969-2 C.B. 117; see also Restatement (Second) of Trusts secs. 368, 372 

(1959); see Bruce R. Hopkins, The Law of Tax-Exempt Organizations, sec. 6.3 (8th ed. 2003) (discussing 

various forms of health-care providers that may qualify for exemption under section 501(c)(3)).

80 Secs. 511-514.

 In general, interest, rents, 
40

royalties, and annuities are excluded from the unrelated business income of tax-exempt 

organizations.81

Charitable contributions

In general, a deduction is permitted for charitable contributions, including charitable 

contributions to tax-exempt hospitals, subject to certain limitations that depend on the type of 

taxpayer, the property contributed, and the donee organization. The amount of deduction 

generally equals the fair market value of the contributed property on the date of the contribution. 

Charitable deductions are provided for income, estate, and gift tax purposes.82

Tax-exempt financing

In addition to issuing tax-exempt bonds for government operations and services, State 

and local governments may issue tax-exempt bonds to finance the activities of charitable 

organizations described in section 501(c)(3). Because interest income on tax-exempt bonds is 

excluded from gross income, investors generally are willing to accept a lower rate on such bonds 

than they might otherwise accept on a taxable investment. This, in turn, lowers the cost of 

capital for the users of such financing. Both capital expenditures and limited working capital 

expenditures of charitable organizations described in section 501(c)(3) of the Code generally 

may be financed with tax-exempt bonds. Private, nonprofit hospitals frequently are the 

beneficiaries of this type of financing.

Bonds issued by State and local governments may be classified as either governmental 

bonds or private activity bonds. Governmental bonds are bonds the proceeds of which are 

primarily used to finance governmental functions or which are repaid with governmental funds. 

Private activity bonds are bonds in which the State or local government serves as a conduit 

providing financing to nongovernmental persons83

Analysis of Value of Tax Exemption for Section 501(c)(3) Hospitals

(e.g., private businesses or individuals). For 

these purposes, section 501(c)(3) organizations are treated as nongovernmental persons. The 

exclusion from income for interest on State and local bonds does not apply to private activity 

bonds, unless the bonds are issued for certain permitted purposes (“qualified private activity 

bonds”) and other Code requirements are met.

In 2006, the Joint Committee on Taxation analyzed the Federal cost associated with taxexempt status for private nonprofit hospitals. 84

 81 Sec. 512(b).

82 Secs. 170, 2055, and 2522, respectively. 

83 For these purposes, the term “nongovernmental person” generally includes the Federal 

Government and all other individuals and entities other than States or local governments.

 The analysis was not an estimate of the revenue 

84 The analysis was performed at the request of the Congressional Budget Office (“CBO”) and 

was incorporated into a CBO report regarding the community benefits provided by tax-exempt hospitals 
41

effects of removing tax-exempt status from hospitals, but was an evaluation of the amount of tax 

savings generated by tax-exempt status, considering the then-current level of activity of such 

hospitals. The analysis was based on data from IRS Forms 990 (“Return of Organization 

Exempt from Income Tax”) filed for 2002. 

The total Federal tax cost associated with the tax exemption for section 501(c)(3) 

hospitals and their supporting organizations for calendar year 2002 was estimated to be 

approximately $6.1 billion, as follows in Table 6.

Table 6.−Federal Tax Cost Estimate for Tax

Exempt Hospitals, 200285

Tax Type 2002 Value 

(Billions of Dollars)

Corporate income tax (Federal) 2.5

Tax-exempt bond financing (Federal) 1.8

Charitable contributions (Federal) 1.8

Total 6.1*

* Details do not add to total due to rounding.

The value of tax exempt status for nonprofit hospitals is extremely difficult to quantify. 

