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Small Business Owner Struggles with Group Insurance before the Affordable Care Act

Theresa BrownGold's painting "Group Insurance" for her art project, Art As Social Inquiry.

(Interview 2009. Oil on canvas, 40 ins. x 30 ins.)

The original 2009 portrait is below. I had to correct things about the original painting that bothered me for years. I was only interested in painting the face. I slapped on the rest of the painting because I was bored. And because the subject is my husband, I let the slapdash result go. I fixed it. The painting is good to go now. :)

Update 2021

This is my husband. He and I have been on the health insurance coverage rollercoaster for our entire life together.

We were married in our twenties. Our careers were just starting. I was a playwright with some success getting small grants. But I hardly made a living.

I kept painting what interested me the most without caring about any other part of the canvas.

My husband quit graduate school to cook. He worked in kitchens cutting vegetables for $4.00/hour in 1984 when I met him. He wanted to make a career as a chef. I waited tables to support myself and my writing. I moved to hosting for $7.50/hour at a new restaurant venture where I met my future husband.

We had no health benefits at our jobs as host and prep cook. My husband was in college and still eligible to remain on his parents' health plan as a dependent.

I was uninsured for most of my twenties. I moved to Philadelphia in the late 1970s to make my way in the world. I paid $160/month for a single room in center city. I cooked on a hotplate and left the lights on at night to keep the roaches at bay. It wasn't so bad. I lived at 16th and Locust, one of the very best neighborhoods in the city.

I never thought of myself as poor. Never. I felt a great future lay ahead. I was fearless. I saw no benefit in paying an insurance premium when I could use the money to make some kind of life for myself.

I know now I would have had no problem getting a single policy from an insurer. Others were not so lucky. I had no preexisting conditions hiding in my medical records for the insurers to dig up. I gave them no reason to deny me a single policy. (Searching a person's medical records for preexisting conditions is called medical underwriting. Insurers could reject an applicant based on her health history. The Affordable Care Act outlawed this practice.) The insurers would have welcomed my premium dollars. Barring an accident, I would have no cause to see a doctor or file a claim. Insurance companies would have made money on me.

I rationalized my uninsured status by saying, "If I was on my bike and a car hit me, the driver's auto insurance would cover my medical bills. I could not have been more wrong. An uninsured subject in this project was hit by a car. The payout fell short. She lived uninsured, in chronic pain, and relying on the kindness of strangers for medical advice.

I only cared about gynecological care. I am forever grateful to Planned Parenthood for providing that care at a very affordable price when I was a young uninsured woman. Thank you thank you thank you.

My husband's love of cooking, his skill, and drive took him far and quickly. The money was not always great but the positions were always an advancement. Not long after we met, he moved from cutting vegetables to managing kitchens. Then from night chef to head chef -- full time salaried positions with health benefits within the same corporate restaurant group. But the money would never get better -- that's what we inferred from management's tepid reaction to my husband's request for a performance-based raise.

By this time we were married and I was pregnant with our first child with a second to follow 17 months after the first. My husband set his sights on higher-paying executive chef positions with health benefits. Changing jobs meant changing health insurers. Insurance was and is tied to employment. My naiveté about being insured ended when we left behind our single life as restaurant workers-- 2 AM meals in Chinatown after our shifts, blowing all our money on Japanese food, sleeping 'til noon. We absolutely had to have health insurance for ourselves and our two babies.

The health insurance landscape was hell. At one head chef job at a chic, renowned small restaurant, we'd raced to the bank on payday. The staff knew the last to cash their checks would be disappointed. There was a good chance the checks would bounce. I'd run to my husband's job, grab his paycheck like a runner grabbing a baton, and race to the bank.

I did not know enough to even question whether the health insurance that came with the job was any good. We had it and I trusted the policy would pay for the birth of our first child. But I was not stupid. In the back of my mind I had to know the insurance was probably shit based on the employer's inability to cover payroll. But I also knew there was nothing I could do about it. I would have our first baby. I would use the health insurance we had. And I would deal with the aftermath.

I knew few people in the restaurant business who were not living hand-to-mouth. Our predicament did not seem extraordinary. In fact, uncertainty, uneasiness, stress, low wages, lousy health insurance -- it all seemed so normal in our industry. A healthy mind knows from moment to moment what it can and cannot change. In that moment, about to give birth to our first child, I had to deal with what was. My husband and I loved each other. The baby I was carrying was growing properly. We never skimped on groceries. Our rent got paid. And we thought the world was ours for the taking. We trusted that our lives would work out.

Health insurance and stress were synonymous. We breathed it in. We managed, addressed, accommodated its presence in our lives. Unstable restaurant employment and health insurance coverage were the proverbial monkeys that were not only on our backs. They were so baked into our DNA, it is a wonder we didn't swing from tress from time to time.

We were young then and didn't know how the private for-profit system worked against their enrollees. And we would not have had the time to do anything about it then as new parents. We were busy trying to keep our babies alive. The Affordable Care Act began to address some of the healthcare industry's misconduct.

Most of our policies were skimpy. Once my infant son needed a hernia operation. I dreaded facing the hospital's billing department. I wondered what our skimpy coverage would pay. I could not tell you what the hospital rep looked like. I just remember her message. She must have seen the distress on my face. She said, "You know, if you make less that $24,000/year, you will pay a lot less."

