Yes. It's a hindrance to most life paths that don't involve full-time employment. As someone with a chronic auto-immune condition I'm effectively tethered to an employer or a spouse if I want health coverage.
Should I choose pursue an art as my vocation or start a company I'd have to be willing to endure a lag in my insurance until whatever I was pursuing became successful enough that I was eligible to be covered by a trade group or had enough revenue to buy health insurance.
Guaranteed, affordable health coverage not tied to an employer or a spouse would remove a incredible burden from my life.
Once the PPACA exchanges phase in next year, will that ameliorate the problems in your case? They seem like they target this case specifically, essentially trying to turn each state's population into a large risk pool that anyone can buy into, rather than having risk pools be employer-tied.
You beat me to it! (For those who don't know, the PPACA is sometimes called "Obamacare" although it should be noted that the name is more a result of political maneuvering than the result of particularly close affiliation with Obama.)
I still think we should go all the way to single-payer. Other countries have had such success with this model that it's becoming very difficult to argue that it's inherently flawed (rather than the other way around). If the US health industry had to compete directly with any of these systems, it would go out of business tomorrow, since they offer similar care (in terms of outcome rates) at half the price per person. That doesn't even include the effects on entrepreneurship and employment!
While the ACA did little to fix the "US health care costs twice as much and doesn't deliver better outcomes" problem, it does have a good shot at fixing the preexisting condition and individual insurance debacles.
I agree it's not really a proper solution. My move from the U.S. to Denmark has been smooth when it comes to healthcare; I've been very impressed at the lack of paperwork and lack of stress over my coverage. But nonetheless I grudgingly supported PPACA, despite it seeming like a mess, because I can't see another way to solve the tied-to-employers issue that's politically feasible, at least for now.
The kind of sentiment that breeds that ignorant opinion is propegated by those that don't want to see single payer because it hurts their profits. The health insurance / for profit hospital / big pharma lobbies are aburdly massive, and like many (most nowadays) industries, they abuse their wealth to exploit faulty political process to see what they want instituted brought into law and to keep advances that invalidate their profit centers from being legal.
If you have a plan to fix the entire American political system, I will happily listen. I just spent 2.5 years working tech in US politics and it did not fill me with optimism.
When you have eliminated the implausible, whatever remains, however distasteful, must be endorsed.
I recall even Ted Kennedy somewhat later in life commenting that not reaching a compromise with Nixon's health-care proposals in the '70s, flawed as they were, was one of his major regrets, because the end result of holding out for proper reform was that here we were decades later, and nothing had gotten passed at all.
The Nixon proposal is an interesting one in retrospect. In some ways it's "left" of PPACA, despite at the time being opposed by Democrats, who preferred a real public plan and criticized Nixon's as a sellout to insurance companies. Although it wasn't single-payer, one of Nixon's proposed compromises would've actually included a public plan as an opt-in possibility (but not the default), reminiscent of the "public option" that more liberal Democrats unsuccessfully tried to include in PPACA.
That link gets UK healthcare wrong. There is private insurance in the UK too, and you can directly buy private treatment. We have a mix of both. Most people do without because the NHS covers everything they need.
There is a relatively insignificant amount of private coverage in the UK; something like 5bn versus 110bn in public coverage, and the NHS is a very large component of that 5bn (as a buyer) as well.
Massachusetts already has much of what PPACA provides as "RomneyCare", a.k.a. the Massachusetts Health Connector and MassHealth. It's exactly what allowed me (as a Type II diabetic) to strike out on my own without much concern.
I pay ~$430/mo (early 30s, single) for a high-deductible plan with low co-pays from a major carrier with no co-insurance. Do I wish my costs were less? Yes. Is it better than having to be someone's employee? Hells yes. Providing this to the entire country isn't the ideal solution for everyone, but it's a big step in the right direction.
> Other countries have had such success with this model that it's becoming very difficult to argue that it's inherently flawed ...