The Form 990 that hospitals file with the IRS does not include all information that would be 

required to compute hypothetical Federal tax liability. The Form 990, for example: (1) does not 

provide information on State or local tax liability, which typically would be deductible by a 

business; (2) records book depreciation rather than tax depreciation; (3) does not reflect taxexempt debt that has been issued by another entity on behalf of the filer; and (4) provides only 

limited information from which to determine possible relationships between the hospital and 

other tax-exempt and taxable filers. Because of these inherent limitations in the data and for 

various other reasons, the estimate carries substantial uncertainty.

 

that was published in December 2006. See Congressional Budget Office, “Nonprofit Hospitals and the 

Provision of Community Benefits” (December 2006), at pp. 5-6.

85 In 2008, the staff of the Joint Committee on Taxation published a tax expenditure estimate for 

the exclusion of interest on State and local government qualified private activity bonds for private 

nonprofit hospital facilities of $12.1 billion for the five-year period 2008 through 2012. See Joint 

Committee on Taxation, Estimates of Federal Tax Expenditures for Fiscal Years 2008-2012 (JCS-02-08), 

October 31, 2008, at p. 56. As with the estimates derived from the above-described analysis, tax 

expenditure estimates are not revenue estimates and do not consider the behavioral effects of changes in 

tax laws. The 2008 tax expenditures publication also includes a tax expenditures estimate for healthrelated charitable contributions of $23.2 billion over the period 2008 through 2012; that figure, however, 

includes deductions for contributions not only to hospitals, but also to other health-related charitable 

organizations. The 2008 tax expenditure estimates are not directly comparable to the estimates from the 

2006 study. 
42

Also, as indicated above, the estimates are not revenue estimates, because they do not 

consider likely behavioral responses to proposed changes in tax laws. For example, such 

behavioral responses might include, corporate reorganizations, shifting of revenues between 

entities, changes in patterns of investment, or changes in charitable contributions.86

 86 In 2008, the staff of the Joint Committee on Taxation described certain tax subsidies intended 

to subsidize or induce behavior directly related to the production of business or investment income. See

Joint Committee on Taxation, Estimates of Federal Tax Expenditures for Fiscal Years 2008-2012 (JCS02-08), October 31, 2008, at pp. 21-23. This description included tax-exempt status for certain 

organizations exempt from tax under section 501(a) that arguably have a direct business analog or 

compete with for-profit entities, such as small insurance companies, mutual or cooperative electric 

companies, State credit unions, and Federal credit unions. Along these lines, some argue that tax-exempt 

hospitals similarly operate much like for-profit hospitals and compete directly with such entities.
43

APPENDIX A

COMPARISON OF PRESENT-LAW TAX BENEFITS FOR HEALTH EXPENSES1

Provision Tax Benefit Class Eligible Maximum Dollar Limit

on Tax Benefit Qualified Costs/Expenses

1. Employer contributions 

to an accident or health 

plan (sec. 106)

Exclusion from gross income 

and wages.

Employees (including former 

employees).

No limit on amount 

excludable.

Contributions to health plan 

for the taxpayer, spouse and 

dependents.

2. Employer 

reimbursement of medical 

expenses (sec. 105) 

Exclusion from gross income 

and wages. 

Employees (including former 

employees). 

No limit on amount 

excludable.

Medical care expenses (as 

defined under section 213(d)) 

of the taxpayer, spouse and 

dependents. 

3. Employer-provided 

health benefits offered 

under a cafeteria plan

(sec. 125)

Exclusion from gross income 

and wages (for salary 

reduction contributions). 

Employees. No limit on amount 

excludable.

Coverage under an accident 

or health plan (secs. 105 and 

106). 

4. Health reimbursement 

arrangements

(secs. 105 and 106)

Employer-maintained 

arrangement providing 

exclusion from gross income 

and wages for amounts used 

to reimburse employees for 

medical expenses. Amounts 

remaining at the end of the 

year can be carried forward 

to reimburse medical 

expenses in later years. 

There is no tax-free 

accumulation of earnings. 

Employees (including former 

employees).

