It is an alluring way to pay for the ambitious plan to expand health coverage to the nearly 50 million people who are now uninsured. Simply put, the government would tax the people who already have the most expensive health benefits, as provided by their employers.
By one Congressional estimate, taxing this “Cadillac coverage,” as some call it, could yield $100 billion in revenue over five years. No wonder Senator Max Baucus, the Montana Democrat who is a leader of the health reform effort, seems keen on the idea. And although the candidate Barack Obama criticized the notion last year when Senator John McCain promoted it, the concept now has some support in his administration as part of an overhaul of the health care system.
“There aren’t that many pots of gold to pay for health reform,” said Jonathan Oberlander, a health policy expert at the University of North Carolina.
But Mr. Oberlander and some other experts say Congress may have a difficult time devising a new tax on health benefits that does not threaten to do more harm than good.
If the plan is not designed carefully, they say, the additional taxes could affect many workers who are far from affluent and put the cost of adequate coverage further beyond the reach of many Americans. Some critics also warn that the taxes could undermine the employer-based coverage that is the bedrock of the nation’s health insurance system.
The details have not yet been worked out. But critics say a tax could add to the burden of many employees, who already pay a hefty portion of their own insurance premiums and have additional out-of-pocket costs in the form of deductibles and annual co-payments.
And many people have high-priced insurance that is expensive for reasons unrelated to the quality of the coverage because they live in a high-cost city or work for a small business with old or sick employees.
“We too often equate expensive health insurance with generous health insurance, and they’re not the same,” Mr. Oberlander said. “It’s not clear that you are going after ‘Cadillac’ health plans at all.”
Right now, the amount that an employer spends on a worker’s health insurance is not taxed as income, and employees can pay their share of premiums with before-tax earnings. The proposals being debated in Congress would start considering some part of the value of the health benefit as income and tax it accordingly.
Representative Charles B. Rangel, the New York Democrat who is chairman of the House Ways and Means Committee, which presides over tax legislation, made clear on Wednesday that he opposed a change in the tax treatment of health benefits.
And employer groups and labor officials have also come out against the idea. They say taxing benefits could endanger the current system of employer-based coverage, which now is responsible for insuring nearly two-thirds of Americans who are under 65 years old and have coverage.
“If we began to tax employee benefits, there would be mutiny at the gate,” said J. Randall MacDonald, an I.B.M. executive who is chairman of the HR Policy Association, which represents corporate human resource professionals. “It’s just counterintuitive to the problem we’re trying to solve.”
The challenge for Congress, aside from the political battles already stirring, is whether policy makers can come up with a proposal that addresses opponents’ concerns, by limiting the tax to the wealthy, or otherwise fine-tuning it.
Proponents argue that the revenue could be raised by taxing only the most expensive policies for those people who can afford the few hundred or thousand dollars at stake — money they say is essential to government’s ability to provide basic coverage to more people.
“We need the money,” said Len Nichols, a health economist at the New America Foundation, which supports overhauling the current insurance system to give more people access.
Some supporters of these plans say the current system gives an advantage to people who get coverage from their employer and to people with high incomes.
“There is a huge consensus that this is inequitable and unfair tax treatment,” said Robert E. Moffitt, a policy analyst with the Heritage Foundation, which has long supported changing the tax laws and contends this is an area that might have significant bipartisan support.
What is more, some economists and policy analysts say the current system encourages overly generous coverage, which they say helps drive up the cost of medical care by keeping patients insulated from the true costs. “One of the arguments for doing it is trying to achieve higher value through the health care system,” said Katherine Baicker, a health economist at the Harvard School of Public Health.
But the political opposition remains fierce.
Union officials, for example, say that the proposed policy could translate into higher taxes for some of its members, many of whose contracts call for generous health benefits. “Capping the tax exclusion would undermine the place where most Americans now get their coverage, before we have built a proven effective, sustainable alternative to employer-based plans,” said Gerald M. Shea, an official with the A.F.L.-C.I.O. in recent testimony before Congress.
And there is little doubt that more expensive coverage does not always mean more generous coverage. Small companies, for example, typically pay more for the same benefits than large employers do. And some companies pay more in premiums because more of their employees are older or sicker.
Moreover, the cost of insurance varies in different parts of the country, so that someone with the same plan in New York or California will pay more than someone in North Dakota.
Congress may be able to balance these issues. But the problem, some policy analysts say, is that if a grand compromise ends up too narrowly defining the group of people who will end up paying the new tax, the amount of money raised might not be enough to make a difference in paying for health reform.
“I think it’s got some traction, but what happens when push comes to shove?” asked Paul Fronstin, an analyst for the Employee Benefit Research Institute, who recently completed a lengthy analysis of changing tax policy.
“If it’s not going to buy them much, why do it?” he asked.