The politics of health care are changing. And one of the most controversial parts of the Affordable Care Act -- the so-called Cadillac tax -- may be about to change with it.
The Cadillac tax is a 40% tax on the most generous employer-provided health insurance plans -- those that cost more than $11,200 for an individual policy or $30,150 for family coverage. It was supposed to take effect in 2018, but Congress has delayed it twice. And the House recently voted overwhelmingly -- 419-6 -- to repeal it entirely. A Senate companion bill has 61 co-sponsors -- more than enough to ensure passage.
The tax was always an unpopular and controversial part of the 2010 health law because the expectation was that employers would cut benefits to avoid paying the tax. But ACA backers said it was necessary to help pay for the law's nearly $1 trillion cost and help stem the use of what was seen as potentially unnecessary care. In the ensuing years, however, public opinion has shifted decisively, as premiums and out-of-pocket costs have soared. Now the biggest health issue is not how much the nation is spending on health care, but how much individuals are.
"Voters deeply care about health care still," said Heather Meade, a spokeswoman for the Alliance to Fight the 40, a coalition of business, labor and patient advocacy groups urging repeal of the Cadillac tax. "But it is about their own personal cost and their ability to afford health care."
Stan Dorn, a senior fellow at Families USA, recently wrote in the journal Health Affairs that the backers of the ACA thought the tax was necessary to sell the law to people concerned about its price tag and to cut back on overly generous benefits that could drive up health costs. But transitions in health care, such as the increasing use of high-deductible plans, make that argument less compelling, he said.
"Nowadays, few observers would argue that (employer-sponsored insurance) gives most workers and their families excessive coverage," he wrote.
The possibility of the tax has been "casting a statutory shadow over 180 million Americans' health plans, which we know, from HR administrators and employee reps in real life, has added pressure to shift coverage into higher-deductible plans, which falls on the backs of working Americans," said Rep. Joe Courtney, D-Conn.
Support or opposition to the Cadillac tax has never broken down cleanly along party lines. For example, economists from across the ideological spectrum supported its inclusion in the ACA, and many continue to endorse it.
"If people have insurance that pays for too much, they don't have enough skin in the game. They may be too quick to seek professional medical care. They may too easily accede when physicians recommend superfluous tests and treatments," wrote N. Gregory Mankiw, an economics adviser in the George W. Bush administration, and Lawrence Summers, an economic aide to President Barack Obama, in a 2015 column. "Such behavior can drive national health spending beyond what is necessary and desirable."
At the same time, however, the tax has been bitterly opposed by organized labor, a key constituency for Democrats. "Many unions have been unable to bargain for higher wages, but they have been taking more generous health benefits instead for years," said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who studies health and public opinion.