آیا بیمه سلامت بر اساس کارفرما مانعی برای کارآفرینی است؟

The focus on employer-provided health insurance in the United States may restrict business creation. We address the limited research on the topic of “entrepreneurship lock” by using recent panel data from matched Current Population Surveys. We use difference-in-difference models to estimate the interaction between having a spouse with employer-based health insurance and potential demand for health care. We find evidence of a larger negative effect of health insurance demand on business creation for those without spousal coverage than for those with spousal coverage. We also take a new approach in the literature to examine the question of whether employer-based health insurance discourages business creation by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. We find that business ownership rates increase from just under age 65 to just over age 65, whereas we find no change in business ownership rates from just before to just after for other ages 55–75. We also do not find evidence from the previous literature and additional estimates that other confounding factors such as retirement, partial retirement, social security and pension eligibility are responsible for the increase in business ownership in the month individuals turn 65. Our estimates provide some evidence that “entrepreneurship lock” exists, which raises concerns that the bundling of health insurance and employment may create an inefficient level of business creation.

The predominant source of health insurance in the United States for working-age adults is employer-provided health insurance. Nearly two-thirds of adults under age 65 and three-quarters of all full-time workers have health insurance through employers (U.S. Census Bureau, 2007). A potential cost of this reliance on employer-provide health insurance is the non-portability of insurance across employers potentially resulting in “job lock.” Workers may be reluctant to switch jobs when otherwise optimal because of the possible loss of coverage due to pre-existing condition exclusions, waiting periods on new jobs, loss of particular insurance plans, and disruption in the continuity of care with their healthcare providers. Concerns about disruptions in health insurance coverage could also influence the decisions of individuals who are contemplating starting new businesses (Holtz-Eakin et al., 1996). Such individuals who are currently covered by employer-sponsored health insurance would eventually lose that coverage if they leave their job. Potential business owners could face high premiums in the individual health insurance market and the possibly prohibitive health costs of being uninsured. Furthermore, changes in health plans and providers may be disruptive and costly. New entrepreneurs may also be exposed to pre-existing condition limitations and waiting periods for coverage if they have a spell of uninsured unemployment between their employer-provided coverage and their new health insurance policy.1 Unless they have alternative sources of health insurance coverage, such as through a spouse's employer, this health insurance conundrum may influence their decision to start a new business. All of these factors suggest that the U.S. focus on employer-based health insurance may restrict the formation of new businesses and create the additional inefficiency of altering who becomes and who does not become an entrepreneur. Although concerns that health insurance costs are “killing new-business dreams” (Egerstrom, 2007 and Keen, 2005) and that health insurance issues distort employment choices to the detriment of start-ups (Leonhardt, 2009 and Baumol et al., 2007) have been voiced for several years, the issue has taken on a new salience with the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA). In the debate leading up to the passage of PPACA, President Obama noted the concern: This is something I hear about from entrepreneurs I meet – people who’ve got a good idea, and the expertise and determination to build it into a thriving business. But many can’t take that leap because they can’t afford to lose the health insurance they have at their current job.2 Under PPACA, states will create “exchanges” where individual consumers can purchase insurance, and insurers will not be able to apply pre-existing condition exclusions and price premiums based on health status.3 Although these features of PPACA have the potential to weaken entrepreneurship lock, PPACA exempts existing health plans from most regulations potentially allowing disparities in the value of health coverage to persist for some time (Eibner et al., 2010). Given these concerns, it is surprising that only a handful of studies have examined whether employer-provided health insurance limits business creation. The few studies in the literature find mixed results, with some estimating that health insurance reduces transitions into self-employed business ownership by as much as 25% and others finding no evidence that health insurance reduces business creation (Holtz-Eakin et al., 1996, Madrian and Lefgren, 1998, Bruce et al., 2000, Wellington, 2001 and DeCicca, 2007). The lack of research on the topic contrasts sharply with a much larger literature that examines the effects of employer-provided health insurance on employer-to-employer mobility (see Gruber and Madrian, 2004, for a review). In this paper, we address the lack of current research on the topic of “entrepreneurship lock” by providing a new study of whether the U.S. health insurance system impedes business creation. We use panel data created by matching consecutive years or months of the Current Population Survey (CPS) and two identification strategies to examine this question. First, following the identification strategy pursued in most analyses of job lock, we compare the probability of turnover of otherwise observationally equivalent employees who differ only in the value that they are likely to place on a current employer's health insurance policy. We estimate difference-in-difference models for the transition from wage-based employment to self-employed business ownership as a function of access to alternative health insurance and family health. Individuals with no alternative means of health insurance who obtain health insurance from their own jobs, and individuals who have poor family health should be less likely to become business owners. Our preferred set of models restricts the sample to workers with employer-provided health insurance, and compares transitions of workers without access to alternative health insurance and with poor family health to those who have access to alternative health insurance and have good family health. The CPS allows us to measure business creation of all types of businesses including incorporated, unincorporated, employer and non-employer businesses. The second identification strategy exploits the abrupt change in health insurance coverage occurring at age 65 due to Medicare. The discontinuity in coverage suggests that a comparison of business ownership among individuals just below the age 65 cutoff to those just above the age 65 cutoff provides a test of the entrepreneurship lock hypothesis that is as close to a random experiment as possible. Although previous studies exploit the discontinuity in health insurance coverage created by Medicare (e.g. Card et al., 2008 and Card et al., 2009), the approach has not been previously taken to identify the effects of health insurance coverage on business creation. The lack of research on the topic may be due to the difficulty in finding a dataset with large enough sample sizes and a high-frequency measure of age. To address this problem, we use a novel procedure for identifying a person's age in months from matching monthly data from the CPS. To our knowledge, this is the first study using this procedure for identifying age in months from the CPS and the first study using the discontinuity created by Medicare to test the entrepreneurship lock hypothesis. The results from this new identification strategy and the difference-in-difference approach using recent data shed light on the question of whether employer-based health insurance restricts business creation in the United States.