The British NHS discovered that by not feeding hospitalized patients they could realize tremendous savings in food, shortened length of hospital stay, followup costs, etc.
> half the price per person
Health care spending will dramatically increase under Obamacare. Americans spend a lot on health care as a lifestyle choice. Obamacare is nothing more than an attempt to recreate the housing bubble using health care.
> The British NHS discovered that by not feeding hospitalized patients they could realize tremendous savings in food, shortened length of hospital stay, followup costs, etc.
Oh, and by the way, the NHS costs us less than US public healthcare costs. Meanwhile, I can get zero deduction, all additions, money for any nights spent in an NHS hospital, private health insurance for $150 a month. How much does yours cost?
The story was covered extensively by bloggers over 5 years ago, and appeared in the press periodically since. Basically, the local NHS trusts fired a lot of hospital staff to save money. They replaced them with service contractors.
So instead of a trained nurse feeding helpless patients, a gormless food deliverer drops a tray off at the patient and leaves. On paper they are still being fed, but in reality patients were starving during the trickiest few hours of recovery. But look at the costs drop!
Similar cost cutting was done for the building caretakers and similar staff. On paper everything is the same just more efficient, but in reality the floors are not getting cleaned, nobody is bringing round tea for the surgeon in the middle of a 12 hour procedure. But look at the costs go down! Look at the readmission rate drop!
Even if true, this seems like it's focusing on one tiny aspect of NHS administration and blowing it up to declare that universal healthcare is somehow ineffective. I'm sure you can find a multitude of issues in private healthcare where cost cutting measures are systematically impacting end patient health.
When looking at whole system costs and value delivery, it's really difficult to conclude that the American healthcare system is anywhere near as efficient as other national universal health care systems.
Well, yeah, except that the starving patients bit never actually happened. That's the bit you're missing.
I know that they had some problems with some NHS trusts as they went more "efficient private sector", mainly with cleanliness, but this was not pervasive throughout the NHS and suggesting it was commonplace is a flat out lie.
Once again, I am not talking about the recent media fight about arguably-cooked statistics. I'm talking about reports from a variety of sources starting in about 2007, including nurses and doctors. If it was a disinformation campaign, it was curiously extensive for not having been used in a media campaign of the day.
Links, fact and numbers. Not "I heard it on the Internet so it must be true". If you're going to accuse the nurses and doctors who work in the NHS of criminal negligence, you ought to have the decency to at least check your facts!
And you never got around to answering my question: is your private insurance cost competitive with UK private insurance?
I see from your linkedIn profile you are a defense contractor in Oklahoma. As is typical of defense contractors I encounter, you yourself make your money from a large, taxpayer supported industry while criticizing other nation's taxpayer supported industries that actually fucking do something, instead of supporting a standing army that is 5 times bigger than it needs to be.
I have nothing against defense contractors, but I do hate ones that have hypocritical small government, conservative political views. Please feel free to put your money where your mouth is and go work in a free market industry. The taxpayers pay your company, and therefore your salary and health insurance.
You appear to be reading rather a lot between the lines. I am not, and nothing in my comment suggested, that government involvement in health care is inherently bad. Nor was there any mention of conservatism, small government, etc.
I merely pointed out that nationwide programs tend to go horribly wrong. Obamacare in particular failed before it was introduced since American health care is already cheap, and any good ideas it might have incorporated were destroyed by its secret process of creation and lack of feedback.
Incidentally, defense workers are ideally positioned as experts on national health care schemes. We have seen exactly how large one-size-fits-all programs almost always destroy themselves.
American healthcare is already cheap? Compared to what industrialized nation? Every metric out there shows this to be wrong. Instead of talking the abstract "healthcare", instead talk about the cost of individual procedures.
Regarding "one-size fits all programs destroying themselves", please explain to me how Obamacare is a one size fits all scheme? It's a conservative policy, designed by the Heritage Foundation think-tank on K Street in DC. (I have a buddy who works at the Heritage Foundation. They all loved Obamacare when Romney was implementing it, and were disappointed that it was only for a single state at the time. Suddenly when President Blackenstein was implementing it, it became evil and socialist.
