Owners of very small businesses—those with fewer than 50 employees—are not required by the Affordable Care Act to provide health coverage to their employees. But that doesn’t mean those employers don’t feel a sense of obligation to their employees or struggle with the decision to forgo a company plan.

Especially since the ACA also mandates that each person have health insurance or face penalties. The individual mandate affects the business owners themselves, who must purchase insurance plans for themselves and their families. For self-employed business owners, health coverage is an ongoing battle between finding affordable medical insurance and being able to cover enough operating costs to keep their company viable.

Rebecca Yates, president of Ark Insurance Solutions, is the owner of five business ventures and does not offer health insurance to her employees. Wanting to provide a level of assistance for her workers, Yates conducted a health insurance analysis to determine which option would work best for their families. After talking with each of her employees, she decided against a company-backed plan.

“It would have cost $400 a month per employee with the company picking up half of that cost,” she says. “But through the exchange, which is based on income and number of kids, they could get policies for $20 a month. My employees were better served by not offering insurance because if it is offered, and considered affordable, the employees can no longer get a subsidy through healthcare.gov.”

In September 2016, the National Federation of Independent Business (NFIB) released a survey given to small business owners, asking them to rank 75 issues according to how much it affected their business. The survey showed 52 percent of small business owners named the cost of health insurance to be a critical problem

The NFIB’s Small Business Problems & Priorities report also showed the cost of health insurance was the number one issue facing small businesses, topping the list since 1986, and causing more concern than government regulations and federal taxes.

Finding creative solutions

Small business owners have several options when it comes to offering health insurance, but even then the options aren’t always affordable.

SHOP Marketplaces have plans for employers with less than 50 employees, but those plans usually have requirements like a mandated contribution from the employer or a high percentage of enrolled employees.

Another option, a Private Health Insurance Exchange, is a medical insurance shop that offers at least two plan options and provides a recommendation for what fits the company’s needs.

The more traditional health insurance co-ops allow business owners to share costs with other employers to lower rates. Finally, private small group plans are still a viable alternative. These groups usually offer more options and carriers compared to SHOP.

Janice Boes does not offer a health insurance plan for her employees. As the CEO and founder of Premiere Event Services and Pierpont Place, she has 10-15 full- and part-time employees.

She’s found that not providing health insurance can be a make-or-break deal when it comes to hiring and retaining employees. “Some employees will leave because they have to have insurance. It’s heartbreaking to lose someone over a benefit we should be able to provide.”

With rising insurance costs, Boes has looked for creative ways to provide alternative benefits to her workers, while searching for affordable coverage for her own family.

One product she offers is a supplementary accident coverage plan through Aflac. The supplemental plan is a level of protection for employees and their families if they encounter a serious illness or expensive accident. Boes also provides a financial bonus that employees can use toward an individual health insurance plan or a rainy day health fund.

She also created a health and wellness program that provides incentives for employees to get fit and stay healthy. “A healthy mind and a fit body can help keep us out of the emergency room. It’s important for me to take care of my employees. I want them happy and safe, and as healthy as they can be,” Boes says. “Does it take care of everything? No. But it’s at least something I can offer my employees.”

For her family, Boes purchased a supplementary plan that covers cancer management. In the event of a cancer diagnosis, the plan will cover everything from treatment to surgery and recovery. She knows a cancer diagnosis without insurance can easily mean bankruptcy.

“My insurance costs keep going up—and we’re healthy,” she says. “I have full-coverage insurance and still had to pay 100 percent for a prescription. I know it’s a cliché, but the rich get richer and the poor get poorer. Middle class America is paying for everything.”

A game of chance

Though the oft-maligned ACA is definitely in need of its own medical check-up, there are several benefits in the plan that business owners hope can stay in place once the reform is finalized. They’re carefully watching the new presidential administration to see if things like coverage for pre-existing conditions and adult children up to age 26, as well as unlimited payouts will stay in effect.

Yates spends time on Capitol Hill, advocating for ways to improve the failing healthcare system, but she knows it’s an imperfect science and things fall through the cracks and end up not being covered. Big problems include the rising cost of prescriptions, hospital care and the number of malpractice cases that fan the flames in the insurance crisis.

“Insurance was designed to be a pool. It was created by ship owners to protect ships. Everyone paid into the pool and if a ship got destroyed, the owner got the bucket of money to buy a new ship,” Yates says. “But now, it’s not a pool. People think they have to get more out than they put in. As long as people have that mentality, it will continue to blow up the system.”

Shelly and Matt George have operated Image Wear for 30 years, doing screen printing for thousands of companies. Offering health insurance to their employees was never an insurmountable problem until the last decade, as higher premiums and deductibles made it difficult to find plans they could afford.

Their own family suffered, too, as their monthly premiums rose to $2,400 and finally broke the bank. They canceled their health coverage and signed up with Christian Healthcare Ministries. The nonprofit cost-sharing group encourages members to voluntarily share the costs of medical bills. It’s not an insurance company, but a cheap alternative to business-destroying premium costs.

Shelly George’s employees are not insured through Image Wear. In the past, employees would purchase their own plans and would get reimbursement for part of the cost. As prices jumped higher each year, reimbursement was no longer an option.

Many of her employees have no medical coverage and some are on their parents’ plans, but even then they can’t afford to go to the doctor because the co-pays are so high. George looked into purchasing a catastrophic plan that would raise the deductible from $3,000 to $10,000, but it only dropped the premiums a couple hundred dollars.

“Most people are just not going to the doctor,” George says. “I have an employee with high blood pressure and no insurance. He’s playing Russian roulette because he can’t afford prescription prices.”

Healthcare mandates have had a definite impact on the growth of the Georges’ business. Not able to find affordable insurance for their workers, the Georges have purposely never hired more than 50 employees (the point at which the law mandates employers offer coverage) because the healthcare costs would end the company.

“We’ve just got to be healthy because we can’t afford not to.”