A major concern with the U.S. focus on employer provided health insurance is that it might restrict business starts. The potential loss or disruption in health insurance coverage due to pre-existing condition limitations, waiting periods for coverage, changes in health plans and providers, high premiums in the individual health insurance market, and risk of high health costs while uninsured may dissuade many employees from starting a business when it would otherwise be optimal. Given these concerns it is surprising that only a handful of studies have examined whether employer-provided health insurance limits entrepreneurship, with the few studies in this literature finding mixed results. We address the limited research on the topic of “entrepreneurship lock” by providing a new study using panel data created by matching consecutive years or months of the CPS and two main identification strategies – difference-in-difference and regression discontinuity models. A first pass at the data reveals that self-employed business owners are much less likely to have health insurance than are wage/salary workers and even our sample of unemployed and part-time workers. Estimates from our two-year panel data from matching consecutive March CPS files also indicate that new business owners have especially low rates of health insurance coverage. We also find that business creation rates are substantially lower among wage/salary workers who have employer insurance than among wage/salary workers who have insurance coverage through a spouse or do not have insurance. To address concerns that workers who have employer-provided health insurance may be less likely to start businesses because they already have a job with a good compensation package and high job quality, we first estimate difference-in-difference models based on the approach taken in the previous literature (e.g. Holtz-Eakin et al., 1996 and Madrian, 1994). Identification of “entrepreneurship lock” arises from the interaction between having employer-provided health insurance and potential demand for health care. Using this first approach, we find some evidence that employer-based health insurance limits business creation, especially for men, but the evidence is not consistent across different measures of potential demand for health care. To improve the comparability of the experimental and control groups, we limit the sample to only individuals who have employer-based health insurance. Identification then comes from the interaction between having a spouse with employer-based health insurance and potential demand for health care. For men, we find consistent evidence of a larger negative effect of health insurance demand on the business creation probability for those without spousal coverage than for those with spousal coverage. Several robustness checks that further refine the comparability between experimental and controls groups provide similar results. Our estimates suggest that “entrepreneurship lock” for men is just over 1 percentage point relative to an annual base business creation rate of 3%. We also find evidence of entrepreneurship lock for women, however, the coefficients are not precisely estimated in a couple of specifications. We also take a new approach in the literature to examining the question of whether employer-based health insurance discourages business creation by examining the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. Business ownership rates increase from 24.6% for those just under age 65 to 28.0% for those just over age 65, whereas we find no change in business ownership rates from just before to just after for the remaining ages in our sample of workers ages 55–75. We estimate several regression discontinuity models to confirm these results. As expected because of the small change in actual age and the orthogonality of included controls, we find a similarly large and statistically significant increase in business ownership rates in the age 65 birth month when the worker qualifies for Medicare. These results are not sensitive to several alternative samples, dependent variables, and age functions, and we do not find evidence from previous studies and additional specifications that other factors such as retirement, partial retirement, social security and pension eligibility are responsible for the increase in business ownership rates in the month the individual turns 65 and qualifies for Medicare. Estimates from the difference-in-difference and regression discontinuity models both provide evidence that the U.S. emphasis on employer-provided health insurance may be limiting the creation of small businesses and influencing the decisions of workers regarding whether and when to start businesses. Our findings are consistent with the argument that relatively low rates of business ownership in the United States may be due to less comprehensive health insurance coverage than in other wealthy countries (Schmitt and Lane, 2009) and that expanding health insurance coverage will encourage business creation (Gruber, 2009). The recently enacted PPACA stipulates that individuals will be able to purchase insurance from insurance exchanges. Insurers will not be allowed to have pre-existing condition exclusions or premiums priced on the basis of health status. These features of PPACA may encourage business creation by providing potential entrepreneurs with a health insurance option should they leave their current employment. However, it remains unclear what the relative value of that option will be. Because PPACA exempts existing health plans from certain regulations, a disparity between the value of health coverage through the exchanges and the value of coverage through some existing employer plans is likely to persist for some time (Eibner et al., 2010). Moreover, the value of insurance provided through the exchanges will be influenced by the way in which states choose to structure them. PPACA will be phased in over the next few years with the availability of a high risk pool for the purchase of insurance in 2010 and ultimately the option of insurance exchanges in 2014. Investigating the impact of these changes on the health insurance market and entrepreneurship is an important area for future research.