Frankly, Obamacare isn't the best solution. I would have much preferred a national, single payer system coupled with private providers, like the system in Canada. You know, the one that has vastly higher approval ratings among its patients than the one in the US. But no, the Republicans scared the old people into thinking they would lose their free, socialist medical care if people under 65 got in on the action, so we got stuck with insurance subsidies.
Yes, dirt cheap. As in we could abolish all payment plans and life expectancy would barely budge. Vaccines and generic antibiotics give you the lion's share of what is possible. Blood pressure and diabetes control gives you most of the rest. If you want to get extravagent, add trivial insurance for broken bones, treatable cancer, and the like.
Obamacare is one size fits all because it tries to give everyone the same treatments. There is simply no way to give $400/month anxiety pills and $100k preventative cardic caths to every dirt farmer in Mississippi. Either the poor will get a heavily rationed version of Medicaid or the budgets will explode.
I think the Massachusetts program is a pretty good idea. I have even considered moving there to get on the rolls. If it actually works in the long run, other states would naturally have adopted similar programs. The only reason to try a single national program is to pander to voters.
One of the big problems in American health care is price manipulation. Obama could have become the first black Republican president by proposing that no Medicare provider may render services to anyone else except according to a uniform fee schedule. (If you think a Latino single mother is pissed off about a $300 aspirin, try talking to a country club Republican.)
So, regarding the uniform fee schedule, what you mean is that any provider who accepts Medicare is required to have a uniform price list which is the same for all non-Medicare/Medicaid customers? As opposed to the nightmarish price variance given based on the clusterfuck of negotiated prices between consolidated provider organizations and insurance companies?
I like that idea. It would have never, ever made it past the medical provider lobby.
Did you see the Time magazine article "The Bitter Pill"? Fascinating, and the article actually provoked the CMS agency in the Federal Gov't to release their data on the "chargemaster" prices at various hospitals vs. the negotiated Medicare/Medicaid price (which is itself negotiated to ensure it covers a hospitals labor/materials for any given procedure).
Government officials find something popular, promise unlimited amounts of it to get votes, then create a program to deliver it with total disregard for economic consequences.
Last decade they bought votes with easy mortgages. After all, even an idiot could see that home ownership was a sound investment. They won two or three rounds of elections with mortgage policy.
This decade it is health care for all! Even an idiot can see that health care for everyone is a sound investment. Just look at these scary charts of runaway growth of medical costs. And the votes roll in.
In reality, most health care consists of vaccines, blood pressure pills, diabetes pills, and the occassional antibiotics. That gives most of the benefits and costs almost nothing.
Most of the costs come from ludicrous end-of-life procedures on old people, most of the rest comes from ludicrous $500k courses of treatments for this like multiple sclerosis and stage 29 recurrent cancer. These are lifestyle choices for well-off people who would rather pay a doctor than leave an inheritance.
Trying to extend this lifestyle to every waitress will destroy the economy. It's no different than last decade's plan to put every hairdresser in a $700k mansion.
As far as "ludicrous end-of-life-procedures for old people", I agree Americans spend far too much on those, but the bulk of that is people who are 65 or older, which is outside PPACA's purview, since they are already covered by Medicare [1]. If you want to argue for Medicare to reform how it treats end-of-life coverage, I'd support that, but anyone who argues that Medicare should spend less on end-of-life heroics runs into hysterics about "death panels" refusing to pay for an extra 10 days of granny's life support. PPACA is trying to fix a fairly different problem, the under-65 segment, where end-of-life treatment is a much smaller proportion of costs.
To eliminate the problem of end of life heroics would it be possible to add something to Medicare like you get x dollars you can leave to your family if you forgo the heroics. Where x is day 10% of the cost of the heroics?
Then people have an incentive to save money but death panels aren't needed.
Of course this is assuming the heroics rarely work.
