The Agenda for America's Entrepreneurs: Healthcare

Access to affordable and quality healthcare coverage remains central to the success and economic wellbeing of America’s small business community. But as the cost of providing healthcare coverage continues to increase, small business owners are left with difficult options that may include increasing employee contributions, switching to plans that offer less coverage or dropping health insurance altogether. None of these options offer a sustainable pathway forward for small business owners who want to support the health and wellbeing of their employees but simply cannot afford the cost of providing healthcare coverage. That’s why Small Business Majority is working to address the shortcomings and inequities of the healthcare industry to better ensure that small business owners and their employees can access affordable and high-quality health coverage. 

• Make permanent the Inflation Reduction Act’s enhancements to the Affordable Care Act’s premium tax credits by passing the Health Care Affordability Act (H.R. 1692). The IRA-enhanced subsidies have cut premium payments by an estimated 44% ($705 annually) for marketplace enrollees who claim the credit, bringing down the cost of healthcare for small business owners and their employees. 
• Extend healthcare coverage to entrepreneurs and their employees in the 10 states that have yet to expand Medicaid by passing the Bridge to Medicaid Act of 2024. The expansion of Medicaid, paired with many of the increased subsidies under the ACA, has allowed more than 6.2 million small business owners and self-employed individuals to gain healthcare. The rate of self-employed individuals covered through Medicaid rose from 7.3% to 11.6% between 2013 and 2016 after Medicaid expansion began in 2014. 
• Protect the small group marketplace from large price spikes by limiting the use of health plans that do not have the same coverage standards as those in the Affordable Care Act (ACA), such as short-term plans and association health plans (AHPs). While AHPs may reduce healthcare costs for certain small businesses with younger, healthier employees, businesses with employees needing comprehensive coverage, including for pre-existing conditions protected under the ACA, could be priced out of insurance plans due risk imbalances in the insurance pool. 
• Allow employees who are offered employer-sponsored insurance to instead opt to receive premium assistance for marketplace coverage. Many times, employers will purchase a costly plan to offer competitive benefits, but in some cases, employees can find better and cheaper coverage though their local marketplace, saving both the small business owner and their employees from paying unnecessary out of pocket costs on healthcare. 
• Hold Pharmacy Benefit Managers (PBMs) accountable by improving federal oversight into PBM practices. This includes requiring price agreement disclosures and detailed reporting, setting reimbursement standards, improving contract transparency and coordinating with state attorneys general. 
• Codify Roe v. Wade to protect the right to reproductive healthcare, including abortion, by passing the Women’s Health Protection Act (H.R. 12/S. 701). In a national poll conducted by Small Business Majority, 72% of women entrepreneurs across the political spectrum support a federal law to ensure women have the right to abortion care and more than one quarter of respondents said that the decision to overturn Roe v. Wade has had a negative impact on their employees and on them personally. 
• Expand access to a full range of reproductive healthcare for women entrepreneurs and their employees by passing the Right to Contraception Act (S. 4381/ H.R. 4121). Small Business Majority research found that 64% of women small business owners say their ability to decide when or if they have children has allowed them to advance in their career and start their own businesses and 76% agree that all women should have access to reproductive healthcare, including abortion care and birth control. 
• Slow the onslaught of anti-competitive hospital mergers and acquisitions and ensure that vertical integration between hospitals and physicians is done to improve patient outcomes, rather than to bolster profits and market power. This can be done by ensuring that the Department of Justice, Federal Trade Commission and Department of Health and Human Services have access to ownership and acquisition data of healthcare facilities and large hospital chains, which will allow the agencies to better evaluate proposed hospital mergers and identify problematic trends or data points that could lead to poorer quality of care and increased costs for consumers.  
• Prohibit anti-competitive hospital contracting practices with insurance companies, such as large hospital chains using their market power to force insurance companies to include certain high-cost providers in their networks. This lack of competition and transparency between insurance and healthcare providers has led to skyrocketing medical costs and increased burdens on small business owners and their employees. 
• Expose predatory billing practices by requiring greater transparency in the healthcare system through the Lower Costs More Transparency Act and by implementing site-neutral payment reforms. These reforms would reduce incentives to consolidate, which leads to increased prices and unfair negotiations, and reduce the cost of care in hospitals and off-campus facilities. 
• Slow down consolidation driven by private equity in healthcare industries by mandating reporting of ownership, profit and price information from private equity-owned healthcare facilities. Private equity acquisitions of healthcare facilities, which occur through debt and leverage buyouts, vertical integration, or roll-ups and mergers, have been directly linked to increased health care prices and utilization which drives up costs for employers and employees alike. 
• Create a national cost commission to set reasonable hospital reimbursement rates based on quality and outcomes.  This model has worked well for certain states and is needed at the federal level to expand efforts to reduce the cost of care.