No limit on amount 

excludable.

Medical care expenses (as 

defined under section 213(d)) 

of the taxpayer, spouse and 

dependents. 

5. Health flexible spending 

arrangements

(secs. 105, 106, and 125)

Typically employee salaryreduction arrangement 

providing exclusion from 

gross income and wages for 

amounts used to reimburse 

employees for medical 

expenses. 

Employees. No limit on amount 

excludable. 

Medical care expenses (as 

defined under section 213(d)) 

of the taxpayer, spouse and 

dependents (but not premium 

payments for other health 

coverage). 

1 The table describes the legal limits that apply under present law. Employers may establish rules and limitations consistent with those under present law. For example, it is 

common for employers to place a limit on the amount of expenses that may be reimbursed through an FSA or HRA. 
44

Provision Tax Benefit Class Eligible Maximum Dollar Limit

on Tax Benefit Qualified Costs/Expenses

6. Deduction for health 

insurance expenses of selfemployed individuals

(sec. 162(l))

Income tax deduction for 

cost of health insurance 

expenses of self-employed 

individuals. Deduction does 

not apply for selfemployment tax purposes. 

Self-employed individuals. No specific dollar limit; 

deduction limited by amount 

of taxpayer’s earned income 

from the trade or business. 

Insurance which constitutes 

medical care for the taxpayer, 

spouse and dependents. 

7. Itemized deduction for 

medical expenses

(sec. 213)

Itemized deduction for 

unreimbursed medical 

expenses to extent expenses 

exceed 7.5 percent of 

adjusted gross income (10 

percent for alternative 

minimum tax purposes).

Any individual who itemizes 

deductions and had 

unreimbursed medical 

expenses in excess of 7.5 

percent of adjusted gross 

income. 

No maximum limit. Expenses for medical care (as 

defined under section 213(d)) 

of the taxpayer, spouse and 

dependents. Medicine or 

drugs must be prescribed or 

insulin. 

8. Health Savings Accounts 

(“HSAs”)

(sec. 223)

Contributions are deductible 

if made by an eligible 

individual and excluded from 

gross income and wages if 

made by an employer 

(including contributions 

made through a cafeteria plan 

through salary reduction). 

Distributions used for 

qualified medical expenses 

excludable from gross 

income. Earnings on 

amounts in the HSA 

accumulate on a tax-free 

basis. 

Individuals with a high 

deductible health plan and no 

other health plan other than a 

plan that provides certain 

permitted coverage. High 

deductible health plan is a 

plan with a deductible of at 

least $1,150 for self-only 

coverage and $2,300 for 

family coverage (for 2009). 

Out-of-pocket expense limit 

must be no more than $5,800 

for self-only coverage and 

$11,600 for family coverage 

(for 2009).

Maximum annual 

contribution is $3,000 for 

self-only coverage or $5,950 

for family coverage (for 

2009). Additional 

contributions permitted for 

individuals age 55 or older. 

No limit on the amount that 

can be accumulated in the 

HSA.

Qualified medical expenses 

include those for medical care 

(as defined under section 

213(d)), but do not include 

expenses for insurance other 

than certain limited 

exceptions.

9. Archer Medical Savings 

Accounts (“Archer MSAs”) 

(sec. 220)

Contributions are deductible 

if made by an eligible 

individual and excluded from 

gross income and wages if 

made by an employer. 

Distributions used for 

qualified medical expenses 

Employees of small 

employers who are covered 

under an employersponsored high-deductible 

health plan (and no other 

health plan other than a plan 

that provides certain 

Maximum annual 

contribution is 65 percent of 

the annual deductible under 

the high-deductible health 

plan in the case of self-only 

coverage, and 75 percent of 

the annual deductible in the 

Qualified medical expenses 

include those for medical care 

as defined under section 

213(d), but do not include 

expenses for insurance other 

than certain limited 

exceptions.
45

Provision Tax Benefit Class Eligible Maximum Dollar Limit

on Tax Benefit Qualified Costs/Expenses

are excludable from gross 

income. Earnings on 

amounts in the Archer MSA 

accumulate on a tax-free 

basis. 

permitted coverage) and selfemployed individuals 

covered under a highdeductible health plan. 