It will, in theory. In the past I would have been ridered or surcharged into oblivion had I applied for individual coverage. Expanding the pool, implementing some checks on costs, and properly operating an exchange would enable coverage for my condition and prevent me from being surcharged more than 25%? when compared with typical healthy person coverage.
That said, we're in an interesting part of the law's implementation. If you live in one of the 26-33(?) states who have currently declined to operate all or part of their own exchange (exchanges in these cases will be operated by the federal government) your state also lost some of the federal funding that was intended for use in spreading awareness and helping people to "navigate" the sign-up and purchasing process of the exchange. The worry thereafter is that if not enough people enroll through the exchanges they may not have enough leverage to keep costs down.
Add to this the idea that some state governments are actively dragging their feet with the implementation of anything exchange related (enrollment starts in October and my state has next to no information out there on the process yet) and we get the potential for messiness.
In my case, I still dream of single payer.
Disclaimer: Typing off the cuff, not a health insurance administrator, etc...
*For those interested in more about how the exchanges are progressing, I find the website of the Kaiser Family Foundation to be excellent:
yeah that's my hope - unfortunately my insurance runs out in oct and I have expensive RXes to get every month, but hopefully I can figure something out
I wish you the best of luck. Check with the manufacturer of your medications to see if they have a coupon program, the other option is to ask your docs for a 3 month supply right before your insurance runs out.
Everyone who has a chronic condition has heard no shortage of "magic bullets" for treating their condition from strangers, so apologies for being that guy.
Anyway, good luck. Hopefully someday our society views health care as infrastructure rather than entitlement, and persons in your situation can start a business without fear.
+1 this research being done. When I bootstrapped Parse.ly by doing consulting in 2009/2010, my biggest costs were rent and healthcare. I wrote about this in my blog post, "Startups: not for the faint of heart". http://www.pixelmonkey.org/2011/04/02/not-for-the-faint-of-h...
To get a good "sole proprietorship" plan for me cost >$1,100 a month. My healthcare cost nearly as much as my rent in Astoria, NYC.
I've spoken to many budding entrepreneurs in NYC, and they have told tell that the loss of an employer-provided healthcare plan is a major factor that stops people from quitting their jobs to start a company.
was this just for yourself, or a family? $1100 seems steep - a 'high deductible' HSA plan for a single person should be < $500/month - it's currently < $350 for two of us.
When I was looking (a few years ago, in California) I had trouble finding HSA plans that included prescription-drug coverage (even with a very high deductible) for less than ~$400-500/mo. There were plans cheaper than that with no drug coverage (starting around $200), but that leaves you on the hook for unlimited liability if you end up needing an expensive prescription (and some can be very expensive). I was looking for something where I self-insure the first $10k in an HSA, and then the plan covers hospitalization+drugs past that. And those exist, but not at the lowest end.
$500/month with some prescription coverage is a guaranteed $6k/year.
$200/month without prescription coverage is a guaranteed $2400/year - $3600 savings. If you know you'll have more than $3600/year in prescription costs, then this plan doesn't necessarily make sense, but unless you know you'll have that much in costs, it doesn't matter.
I was looking for something where I self-insure the first $10k in an HSA, and then the plan covers hospitalization+drugs past that. And those exist, but not at the lowest end.
Not sure what you mean. Those are the only HD/HSA plans I see - you self insure up the first $2k/$5k/$10k, and the insurance plan covers stuff after that. Most I've seen, deductibles under $10k carry a co-insurance split between you and the insurer up to a certain amount. In our case, if we just took the $10k deductible, we'd get everything covered after our initial $10k, and that is the 'lowest' end (I'm thinking you're meaning cost - maybe you mean something else?)
My worry is coverage of prescription drugs above $10k/yr. I'm perfectly fine paying for normal prescription drugs, but when I was looking for high-deductible insurance, all the cheaper plans explicitly said "no prescription drug coverage", even above the high deductible, which I didn't feel comfortable with. To me the idea of the high-deductible plans was that I cover regular costs in return for coverage in the event of a catastrophic illness. For example, in the unlikely event I'm diagnosed with MS and need a Copaxone prescription ($40k/yr), I can't self-insure that amount.
