A Pioniq Rebuttal - Changes needed for Startup Healthcare - McStartup Blog - McStartup

A Pioniq Rebuttal - Changes needed for Startup Healthcare

Posted on Monday, March 29, 2010 at 11:36AM by

Jeff |

While political topics are seldom covered in this blog, it seems inevitable that they'd come up now, with all of the changes going on that could effect startups and small business. Still, I probably wouldn't have written if not for the blog post of my good friend and co-founder Peter Fuller, recently made about the benefits of healh care reform for small business. I have a differing opinion about the issue, and while normally I would argue with him over a cheeseburger at lunch, I can’t do that because he’s on vacation this week. Thus, he will have to suffer my wrath via the blogosphere. LOL.

First and foremost, I will agree wholeheartedly with Peter that the health insurance system in the US is absurd. The concept that health insurance is provided by your employer, versus being something you get for yourself, defies logic. Your employer does not (generally) pay for your car insurance or your homeowners/renters insurance, so why health care? You can trace back the history to where this originated, (and it stems from yet more government regulation and tax code manipulation), but suffice it to say that it doesn’t make logical sense to have your insurance tied to your employer. It limits your choices and creates an artificial tie to your employer that is completely unnecessary.

Peter argues that the SHOP Exchange, a shared pool of insurance for small business will help startups. I disagree.

Some of the benefit touted for small businesses is a 35% tax credit to offset the cost of providing health insurance. There are a number of limitations to this scheme that make in ineffective for many startups:

1) the business must have fewer than 10 employees and an average salary of less than $25,000 per year.

The average per capita income in the US is $37,000 per year. Even in the poorest state, Mississippi, the average income is $27,000, well north of the maximum average salary to qualify for this tax credit. Most states are north of $35,000 – 40% higher than the minimum threshold.

Second, the offset to the insurance cost is a tax-credit to the company. In order to get a tax credit, a company has to be in a situation where it is paying taxes already. Many startups are not making a profit, and therefore are not paying income taxes to begin with.

Even if you hire people at 40% below the average salary in the US for the early days of your startup, you are almost certainly going to need to increase salaries before you start churning out a profit. So by the time you actually can utilize the tax credit (when earning a profit), you’ll no longer qualify because your average salary will be over $25k/year.

So to get the credit, you must (1) be profitable, (2) pay an average salary of under $25k, and (3) have 10 or fewer employees.

In fact, the only age group where the average income is below $25,000 are those in the 15-24 year old age group, largely consisting of part-time employees.

While there are certainly some small businesses that qualify, I would hardly call such a system a boon to startups. I suspect no one who visits this site has their eyes set on creating a company that pays it’s employees and owner next to nothing while squeaking out a profit and never growing past 10 people. That’s hardly a vision of the American Dream that drives people to become entrepreneurs.

For all that, the estimate is that premiums will drop 1-4%. I suspect the margin of error for such a calculation is north of that range, but I’ll let it slide for the moment. Using Peter’s own numbers suggests that for his group plan, he would save $6.75 a month.

Call me a skeptic, but I don’t believe the make-or-break decision on starting a new business is going to come down to seven bucks a month.

2) Employers can choose not cover employees. The minimum penalty is $750 per employee for businesses with over 50 workers

If you don’t provide adequate coverage for your employees, there *was* a $750 fine. Peter argues that this gives employers an out, in that they can just pay the $750 and not provide health insurance if they so choose.

While we won’t know how the law will play out until someone tests it, it is likely to not be this easy.

First, in the “fix-it” bill that was approved after the first legislation became law, this penalty was increased to $2,000, so the $750 number is no longer correct.

Second, if an employer does not provide insurance and an employee gets seriously ill, it is likely that the employee would have grounds for a lawsuit, given that the employer was knowingly in violation of federal law by not providing insurance. The courts will have to decide, but it seems plausible – even likely – that a court would find in favor of the employee, force the employer to provide the coverage, force the employer to pay for damages incurred by not proving coverage, and also sustain the $2,000 penalty.

As such, the $2,000 penalty is not an out so much as it is a near guarantee that you’ll be paying for healthcare, damages, and the $2,000. That is not a help to startups at all.

3) Simple economics suggests insurance premiums will increase.

Regardless of where you stand on the morality of the issue, you can’t argue with the fact that forcing insurance companies to eliminate lifetime maximums and eliminate pre-existing exclusions. Previously, you could, for example, purchase a policy with no lifetime limit, or purchase a policy with a limit of say $2 million in maximum benefit. Guess what? The policy with the cap was cheaper – of course.

So no, in eliminating these things, the rates will have to increase. Some hold out hope that by increasing the number of people in the pool that are young and healthy, it will offset these increases. I remain skeptical of this math, as the sheer volume of people who already did have coverage and would experience a premium increase grossly outweighs the number of new people added to the insurance pool as a result of the legislation.

You have probably also read about the “Cadillac Tax” that is part of the new law. This provides for a 40% tax on any health plan that exceeds $10,200/year for an individual. The rate itself is absurdly high, but what you may not know is that the insurance company itself pays for the tax due. This will, or course, result in higher insurance premiums as well, and would likely be spread across the entire insurance pool, not just on those plans were the tax was triggered.

By the way, Kaiser reports that in 2009, the average premium for employer-provided health care was over $13,000.

Conclusion

It seems logical and inevitable that this law will result in increasing insurance premiums that will negatively impact all businesses, large and small. Tax credits are of no use to most early stage startups, and the SHOP programs have a near meaningless cost benefit even if you take the CBO numbers at face value.

I am all for health insurance system changes, particularly those that would help move insurance choice directly into the hand of individuals where they can choose from a variety of plans that meet the needs of their families. Let people decide if they want to pay for a plan that excludes an existing condition or allows for coverage, covers unlimited benefits, or caps out at $2M in benefits. I see no reason to limit consumer choices.

Certainly allowing insurance companies to write policies where they can drop the insured when a health problem arises is borderline fraudulent, even if such provisions exist in the fine print. If health insurance were primarily purchased by individuals rather than companies, I suspect consumer protections would have already been put in place against this kind of practice.

What will benefit startups is a more competitive insurance marketplace, where a larger choice of plans and providers lowers cost. What will benefit them even further is a market in which insurance is held by the individual, so that when you are trying to convince that prospective employee to leave their current employer and join your startup, an hour long conversation about the difference between your health plan and their current health plan ensues. If insurance traveled with the individual, then they can weigh the benefits of the new job with the old more easily, without the burden of trying to navigate the switch from one plan to another without triggering a lapse in coverage and putting themselves and their families at risk.

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