I was thrilled but scared. Did we make under 24K? I never put together we were being offered charity care, free or discounted healthcare for low-income people. I was taking care of two babies 17 months apart. I knew nothing about anything especially healthcare policies and practices. I voted in most of the elections but not too much else. I was bouncing wailing babies and changing diapers. I never ever thought of us as low-income. I thought of us a millionaires in the making. If the billing rep had used the words low-income I would have said, "Well that's not us. We won't qualify."

I found our latest tax return. We made $23,800 for a family of 4 in 1986 ($55,907.28 in 2021 dollars), $200 below the limit for charity care. We must have paid the hospital a nominal fee because I can't remember what it was. I remember very well the relief that ran through my body like hearing a biopsy was negative, or a child was in a car accident but not injured. I was so grateful. So so grateful.

A few months before our son's hernia operation, our landlord raised the rent $25 on our little South Philly house to $425/month. I told my husband we couldn't afford it. We moved around the corner to a second floor 2-bedroom walk-up apartment for $300/month a week after I gave birth to our second child.

We were raising two babies on not a lot of money. I wanted to kiss the hospital rep. Our son's operation would not ruin our finances. I can still cry thinking about it. I thought we were smart, great money managers and capable of turning the world upside down with our dreams. And we really needed that charity care to give us a leg up on making our dreams come true. The hospital rep was kind and gracious. She never referred to us as low-income people getting a handout. She saw us as people.

We've had every kind of healthcare policy over the almost 37 years we've been married. The Affordable Care Act is now my husband's safety net. (I've aged into Medicare.) My husband started his own consulting company. I don't know if he would have been able to strike out on his own without a way to get affordable, comprehensive coverage.

The ACA limited the out-of-pocket costs an individual would have to pay to $8,700 for a plan on the marketplace in 2022. Although not all plans on the marketplace have unreasonable deductibles.

Before the Affordable Care Act, many policies had no out-of-pocket limits. So a cap is some improvement. But what good is a tool to help us live our lives when using that tool could bankrupt us? Four in ten adults in the US are unable to afford a $400 unexpected expense. Even a $1000 deductible could bury a family. We have a way to go to make our healthcare system work for everyone.

The painting is great and awful in equal measure. I love it because the face is my husband's perfectly. I got bored with the rest of the painting and slapped it on. And it shows though I had a bit of fun with my little joke in the tee shirt. The painting is in the studio now. I poured acetone on the shirt in the painting. I've started scraping off the old paint. I'll leave the face. I'm playing around with getting the old paint off. I'm exercising painter's prerogative by changing the portrait any way I please.

The portrait story (after the Artist Note) covers our time as small business owners.

Artist Note (3/2012)

I am the partner in the story. Actually, I handled all insurance matters for our businesses. I use my husband’s portrait to represent small business. I needed models when I started investigating how people access healthcare. We had a lot of experience as small business owners. And my husband was an easy get for the project.

My husband and I owned two small businesses consecutively over 12 years. The first business was a prepared food store; the second a restaurant. Several years into the second business I found myself saying to my husband that we should hire two part-time people to replace a full time employee who was leaving.

I had a thunderbolt moment. If I was thinking how to reduce employees' hours to part time to avoid paying health benefits to full time employees, so were many hundreds of thousands of other small business owners across the country. I thought, “Is this any way to run a country?” That was the moment I decided I would dedicate myself to finding out what was really going on with healthcare in the US. I started interviewing people and painting their portraits as a way to understand how healthcare was and was not working for Americans.

Small business keeps a dirty little secret. (This was my assessment before the Affordable Care Act) When a person interviews for a full time position with benefits, the employer is wondering if that person has a chronic medical condition that would cause him to actually USE the benefits. Overusing the health benefit could cause premiums to go up for the entire group. I can’t say my business partner/husband ever thought that way. He probably never did since his mind doesn’t work that way. But I sure did since I handled the insurance matters for our businesses.

I have learned through my subjects, research, and so many stories people share with me that insurance companies look to drive small businesses off their rolls if those businesses have big claims. Insurance companies do this by raising the rates so high, the small businesses can no longer afford to pay the premiums.

I have come to the conclusion in 2012 that the employer-based system for providing healthcare to a nation has outlived its usefulness.


(Please note. The Affordable Care Act would have made getting health insurance for ourselves and our employees much easier. We and our employees could shop for insurance on the online marketplaces without fear of having to pay more if we had preexisting conditions. The Affordable Care Act became law in 2010 and was fully implemented in 2014)

How it started...

Small Business Owner 2009, age 47, Insured

This small business owner saw his insurance premiums for his very small group plan increase 4%-20% every year for the last 10 years.

No one in the group uses the insurance very much. The owner hopes this makes his small group more attractive to the insurer. If employees have a lot of claims, the insurers might raise the premiums so high in an effort to bully the business into dropping the health plan altogether.

The group comprises the owner, his business partner/spouse, and one or two employees depending on the year. (The owner's children were listed as dependents on his policy.)

Every year at the renewal date, the company pays more for health insurance for a policy that covers less. Paying more for less is the company's strategy for controlling cost.

The owner used to pay 100% of an employee's premium. He has started asking employees to make a monthly contribution to help pay their insurance premiums.

The owners also reduce healthcare costs by not hiring full time employees since coverage is offered to full time help only. The subject avoids unpredictable insurance rate increases by hiring as few full time workers as possible.


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