New York state law requires strict community rating, which means that an insurance company must charge the same prices to all customers.
Elsewhere people with known health problems are charged higher premiums to cover their higher health costs. In New York that's illegal, so instead everyone is charged high premiums.
Do people move/select based on this? I don't know if $1k/mo difference is enough to get people to move, since NYC is expensive (and thus obviously attractive to account for that). It would be an interesting study -- moving cities or states is way easier than countries.
Anecdotally, when we started hiring for Matasano, availability of health insurance was the #1 concern we heard from candidates. It even beat salary. Also: I almost didn't get to do Matasano, because private health insurance refused to cover my wife and my daughter.
Yup, changing jobs recently, trying to calculate pricing/coverage comparisons between health benefits took up more time than all the other negotiation/salary/vacation/etc aspects of the offer.
Yes, and duh. Corp provided health insurance means the employer controls the labor liquidity, not the employees. The hypocrite Republicans should have loved to offload the cost of health insurance onto the taxpayer, not the corp. But the power of employee control even trumps direct bottom line profits.
Wal-Mart gets it, that is why it encourages employees to seek public assistance and pays them so little that they still qualify.
Looking at the Nordic countries you might possibly make the counterpoint that publicly funded health care implies a taxation model that makes it economically unrewarding to become an entrepreneur.
Is taxation actually higher in the Nordic countries for entrepreneurs?
If you bootstrap yourself to $100k as a 1-man company in the Valley, the taxes come out to something like:
$7,000 CA income tax
$14,000 self-employment payroll tax
$16,000 federal tax (after deducting eligible portions of the above two)
-------
$37,000 (37%)
In Copenhagen, it would come out to [1]:
$8,000 labor-market contribution (AM-bidrag)
$24,000 municipal tax (kommune + healthcare tax)
$7,000 national tax (grundskat+topskat)
-------
$39,000 (39%)
The tax is 2% higher, but the Danish version of the healthcare tax buys you healthcare coverage starting now, while the American one only buys you Medicare in the future. So I think you actually come out ahead in the Danish system.
True, although a VAT is complex in its effects. Since it's applied throughout the supply chain on added value, not only at the point of sale, it acts partly as a sales tax, partly as a corporate tax, and in some cases as an excise tax. It may push up final prices to consumers, but it may also push down wages, or push down corporate profits, or have effects anywhere else through the supply chain, depending on each party's pricing power at various stages.
How it impacts an individual also depends on how they spend their money. I spend a large proportion of my money on rent, airfare, and foreign trips, none of which incur Danish VAT, so it hits relatively little of my spending.
You imply that entrepreneurs do it primarily to get rich. That may be true for some, but it's not universally true. Many of us want to do interesting work to create something meaningful, while maintaining some control over our own lives. The way the US healthcare system is set up, leaving a big employer is incredibly hard after the age of 30-35. (I've done it myself.)
It's also not obvious that Nordic countries (e.g. Finland) have less entrepreneurship than the US does. If they do (I couldn't find hard data), it's as likely to be for cultural reasons as economic ones.
Scandinavia has produced a disproportionate number of artists and athletes - another kind of "entrepreneur." No doubt access to healthcare made it easier for them to pursue their passion.
I've never understood this argument. Unless the marginal rate is actually 100% how does higher taxation cause business owners to want less money? This strikes me as employee (i.e. dollars for hours) thinking. If you had to work more hours to earn more than I could kind of see how a higher marginal rate would discourage you from doing that but the owner of a $5million/year business doesn't work 10 times more hours than the owner of a $500,000/year business.
