Forward Thinking

Forward Thinking

Issue: April 2021
Source: Wealth Protection Planning for Orthopaedic Surgeons and Sports Medicine Specialists and Wealth Planning for the Modern Physician: Residency to Retirement are available free in print or by ebook download by texting OT21 to  844-418-1212 or at Enter code OT21 at checkout.
Disclosures: Bhatia, Foos and Mandell report no relevant financial disclosures.
April 19, 2021
5 min read

What orthopedists should know about Biden’s tax proposals

Issue: April 2021
Source: Wealth Protection Planning for Orthopaedic Surgeons and Sports Medicine Specialists and Wealth Planning for the Modern Physician: Residency to Retirement are available free in print or by ebook download by texting OT21 to  844-418-1212 or at Enter code OT21 at checkout.
Disclosures: Bhatia, Foos and Mandell report no relevant financial disclosures.
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With the Democrats controlling both houses of Congress, there is a likelihood that President Joe Biden’s tax proposals may pass this year.

To understand what new tax laws might look like, we can examine what has been proposed, what Biden talked about during the campaign and some ideas that have been brought up since the campaign. Although we have no way of knowing what tax law will be passed, it is helpful for orthopedic surgeons to know at least what has been discussed as they connect with advisors to have 2020 tax returns prepared and look ahead to 2021 tax planning.

Income taxes

In terms of income tax rates, Biden has proposed a return of the top individual tax rate to 39.6%, which is up from the current 37%. This would affect those with taxable annual income above $400,000. There are a lot of questions about what that means. Is the $400,000 threshold for single taxpayers, as well as taxpayers who are married filing jointly? Will there still be a difference at the top rate for those two classes of taxpayers?

Doctor Name, MD
Sanjeev Bhatia
David B. Mandell
David B. Mandell

Keep in mind that, under current law, the top individual tax rate is slated to go back up to 39.6% in 2026 because the individual portions of the tax law that was passed at the end of 2017 were temporary.

Biden’s tax proposal also would increase the tax rate for C corporations from the current flat tax rate of 21% to 28%. This is still well under that 35% rate that many medical practices were taxed at as personal service corporations in the past, but it would be an increase from today’s position.

Social security taxes

A significant change for many orthopedists would be Biden’s proposal to assess social security tax on wages above $400,000. Under current law for 2021, employees pay 6.2% and employers pay another 6.2% on the first $142,800 of wages per employee. Biden’s proposal would have that same tax — 6.2% for employees, 6.2% for employers — assessed again once wages exceed $400,000. This would create a wage gap from $142,800 to $399,999, where there would not be any social security taxes on the wages. However, once an employee’s wages reached $400,000, social security taxes would again be assessed. Remember that this tax is in addition to Medicare taxes of 2.9% to 3.8% which are already paid on an unlimited amount of wages.

The consequences of this proposal, if it becomes law, include placing an increased importance on how orthopedic practices are structured tax-wise and how they pay compensation to the physician owners. For example, if an orthopedic practice is taxed as an S corporation, it will be even more important for the physician owners to determine how they can minimize the amount of compensation as wages while remaining “reasonable,” as required, and also maximize the amount of owner distributions.

Corporation practices, which typically try to eliminate net taxable income at the corporate level by paying out bonuses to the owners in the form of W2 wages, may become even more problematic tax-wise if this proposal becomes law. We would not be surprised if many orthopedists look to convert C corporations to S corporations as part of their strategy under a new tax law.

Capital gains, qualified dividends

If passed, the segment of Biden’s tax proposal that concerns capital gains and qualified dividends would represent a major change from the status quo for the highest-earning orthopedists. His proposal includes taxing capital gains and qualified dividends at ordinary income tax rates for taxpayers who earn more than $1 million. Currently, the tax rate on long-term capital gains and dividends for taxpayers in the highest tax bracket is 20% plus 3.8% net investment income tax under the ACA for a total of 23.8%.

This proposal would bring capital gains taxes for those who earn more than $1 million dollars up to the 39.6% rate, presumably still with the 3.8% surtax. If this proposal becomes law, these earners will need a keen focus on managing capital gains and harvesting losses against gains, as well as a sharpened awareness of the tax drag on investments.

Also, for orthopedists who sell or merge their practices, installment sales may become more valuable by dictating that income is received during the course of more than 1 year, thereby attempting to keep the physician’ s income below the $1 million threshold.

Itemized deductions

Biden has proposed capping the value of itemized deductions at 28% for those in the top tax bracket. For example, a physician at the 39.6% tax rate who deducts mortgage interest would get a benefit of only 28 cents for each dollar of the deduction instead of 39.6 cents on the dollar. In other words, these deductions would be worth less to a high-income taxpayer in terms of their capacity to reduce taxable income.

Biden has also proposed to restore the Pease limitation for individuals with more than $400,000 in taxable income. The Pease limitation, which essentially reduces itemized deductions for high-income taxpayers, was eliminated by the 2017 Tax Cuts and Jobs Act.

There is one piece of good news, especially for orthopedists in states with high state and local income taxes or high property taxes. It has been reported that Biden, along with House Speaker Nancy Pelosi, D-Calif., and Senate Majority Leader Charles E. Schumer, is in favor of getting rid of the current state and local tax (SALT) deduction limitations, which limit a taxpayer to a maximum total deduction of $10,000 for all state and local income taxes and real estate taxes. If the SALT limitations are repealed, taxpayers could go back to being able to deduct all of their state, local and real estate taxes on their federal tax returns.

Childcare credits

For orthopedists who pay for childcare, the current law limits expenses that can be used toward the childcare and dependent care credit to $3,000 per child per year or $6,000 for multiple children. For taxpayers with adjusted gross annual income above $43,000, the credit is limited to 20% of these expenses. Biden’s proposal includes an increase in eligible expenses to $8,000 for one child and $16,000 for multiple children with a credit of up to 50% of those expenses available for taxpayers who earn up to $125,000.

Estate/gift taxes

Under Biden’s proposal, the estate tax exemption would be reduced back to 2009 levels of an individual estate tax exemption of $3.5 million and a gift tax exemption of $1 million. Currently, the estate and gift exemptions are both more than $11 million per person.

Not only do we not know which tax proposals will become law, we also do not know when any new tax law would become effective. A new tax law can be retroactive to January 1 of the year it passes or may not take effect until January 1 of the following year. In other cases, new tax law could be partially in place for the year of passage (ie, 2021), with some aspects effective in 2021 and others not effective until 2022.


While it is important for physicians to prioritize forward-looking tax planning every year, it is even more so this year with the possibility for significant tax law changes on the horizon. Orthopedists should commit to staying updated on the present proposals that may become part of a new tax regime and consider planning options that may help to mitigate any detrimental impacts of a new law.