Definition of high-deductible 

health plan differs from that 

for HSAs. No new 

contributions may be made 

after 2007 except for 

individuals who previously 

had an MSA or work for an 

employer that made MSA 

contributions.

case of family coverage. No 

limit on the amount that can 

be accumulated in the MSA.

10. Health Coverage Tax 

Credit (sec. 35)

Refundable tax credit of 80 

percent of the cost of 

qualified health insurance 

coverage. 

Individuals receiving trade 

adjustment assistance and 

certain individuals receiving 

benefits from the PBGC. 

Limited to 80 percent of the 

cost of qualified health 

insurance for months of 

coverage beginning April 

2009. Limited to 65 percent 

of the same cost for months 

of coverage beginning after 

December 31, 2010. No 

specific dollar limit. 

Qualified health insurance as 

defined in section 35(e).
46

APPENDIX B

COMPARISON OF VALUE OF HEALTH TAX BENEFITS: NON-HIGH-DEDUCTIBLE HEALTH PLAN

Assume that husband (H) has a health insurance plan that provides coverage for his wife (W) and dependents. The policy’s premium is 

$850 per month ($10,200 annually) and has a $700 deductible. The family’s out-of-pocket expenses are approximately $1,400 for the year. Thus, 

H’s annual medical costs are $11,600. H and W file a joint income tax return and their annual adjusted gross income is $80,000.

Situation

Tax-Subsidized 

Employer 

Premiums

Tax-Subsidized 

Employee 

Premiums

Tax-Subsidized 

Out-of-Pocket

Expenses

Value of 

Employment 

Tax1 (E) and 

Income Tax2 (I) 

Subsidy

Value of Total 

Tax Subsidy as a 

Percentage of 

Total Health 

Costs

(a) H’s health insurance is provided 

through his employer. The 

employer pays 75 percent of the 

premium for such coverage.

$7,650 $0 $0

$1,086 (E)

$1,913 (I)

$3,000 total

26%

(b) The employer also allows the 

employee’s share of the annual 

premium to be paid on a tax-free 

basis (i.e., through a cafeteria plan).

$7,650 $2,550 $0

$1,448 (E)

$2,550 (I)

$3,998 total

34%

(c) The employer also offers a 

reimbursement account

(i.e., either a health flexible 

spending arrangement or a health 

reimbursement arrangement).

$7,650 $2,550 $1,400

$1,647 (E)

$2,900 (I)

$4,547 total

39%

(d) H is self-employed.3 NA $10,200 $0 $0 (E)

$2,550 (I) 22%

(e) H does not have employerprovided coverage and is not

self-employed.3

NA

Taken into account 

in determining 

itemized deduction 

of $5,6004 

Taken into account 

in determining 

itemized deduction 

of $5,6004

$0 (E)

$1,400 (I) 12%

1

 The employment tax subsidy includes both the employer and employee portions of old-age, survivors, and disability insurance (“OASDI”) and hospital 

insurance (“HI”). The effective employment tax subsidy rate is the combined employer and employee tax rate divided by gross-of-tax compensation. The 

effective subsidy is thus 0.153 / (1 + .0765) = 14.2%. The subsidy rate drops substantially for taxpayers with earnings above the Social Security earnings cap. 2 This example assumes an effective marginal income tax rate of 25 percent. Subsidies to state and local income taxes are ignored here. 3

 This example ignores the fact that this policy in an individual market would either be more expensive or provide less comprehensive coverage. 4