You're right to look at the marginal tax rate but you're not considering all the options available. For goods like a hamburger it's easy to see why a tax on hamburgers makes people buy less hamburgers. Hamburgers cost more with the tax, so you can save money by buying chicken nuggets instead. This doesn't mean everyone will switch to chicken nuggets, just that many people who slightly preferred hamburgers to chicken nuggets before the tax will now switch over and slightly prefer the chicken nuggets after the tax.
For business and entrepreneurship the argument is the same. Increased taxes and other types of costs decrease the rewards so you'll end up with less of it. It's not that business owners don't want more money. It's that they are continually deciding between many options.
For example, years ago I had to decide between going to graduate school, getting a job in industry, and starting a business. The tax and subsidy breakdown is drastically different between all three. Of course tax implications wasn't the biggest factor in my decision, but it mattered.
At least in Finland entrepreneurs are taxed less than many full-time employees. Corporations are taxed at a flat percentage (about 28% of the profits), while income taxes are progressive and up to 50%. In fact, your argument doesn't make much sense.
High taxation doesn't logically imply that it's necessarily unrewarding to become an entrepreneur but rewarding to be a full-time employe. You can have high taxes for entrepreneurs and low taxes for employees, or high taxes for both, of low taxes for both, or high taxes for employees and low taxes for entrepreuners.
A lot of high-earning individuals are actually using the lower tax rate of corporations to lower their tax rate. If you look at a graph of tax rate versus income, it slowly increases, but after about 60k/year it becomes possible to lower the tax rate using tax palnning.
> At least in Finland entrepreneurs are taxed less than many full-time employees.
It is true in high income levels that you can gain with tax planning, but I wouldn't say many are taxed less. Actually taxes/costs are pretty hurting for many starting entrepreneurs or small businesses.
If entrepreneur wants money out of the company (like for rent), she pays the taxes twice. Once as a corporation (28%) and then again as capital gains tax and/or as an income tax (+ all the costs that comes with employing yourself). Rule thumb for starting entrepreneurs that you need to make at least twice the money you want to make as an individual since taxes and costs the other half.
This is more of a case that wealthy individuals have more options and sometimes they use them and not about entrepreneurship. If you don't have a high income, you're probably paying more taxes(+costs) as entrepreneur than as an employee.
>If entrepreneur wants money out of the company (like for rent), she pays the taxes twice. Once as a corporation (28%) and then again as capital gains tax and/or as an income tax (+ all the costs that comes with employing yourself). Rule thumb for starting entrepreneurs that you need to make at least twice the money you want to make as an individual since taxes and costs the other half.
An entrepreuner may be taxed the same way for his/her work as an employee is if he/she wants to. If he pays the income tax, I think that can be reduced from the corporation's profit tax just like any other corporation. There's also tax free possibilities up to 60 000€.
Yes, I'd say it's a huge one, particularly if you have or are planning to start/extend a family. I'd be overjoyed my coverage as a "self-employed" contractor were nearly as straightforward and affordable as it was in my FTE days.
This had a huge mindshare for me when deciding who to approach as a co-founder. While I'm younger and incredibly healthy, my ideal co-founder is 9 years older than me and spent much of his 20s as a semi-professional athlete. It's catching up to him now. After I approached him, I brought up healthcare and that I knew it would be important to him and that we'd figure that out together somehow. We were both disappointed at how little healthcare reform shelters entrepreneurs. In the end, languishing at someone else's company, but insured, is not the way he wanted to spend his life. If he had a family, that might have been a harder decision to make.
I recently set up group health insurance for my five person company. Before then we'd all been on individual plans. I felt really awkward making medical decisions for our employees. The HSA high deductible plan was the best option for my husband (co-founder) and myself, but I didn't know if anyone had any medical issues, or when they intended to start families.
Also, we founded our company five years ago, and it was just the two of us for years. One of the things that kept us in California was that we had selected Kaiser health insurance, and it was unclear if we could get pregnancy coverage on another plan in another state.
