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House Shouldn’t Repeal Limits on Tax-Advantaged Health Accounts

June 20, 2016 at 1:00 PM

Update, June 21:  For more on this legislation, which the House will consider on June 22, click here.

The House is expected to consider legislation this week from Ways and Means Committee member Lynn Jenkins to repeal health reform’s limit on flexible spending accounts (FSAs) and other tax-advantaged health accounts like health savings accounts (HSAs) to buy over-the-counter medicines.  The limit, in effect now for more than five years, is both sound tax and health policy and should be retained.

Health reform raised revenue by conforming the definition of medical expenses that individuals can cover with FSAs and other tax-advantaged accounts with the income tax code’s long-standing definition for itemized deductions for medical expenses.  As a result, starting in 2011, individuals could no longer use these accounts to receive reimbursements for over-the-counter medications and other over-the-counter items without a prescription or a letter of medical necessity from a physician.  

This limit makes sense because:

  • Few workers benefit from the tax break these accounts provide.  In 2010, 39 percent of all workers had access to FSAs through their employers and only 37 percent of those with access participated, according to the Congressional Research Service 
  • High-income people benefit disproportionately.  That’s because they’re in higher tax brackets, tend to consume more health care, and can afford to deposit larger amounts in their accounts.  Middle- and lower-income people benefit much less, if at all, because they pay little or no income tax and therefore can receive little income-tax savings from tax-advantaged accounts. 
  • Administration and compliance are costly.  Employers must manage the accounts themselves or hire a vendor to do so — typically at a cost of about $60 a year per participant.  Accountholders must spend hours complying with onerous recordkeeping requirements to ensure that they’re using their accounts only for approved items.
  • Tax-advantaged accounts encourage overconsumption of health care.  The accounts make people less price-sensitive and reduce the effectiveness of cost-sharing requirements in controlling health care use.  Moreover, before health reform’s restriction on over-the-counter items, funds in tax-advantaged accounts could be used to buy nearly any health care item or service, regardless of whether it was medically necessary, cost effective, or of meaningful health value. 

Congress’ Joint Committee on Taxation has offered several reasons to use the same definition of “medical care” for both tax-favored accounts and itemized deductions.  First, different definitions of “medical care” for different provisions caused similarly situated individuals to receive unequal tax treatment.  Second, purchases of over-the-counter medicines and other items (such as pain relievers, cold remedies, and sunscreen) constitute routine personal expenses, which generally aren’t considered deserving of a tax subsidy.  Third, “providing a subsidy for over-the-counter medicines may also result in less compliance, as it may be more difficult to distinguish products that are medical from those that are not, such as toiletries and products that promote general health.” 

Purchases of over-the-counter medicines also are a very minor expenditure for most people.  About 9.8 million households used an FSA to purchase over-the-counter medications in 2010, spending an average of $136, according to one survey — which would have conveyed a tax benefit of only $14 to $48, depending on the household’s tax bracket. 

The limit on FSAs and other tax-advantaged accounts remains a sound way to help pay for helping to extend health coverage to 24 million more Americans while lowering the deficit.  The House should reject the proposal to repeal it.


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