The Small Business Health Care Crisis

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148 and P.L. 111-152) contains several provisions to encourage employer-sponsored health coverage, particularly among small businesses. The provisions that most directly relate to small businesses are (1) an employer penalty for not providing health insurance, (2) a tax credit to increase the affordability of health care for the smallest firms, and (3) small business health insurance exchanges designed to increase plan options and lower plan costs. Several events have altered the ACA's implementation since its enactment in 2010. Most notably, the Obama Administration delayed the implementation of the employer penalty and part of the small business health exchanges from 2014 to 2015 to allow more time for developing these provisions and allowing firms to come into compliance. Subsequently, the Administration suspended the penalty for employers with fewer than 100 full-time equivalent (FTE) employees for an additional year (until 2016). These delays have added to uncertainty over the potential effects of the ACA on small businesses. First, this report explains how employer-sponsored insurance can be used to address concerns about health insurance coverage and cost. Second, it summarizes the three ACA provisions most relevant to small businesses, listed above. Next, it analyzes these provisions for their potential effects on small businesses. Finally, this report presents several approaches that could address some concerns associated with these provisions (particularly the employer penalty). According to analysis of the most recent employer size and insurance coverage data, the ACA's employer penalty is structured so that it could exempt approximately 96.2% of employer firms simply because these firms would be too small and thus fall below the employer penalty threshold of 50 FTE employees. These exempt firms account for approximately 27.6% of all workers. After accounting for firms that already provide insurance, less than 1% of employer firms could be subject to the employer penalty. Although 72.4% of all employees work for firms that are large enough to be potentially subject to the penalty, only about 2.4% of employees work in firms that do not already offer health insurance. Less than 4% of small businesses that could have been eligible for the small business health care tax credit in 2010 actually claimed it. According to a report by the Government Accountability Office (GAO), many business owners felt that (1) the credit was too small of an incentive to begin offering insurance; (2) even if these small employers offered health insurance, some employees declined coverage because they could not afford their share of the premium; and (3) the rules were too complex. President Obama has proposed simplifying and expanding the credit.

The private health insurance industry is unable to provide nearly 40 million Americans with basic health care. Relying on data from a wide range of publications about this secretive industry, Lawrence D. Weiss investigates the causes of the industry's problems and analyzes the social effects of the growing crisis. The causes include excessive overhead costs, widespread inefficiency, and exemptions from antimonopoly regulations; the social effects include small businesses' inabilities to provide adequate coverage for their employees, the reluctance of many carriers to insure certain social groups, and the disproportionate burden on minorities. Addressing these dilemmas, Lawrence D. Weiss offers a timely and important analysis of the health insurance crisis in America.