I am from France and moved to the US over five years ago. I have been altering between working for an employer and taking time off to work on my projects. Within the first 2 years, I realized how cumbersome it was to switch healthcare and be covered between jobs, so I signed up for a private healthcare at once. I chose to have a low general coverage but a good one for accidents, I pay $20-40 for a doctor visit, nothing for annual dental check ups. No vision or drugs coverage (what's the point, for expensive drugs, the same drugs from the same labs are still cheaper in Mexico than a good insurance copay, and I have 20/20 vision). My insurance has been $90 per month for the first two years and recently went up to about $110 per month. When working for an employer, they would sometimes pay some extra cash when denying their coverage, if they don't, just add their insurance but keep the private one. My understanding is that the PPACA will make the cost of those single payer insurances go up a bit.
That's great for you, obviously you have no documented chronic health conditions that would exclude you entirely from private insurance. Unfortunately for me, I do, and am considered uninsurable as am individual, leaving only employer sponsored group coverage as a viable option until next year.
I actually do have a minor chronic condition, causing inflammation of my sinuses and a subsequent poor sleep/fatigue. I can permanently cure it by opting for a nasal surgery which my private insurance is willing to pay most of the cost. Until then, I treat it with a nasal corticoid, one flask cost $150 in the US, $45 with the drugs copay I had on my first job, but only 25 euros shelf price in France, I just refill when I visit (I use about 5 flasks a year). I definitely agree that the PPACA provision easing coverage for those with a pre-existing condition it a good thing.
I agree, and when making the conscious decision to get a entry-level private insurance, I made the calculation that what I save on a lower price insurance I could use to spend more on healthier food, in addition of me being physically active, and in my 20's, which makes me a lower risk profile and try to take advantage of it. I also realize that as I get older, I will probably need to set more aside for health-related coverage.
> for expensive drugs, the same drugs from the same labs are still cheaper in Mexico than a good insurance copay
If you're lucky enough not to get any major condition, sure, you can buy antibiotics or whatever from Mexico. But even at Mexican prices you will probably not be able to pay out of pocket for something like Avastin (cancer) or Copaxone (multiple sclerosis).
Yes, if insurance had nothing to do with your employer, the employer would be easier to leave.
Imagine if your house and car and food were all paid for by your employer. And with a tax subsidy that makes it seem cheaper to do it that way than pay for these things on your own. Yes, leaving an employer would be a complicated choice.
I'm also not convinced employer insurance is the deal people think it is. When I left my last full time job and continued the insurance using COBRA, it cost me $400 a month. I think you wind up subsidizing everyone having a baby or that do have major health problems.
I'm in my late forties and have a high deductible policy that only cost me $150 a month before Obamacare made it go up to $260. I don't see it as much of an impediment, even now. People can spend more on coffee.
Granted, if you have poor health or a family, this can cost quite a bit more. But these things by themselves can often be a greater barrier to entrepreneurship than the cost of insurance.
The larger the employer, the better the deal they can work out with the insurance provider for their employees. This is definitely one of the reasons why jobs with IBM or UBS, say, are more desirable to most folks than the assured struggle called entrepreneurship.
Preferred pricing for large employers, vs small employers, vs individuals never made sense to me except for private insurers to divide up groups to maximize profits. If insurers were simply trying to provide best-value, then every customer should be in the same risk pool and excess administration costs to create and apply different rules for different groups could be eliminated. Instead, all the private insurers create many groups with complex rules, different coverage levels, then have to administer all these slightly different rule sets. That complexity then has to be dealt with by everybody, the customer, the health provider, as well as the insurer themselves.
Profits are possibly maximized but value provided to customers and society is destroyed. I think this is pretty much reflected in the roughly 2x per capita costs for private healthcare in the US vs costs for universal care in many other first world nations.
Should I choose pursue an art as my vocation or start a company I'd have to be willing to endure a lag in my insurance until whatever I was pursuing became successful enough that I was eligible to be covered by a trade group or had enough revenue to buy health insurance.
Guaranteed, affordable health coverage not tied to an employer or a spouse would remove a incredible burden from my life.