Had an epiphany like this after an earlier startup project failed, which my cofounder and I had tried to do following the formulaic approaches advocated by various accelerators, investors, and experts (often people with zero experience running a startup, but had been involved as angels after BigCo stock options vested, and then got into mentoring local accelerators).
I hated the startup theater, pitching, networking, and accelerator applications including YC and TechStars and MassChallenge. My cofounder flaked. I wound down business #1, returned most of the investor capital, and then started out on #2, determined to do things completely differently.
For #2, I had 3 criteria:
1) Prototype on my own, without an engineer
2) Don't just talk lean, do lean
3) The product must generate revenue from day 1
While I am not an engineer, I had strong enough digital skills to set up websites and leverage other tools to prototype. Month 1 was building the prototype, month 2 was getting it out to the marketplace and actually getting some early sales ... and then plowing that money back into the business to improve the product. 10+ years later, the business brings in a respectable middle class income, has helped put my kids through college, and, as TFA articulated, lets me "pursue any and all ludicrous business models, with no oversight."
Like a lot of people who bootstrap, I had to consult as well (still do, mainly as a hedge against platform risk). I am eternally grateful to my spouse who not only has an income to help support the family, but also good health insurance (more on this below, see https://news.ycombinator.com/item?id=40707068).
I'm always amazed how blatantly clear it is that having health insurance tied to employment specifically discourages this kind of entrepreneurship, and the ability to "strike out on your own".
Literally handcuffs keeping people at their jobs.
On the other hand startup culture and entrepreneurship are much more common in the US, compared with the EU. But the latter does not tie health insurance to employment, in most countries. Probably other factors are more important.
Doesn't mean Universal Healthcare wouldn't be a net win for entrepreneurship.
We should unlock all barriers to entry that we possibly can
Universal Healthcare in the US will negatively impact entrepreneurship.
Why?
It's a net win for everyone except the middlemen.
I think to have an honest conversation about universal healthcare is to admit that it would cause health care rationing. Costs would be tighter across the board, and the best experiences of health care services enjoyed with (many) corporate plans would degrade, relatively speaking (unless supplemental private insurance continues). Doctors would probably make less profit, not just insurers.
I think it's okay to talk honestly about that. There's a LOT of waste and purely indulgent service in the current system. And as a person striking out on a business venture, I don't need concierge health services. I need a health safety net.
I think it hurts the conversation about UHC when that's waved away - telling people that they'll be bringing the best of low deductible in-network, gratuitously provided services to everyone.
UHC isn't about bringing great service to everyone, it's about bringing a higher level of minimal coverage to everyone.
I don't think so. I think it means other factors are also very important.
I think both things are true, that we're getting a bunch of things right toward a successful entrepreneurial culture, but are also getting this one thing massively wrong and leaving a huge amount of further potential on the table!
Yep. I’ve been saying for awhile now that universal healthcare would likely lead to one of the biggest small business booms ever. Not only does it help people strike out on their own, but makes easier/cheaper for them to hire.
On the other hand, it would make it harder for big business to retain talent.
This is a feature, not a bug.
You mean they would have to offer a good job with competitive wages, enjoyable work conditions, good benefits (mat leave, paid time off, sick pay, etc.) and a good career path?
This is why big business is not an ally for anything that makes health care cheaper or easier to engage. It's a great system for them.
Same for housing. In Tokyo median rent price for a 1BR is $600-$700. No onerous contracts either with month-to-month rental options. The freedom to explore creative and business endeavors without these worries cannot be overstated.
Alright here are three health care reforms that we could implement without going all the way to Universal Health Care:
1. Anyone who pays cash for a procedure should pay a price that is no more than the lowest price that any insurance company has negotiated for the same service.
2. Anyone who buys a health care plan from the marketplace should get a price that is no more than 10% higher than the cheapest negotiated price any company pays for the same plan.
3. Anyone should be able to deduct the cost of health care for income tax purposes, not just companies that buy health insurance for their employees.
Those are fair. But why impose them through regulations?
Entrepreneurs see business potential on this arbitrage opportunities.
Well, for starters, two things come to mind:
1. The healthcare and health insurance marketplace is riddled with regulation. There is no such thing as offering a health insurance plan or a healthcare service in the United States absent any regulation. Every existing service is, more or less, imposed via regulation.
