Policy Agenda: Healthcare

Access to affordable, quality healthcare significantly impacts small businesses because they and their employees have historically comprised a disproportionate share of the working uninsured, while those small businesses with coverage paid 18% more on average than larger companies. This changed when the Affordable Care Act (ACA) was enacted, which strengthened the small group market and provided healthcare to millions of small business owners. Indeed, more than half of all ACA marketplace enrollees are small business owners, self-employed or small business employees. But recent rollbacks to the ACA—including expanded access to junk plans and association health plans—have destabilized the market and caused small businesses and their employees, particularly women and people of color, to pay higher premiums at a time when affordable coverage is needed most. 

We must protect and strengthen our nation’s healthcare system and the ACA. This will help close inequities in health coverage that plague our small business communities. 

Top three priorities for Congress to support small business

• Strengthen the current system of subsidies that has helped make healthcare more affordable for many entrepreneurs. For example, we recommend offering additional cost sharing to those who are otherwise eligible for premium tax credits and have incomes below 400% of the federal poverty level (FPL) and expanding subsidies to people making up to 600% of FPL. 
• Protect consumers from surprise billing by limiting patient cost-sharing to the amount they would owe to an in-network provider, setting a payment standard regarding what insurers owe providers in these situations and prohibiting providers from balance billing patients.
• Provide a special open enrollment period for individuals who lost their job or shut down their businesses as a result of COVID-19.

Expand access to coverage

• Guarantee health protections for individuals with pre-existing conditions. This includes ensuring that Section 1332 "state innovation" waivers uphold the ACA's principles and do not encourage people to sign up for less comprehensive coverage or destabilize the insurance markets.
• Close the coverage gap by continuing to expand Medicaid in states that haven’t done so. Roughly 616,000 small business employees could gain coverage if all remaining states expanded Medicaid.
• Provide additional health coverage options by allowing people to buy in to Medicare or Medicaid. 
• Ensure access to reproductive healthcare and birth control, which our polling shows is critical to women entrepreneurs as they launch and grow their businesses.

Aggressively address underlying issues of cost and affordability

• Address the rising costs of prescription drugs, as these costs are hurting small business owners' bottom lines. 
• Pass healthcare tax equity for the self-employed so that freelancers can deduct their healthcare expenses from their FICA tax obligations-just like other business entities. 
• Strengthen market stability
• Block the extension of short-term, limited duration insurance plans. These plans are intended to fill gaps in coverage in the event of job loss or other life changes, but are not required to cover essential health benefits like prescription coverage or mental health treatment and can come with hefty deductibles. Leaving them in place will cause younger and healthier people to leave the marketplaces and create an unbalanced risk pool that raises costs for everyone else.
• Oppose efforts to implement association health plans (AHPs), which would encourage younger, healthier groups to purchase inadequate coverage, thus increasing costs for most of the small group market. 
• Create a reinsurance program to help stabilize premiums in the health insurance marketplaces by providing support for insurers facing high financial losses. 
• Guarantee payments to insurers for cost-sharing subsidies, which will help many entrepreneurs and small business employees afford health coverage.
• Strengthen risk adjustment for carriers in order to keep costs down for consumers and incentivize insurers to remain in the health insurance marketplaces. 
• Reinstate the individual mandate to ensure that healthcare risk pools are as robust as possible, bringing down healthcare costs for everyone.