 Medical expenses are deductible to the extent they exceed 7.5 percent of adjusted gross income ($80,000 X 7.5% = $6,000. $11,600 - $6,000 = $5,600). In

addition, the taxpayer must claim itemized deductions on Schedule A. For most taxpayers, this means that total itemized deductions exceed the standard 

deduction. For alternative minimum tax purposes, medical expenses are deductible to the extent they exceed 10 percent of adjusted gross income.
47

APPENDIX C

COMPARISON OF VALUE OF HEALTH TAX BENEFITS: HIGH-DEDUCTIBLE HEALTH PLAN

Assume that H has a high-deductible health insurance plan that provides coverage for his wife (W) and dependents. The policy’s premium is $765 per 

month ($9,180 annually) and has a $2,000 deductible. H makes contributions of $2,000 to a health savings account (“HSA”). The family’s out-of-pocket 

expenses are approximately $2,420 for the year. Thus, H’s annual medical costs are $11,600. H and W file a joint income tax return and their annual adjusted 

gross income is $80,000.

Situation

TaxSubsidized 

Employer 

Premiums

Tax Subsidized 

Employee 

Premiums

Tax-Subsidized 

Out-of-Pocket 

Expenses

TaxDeductible 

HSA 

Contribution1

Value of 

Employment Tax2 

(E) and Income 

Tax3 (I) Subsidy

Value of Total Tax 

Subsidy as a 

Percentage of 

Total Health Costs

(a) H’s health insurance is 

provided through his employer. 

The employer pays 75 percent of 

the premium for such coverage.

$6,885 $0 $0 $2,000

$ 978 (E)

$2,221 (I)

$3,199 total

28%

(b) The employer also allows the 

employee’s share of the annual 

premium to be paid on a tax-free 

basis (i.e., through a cafeteria 

plan).

$6,885 $2,295 $0 $2,000

$1,304 (E)

$2,795 (I)

$4,099 total

35%

(c) The employer also offers a 

reimbursement account

(i.e., either a health flexible 

spending arrangement or a health 

reimbursement arrangement).

$6,885 $2,295 $2,4204 $2,000

$1,647 (E) 

$3,400 (I) 

$5,047 total

44%

(d) H is self-employed.5 NA $9,180 $0 $2,000 $0 (E)

$2,795 (I) 24%

(e) H does not have employerprovided coverage and is not 

self-employed.5

NA

Taken into account 

in determining 

itemized deduction 

of $5,6006 

Taken into account 

in determining 

itemized deduction 

of $5,6006

$2,000 $0 (E)

$1,900 (I) 16%

1

 Amounts contributed to a HSA can be used to pay qualified out-of-pocket expenses on a tax-free basis. 2

 The employment tax subsidy includes both the employer and employee portions of old-age, survivors, and disability insurance (“OASDI”) and hospital insurance (“HI”). This 

example assumes that HSA contributions are made by the taxpayer. HSA contributions made by the employer would also be excluded from wages for employment tax purposes. 

See footnote 1 to Appendix B for calculation of employment tax subsidy.

3

 This example assumes an effective marginal income tax rate of 25 percent. Subsidies to state and local income taxes are ignored here. 4

 Individuals eligible to make contributions to an HSA must have a high deductible health plan and no other health plan, other than certain permitted coverage. The 

reimbursement account is permitted if it allows reimbursements only for certain limited purposes (e.g., vision or dental) or in certain other limited situations. 5

 This example ignores the fact that this policy in an individual market would either be more expensive or provide less comprehensive coverage. 6

 Medical expenses are deductible to the extent they exceed 7.5 percent of adjusted gross income ($80,000 X 7.5% = $6,000. $11,600 - $6,000 = $5,600). For alternative 

minimum tax purposes, medical expenses are deductible to the extent they exceed 10 percent of adjusted gross income. Distributions from an HSA are not taken into account in 

determining the itemized deduction. If H used distributions of $2,000 from his HSA to pay qualified medical expenses, the itemized deduction would be limited to $3,600.