2. The current health insurance system dates, in its current form, either to shortly after WWII or to the adoption of the ACA, depending on your perspective. That’s somewhere between 14 and 75 years. Where are the plans you speak of from these entrepreneurs? What are they waiting for, letting all of this sweet, sweet, arbitrage pass them by? Biding their time? Toward what end?
Is that universal healthcare with extra steps? Almost, but on a serious note, why not go all the way with universality?
All else being equal, I'd rather see the pricing pressure done by market competition rather than enforced price caps benchmarked against some metric controlled by the industry (see Medicare Part D - gov. negotiates hard to only reimburse xx%, drug industry says fine, we'll just raise the book price - you'll get your talking point, and we'll still get our asking price).
So more significantly:
* bring back association health plans across state lines and industries, so small businesses can band together for group rates. https://news.bloomberglaw.com/daily-labor-report/biden-admin...
* Expand Direct Primary Care. https://www.dpcare.org/
* Allow primary care physicians, dentists, etc. to offer services without a state board providing "certification of need". This seems to just be gate-keeping / moat-building.
I'm not saying either or all of these are a perfect solution (nor do I think we need to find that solution immediately). As a small business owner, they'd make the health insurance handcuff problem easier to navigate by driving costs down.
I will say this - flying solo without health insurance does make you a FAR better consumer of healthcare services. You will comparison shop (made easier by price transparency rules). You will critically consider the necessity of gratuitous tests / procedures. You will learn that doctors are running profit-minded businesses like everyone else.
It also makes you reconsider some life choices (re: physically risky behavior).
I think the biggest fear I faced was the lack of catastrophic coverage (cancer, etc.). When we didn't have insurance (both small business owners) my wife and I probably consumed less than $1000 of direct services combined, per year. That part (direct pay for services used) was fine. Walking the tightrope without a safety net for expensive medical developments was our biggest risk. With kids it's even less of an option to operate that way. I've known many that have returned to corporate jobs for this reason alone.
Or just have Medicare for everyone.
The current scheme only benefits rich people whose ability to pay outrageous insurance rates is easy and less than taxes. Poor people get substandard care, middle class workers get boned. I spend more on healthcare than taxes, and half my taxes are paying for stupid healthcare, either directly or through proxy.
What are some good examples of countries with a different healthcare policy and more entrepreneurship, small businesses, and/or craftspeople than the USA?
Taiwan has a solid national health insurance plan. The number of small and medium sized businesses is very high for a country with a working age population of 16 million people:
Taiwan boasted more than 1.59 million small and medium enterprises (SMEs), according to the White Paper on Small and Medium Enterprises in Taiwan, 2022. This accounts for more than 98 percent of all enterprises, an all-time high. Further, SMEs employed 9.2 million people, representing more than 80 percent of the total workforce.
https://www.moea.gov.tw/MNS/english/news/News.aspx?kind=6&me...
I think the official number undercounts the many micro-businesses that exist around the food industry, markets, and services.
People don't appreciate how expensive health insurance in the US is. A high-quality PPO plan for a whole family on the open market can cost $4k/month.
It really is a detriment to entrepreneurship in the U.S., as well as early retirement for those who have saved up enough money but are locked into a job until Medicare kicks in at 65.
One other observation: During the pandemic my spouse left her job to work with me full time. We had COBRA (health insurance based on her previous plan per federal law) for 18 months, which was great. Then we had to go to the open health marketplace. What a freaking disaster that was.
If you make any sort of middle class income, which we did through my business, you don't qualify for any breaks in our state's marketplace (Massachusetts Health Connector). The broker database they had for small businesses insurance was a joke - no one ever returns your call; it seems they are looking for midsized businesses where their commission will be larger.
I spent many hours comparing family plans on the Massachusetts Health Connector and eventually decided to bypass the marketplace and purchase insurance directly from the insurance company because it was a little less expensive and had a slightly lower deductible (but was still sky-high compared to COBRA/her previous employer's plan). We got reamed on the monthly insurance cost as well as the crazy-high deductible. She eventually went back to her old employer, and one of the primary reasons was getting access to affordable health insurance without crushing OOP costs.
This is not an accident.
This is the whole point.
The career accelerator people kill me. Honestly why do I want to hear from someone who's biggest risk was getting a job talking to people taking big risks.
I have a similar startup backstory to this, for my second venture I went fully to the get paid to do your work camp. It's still hard, harder than anything I've ever done, but it's working out.