The $962 billion (over 10 years) in low- and middle-income tax subsidies provided by the Affordable Care Act (ACA) have now taken center stage in public discourse as the Supreme Court considers King v. Burwell, a case that could strike down as much as 87 percent of these subsidies going forward by not allowing the subsidies in states without a state-run health insurance exchange. On average, these tax subsidies pay out $268 monthly per eligible person and cover 72 percent of the cost of paying for health insurance premiums. Given this, if the court strikes the subsidies down, it is possible that millions of low- and middle-income Americans would lose their health insurance going forward because they will no longer be able to afford it.
The ACA tax subsidies are available to individuals who enroll in a health insurance plan through an exchange and have a household income between 100 and 400 percent of the federal poverty level (FPL). They are paid out each month in advance directly to insurers and are set up to ensure that low- and middle-income families will only pay a sensible percentage (with this percentage increasing as income rises) of their overall income. For example, the subsidies would ensure that a family at the federal poverty line will not have to pay more than two percent of their income on healthcare premiums, while a family at 400 percent of the poverty line will not have to pay more than 9.5 percent of their income.
When filing their tax returns this year, individuals have to reconcile the subsidies they received based on their estimated income with the income they actually received, sometimes resulting in an additional refund or payment back to the IRS. A new report from the Kaiser Family Foundation predicts that 50 percent of subsidy-eligible tax households will owe some repayment and 45 percent will receive a refund.
While the Supreme Court may strike down the tax subsidies in many states, as we’ve noted before, the move would be a pretty radical one given that it would mean tearing crucial benefits from 7.5 million Americans based on a technicality. The Supreme Court has previously upheld the core of the ACA in 2012, when it rejected claims that the ACA’s imposition of a fee on those who do not purchase health insurance is unconstitutional by arguing that the fee constitutes a tax.
At this point, it is unclear how the Obama Administration, the Republican-led Congress or various state governments would respond if the Supreme Court were to strike down the tax subsidies. Much of the ambiguity is driven by the uncertainty over the precise approach the Supreme Court could take in its ruling, which even in ruling against the tax subsidies could potentially allow the Obama Administration or state governments some avenue for ensuring that the tax subsidies stay intact.
When the Supreme Court announces its decision, likely in late June, here’s hoping it will not make health insurance more expensive or even unobtainable for millions of middle- and low-income Americans by striking down the majority of the ACA's tax subsidies.