It’s no secret that, for years, health care costs have been on the rise, reflecting a massive burden for employers and employees alike.
According to the Kaiser Family Foundation, the average premium for employer-sponsored family coverage has increased approximately 54 percent since 2009. In 2019, the average annual premium for employer-sponsored health insurance was $7,188 for single coverage — a 4 percent increase over the prior year. For family coverage, the average premium rose 5 percent in 2019 to $20,576.
Now, in the wake of COVID-19, that cost could be exacerbated, as health plans look for ways to recoup the cost of mass testing and widespread treatment. For example, in New York, insurers originally sought a near-12 percent rate hike to health plans. The state government stepped in to quash that plan, instead opting for only a marginal hike, but that’s just for 2021. In 2022 and beyond, health care costs have the potential to soar.
Steph Tulley is the founder and CEO of Actuology. Tulley propels sustainability and success through: innovative economic strategy, dynamic consumer knowledge, and deep industry insight. Actuology's high-paced leader builds technology to augment human interaction, and future-proof the success of her industry.A New Yorker by birth and a quasi-Nomad by nature. When she is not working, Tulley has an adventurous streak. She has been known to spend countless hours playing in the field of natural history, and extreme wildlife photography.
Dror Pockard is Chief Strategy Officer at Earnix. He has over 30 years of experience building and leading start-ups, and in senior executive roles in large global companies. His expertise lies in strategy, business development, and M&A.
Prior to joining Earnix, Dror was CEO of Colibri Spindles Ltd., a company focused on connecting Industry 4.0 manufacturing devices with the emerging Internet of Things (IoT) market. Prior to that, he was CEO of eGlue Business Technologies, a start-up in the real-time interaction/next-best-offer space. And prior to that, he was CEO of Telrad Ltd. a telecom products and services company.
Earlier in his career, Dror held several leadership roles at Amdocs Inc., including: head of their Consulting and Systems Integration Organization, and president of the CRM division. Dror also established the Israeli office of Ernst Young Management Consulting and managed it for 3 years.
Dror holds an MBA in Information Systems and a BA in Management and Economics from Tel Aviv University, Israel. He is a mentor in the Israeli Microsoft Accelerator, and is a board member of the Branco Weiss Institute and Yuvalim, two charities in the education space.
Ifty Kerzner is President and Co-Founder of Kissterra, the world's first insurance marketing operating system. A skilled tech entrepreneur in the financial service and data management sectors, Ifty's passion for business, innovation, and people led him to found several companies. Prior to his career in tech and business, Ifty was part of the Israeli entertainment industry, as both a popular singer/songwriter and host of a TV show. He holds an LLB with distinction, an M.A. in Political Science, and is also a graduate of the Lyndon B. Johnson School of Public Affairs' Leadership Program.
So, if an even bigger health care premium crunch is coming, is there any way for taxpayers to find some relief? Potentially.
Last year, President Donald Trump issued Executive Order 13877, which directed the Internal Revenue Service on how to treat certain types of health plan arrangements. This year, the IRS responded by issuing proposed regulations. These new regulations included guidance for two alternate health care strategies — direct primary care, or DPC, arrangements and health care sharing ministries, or HCSMs. Under the proposed regulations, amounts paid for DPC arrangements and HCSMs are treated as deductible medical expenses. And that just may be the key to unlocking the respite many taxpayers desperately need.
What are DPC arrangements and HCSMs?
Before ditching traditional health insurance plans, taxpayers first need to understand how DPC arrangements and HCSMs work. Because these arrangements can take on a variety of forms, they will need to inquire about specific eligibility requirements and any limitations on the types of health services covered.
Under DPC arrangements, a patient contracts with their doctor for the provision of typical primary care services (e.g., preventative care, annual checkups, laboratory tests, etc.). Fees are usually fixed and paid on an annual or monthly basis (a typical monthly fee for a DPC arrangement is around $100), and in some cases doctors may charge an additional visit fee when services are performed. Obviously, this would be far more affordable than traditional health plans; however, many patients that pursue DPC arrangements also enroll in a high-deductible health plan to cover visits to specialists, urgent care or hospitals.
HCSMs are organizations whose members share medical expenses in accordance with a common set of ethical or religious beliefs, thus creating a cost-burden sharing system. According to the Alliance of Health Care Sharing Ministries, 1.5 million Americans are active members of an HCSM, and to date, the Department of Health and Human Services has certified 108 HCSMs.
That doesn’t mean it’s a slam dunk option for everyone, though. Proposed regulations lay out some detailed criteria that a group has to meet to gain HCSM status. For example, the organization has to have been in existence at all times since Dec. 31, 1999, and medical expenses of its members must have been shared continuously and without interruption since at least that date. It also must conduct an annual audit that’s performed by an independent CPA firm in accordance with GAAP, and have that audit made available to the public upon request. But if an organization can check all those boxes, it raises some intriguing options for some taxpayers that may be looking to save money during these uncertain times.
The grey area
While some of these options may seem enticing, they won’t be ideal for every taxpayer. For example, it appears that the IRS suspects its definition of a DPC arrangement may be limiting. Therefore, the agency is requesting comments on whether to expand the definition to include contracts with nurse practitioners, clinical nurse specialists or physician assistants who provide primary care services. Also, the IRS is requesting comments on whether other medical arrangements that don’t meet the definition of direct primary care (e.g., dental care or certain specialty services) should be included.
Meanwhile, the biggest disadvantage of HCSMs is inconsistent health coverage. HCSMs aren’t required to cover pre-existing conditions, cap out-of-pocket expenses or cover essential health benefits. They also can impose annual and lifetime benefit caps. In addition, because they’re based on common ethical or religious beliefs, HCSMs may require their members to abstain from certain activities. For some, this may seem too restrictive.
What’s more, if a taxpayer wants to take advantage of a health savings account, taking part in a DPC arrangement would limit, or in an HCSM’s case, outright preclude an employee from contributing to that HSA, which can offer substantial tax benefits.
The jury’s out
As health care costs continue to soar, some taxpayers will undoubtedly want to consider health care alternatives, but tax pros will have to weigh all the pros and cons before suggesting an alternative. Depending on the taxpayer’s circumstances, a DPC arrangement or an HCSM could either be a great fit or a square peg in a round hole. Preparers can help determine which category — if any — is right for their clients.
