Just because I don't understand American healthcare doesn't mean I shouldn't provide it (Or: Screw You, Papa John)

By Paul Bradley Carr , written on May 4, 2013

From The News Desk

It might not seem like it, but ordinarily before I express an opinion, I spend a lot -- a lot -- of time considering both sides of the argument.

Before I decided Julian Assange was a hypocrite, for example, I read everything there was to read about him. Spoke to friends and enemies (and friends turned enemies). Read more interminable blog posts and impenetrable self-published books about the guy than anyone should be expected to suffer in a lifetime.

Similarly, before declaring Travis Kalanick a dick -- a statement with all the hallmarks of a knee-jerk -- I even went so far as to re-read Atlas Shrugged to make sure that being a Randroid is absolutely, beyond all reasonable doubt, A Bad Thing.

This level of diligence is why when I state something on the record, I'm always -- always -- right.

It's that concern to know what the hell I'm talking about before talking about it that has prevented me from weighing in on the debate over American healthcare, or Obamacare or socialized medicine, or whatever you people are calling it today. As someone who writes about startups, and has recently become a founder myself, I certainly should have an opinion on whether startups should have a legal, or at least moral, obligation to offer healthcare to their staff.

But the truth is, no matter how much I read on the subject, I still don't properly understand how American healthcare works. A few weeks ago, I read Steven Brill's incredible exposé of healthcare billing in Time magazine. I understood every word of the piece, and learned a lot about how the widow of a cancer victim is able to be saddled with almost a million dollars in debt to supplement her grief. I learned about how, at the same time, some American "non profit" hospitals have so much spare money that they're forced to build more and more buildings just to get rid of it all.

Shortly afterwards, I spent an hour talking to Dr Zubin Damania about his own experiences witnessing doctors referring patients to expensive treatment centers in which they themselves have financial stakes. We discussed the Brill article at length and Damania was able to confirm every detail. In some cases, he painted an even more depressing picture than was found in the Time piece.

Then -- in for a penny, in for a pound -- I read the 900+ pages of the Patient Protection and Affordable Care Act ("Obamacare"). Then, realising that I'd comprehended maybe 35% of it, I read this excellent summary of the Act on Reddit. (The last time you'll ever see me use the words "excellent" and "Reddit" in the same sentence.)

To understand the other side of American healthcare, I turned to the reams and reams of op-eds and legal arguments against Obamacare and crazy YouTube videos, most of which seemed to boil down to the idea that the government shouldn't be able to tell people what to do. I also read the AHA's rebuttal (pdf) of Brill's piece. I read interviews with people like Papa John boss John Schnatter in which he explained that Obamacare would force him to cut back employee hours and raise the cost of pizza in order to both cover the cost of providing affordable healthcare to employees, and avoid paying it.

I wanted to understand both sides of the argument. I really did. With every issue -- including the really icky ones like gun control, abortion, God and Wall Street -- it's usually possible to find strong, articulate opinions on either side. It's simply not true that gun lobbyists want more children to die in school shootings, or that pro-lifers hate women. Nor, by the way, is the opposite of either of those positions true. The bigger the issue, the more complicated and nuanced the argument.

And that's why healthcare has left me so stumped. Maybe it's because I'm a Brit, and we have the national health service. Every man, woman and child in the UK is entitled to free healthcare from cradle to grave. If you want private medicine, that's available too, but it's generally the preserve of the well-compensated. Hell, there were times in my life when I had private medical insurance in the UK and still chose to go to an NHS doctor because it was easier and the standard of care was just as good.

America is a bigger country so free healthcare is off the table. I get that.

What I don't get is why anyone would oppose a bill that makes affordable healthcare accessible to more people. I literally cannot comprehend the arguments against that, to the point where they seem utterly nonsensical. Yes, it means the government telling people what to do: But it's telling them not to get sick. Obamacare, to my uneducated eyes, seems like one of the finest and most noble pieces of legislation drafted in decades. Private mediacal insurers will still get paid billions of dollars every year, and fewer Americans will die painful, expensive deaths. I know I'm missing something bad or un-American about that trade-off but I genuinely can't see what it is.

So I'm not going to try to give a definitive opinion on what America should do about healthcare. Sorry America, you're on your own here. I'm just a clueless Brit.


As a pundit, I can keep ignoring the healthcare debate until I understand it. As a startup founder, though, I don't have that luxury. NSFWCORP's headcount continues to grow and several of our team has young children, including newborn babies. Obamacare demands that, once that full-time headcount hits 50, we'll have to offer them insurance, whether we like it or not. But even before that, a growing number of our new employees are asking whether we offer a healthcare plan.

Offering healthcare adds thousands of dollars to our monthly outgoings-- a big amount of money for us. And so before we hit that 50 employee mark and the decision is made for us I need to fully understand the nuances of healthcare in America. I need to figure out when the time is right to offer healthcare. I need to know if there are some clever gymnastics I can do to keep the number below 50 for as long as possible.


Or I could just give my employees healthcare right now. Because the right to not die a horrible expensive death is a pretty basic human one. I could stop trying to understand the utterly incomprehensible economics of American healthcare and ask myself a simple question: If there's anything I can do to protect the health of my employees and their families, shouldn't I just close the fucking spreadsheet and do it?

I spent an embarrassingly long time taking advice from people on how to manage our healthcare responsibilities under the law. I solicited opinion on whether employees joining the company should be expected to understand that there are certain sacrifices that startups have to make -- and one is not being able to afford to offer healthcare right away. Sorry.

I got some great advice on how to rationalise and explain why we couldn't provide health benefits. Advice so great that even I was almost convinced that it'd be borderline fiscally irresponsible for me to spend investor money on keeping my team and their families out of the grave. At least one of our team needed healthcare and we'd promised to figure it out for them as a condition of their employment, but maybe there was some clever way to cover their COBRA payments for a while to avoid having to make a decision that could risk the company.

As I wrote last week, NSFWCORP is very close to breaking even, but we're still burning investor cash. There's a very real chance that setting up a healthcare plan will shorten the lifespan of the company. Surely the team would understand that. Surely it's better for them to be guaranteed a job for longer, than to have healthcare right now. Surely they can wait? At least until I truly understand the data? The arguments either way?

It's not a nice feeling: The moment, in the middle of the night, where you realise you're genuinely trying to debate whether there's a business case for making it harder for a human being to be able to visit a doctor, or to have their spouse and child receive basic medical treatment without threatening the roof over their head. What kind of monster does that? I might as well be debating whether our team should be expected to pay for its own oxygen. I mean, is it really *my* problem that they can't breathe without it?

Less than 24 hours after I'd had that realisation, I sat down with my old pal Dr Zubin and asked him a simple question: Who can I trust to provide the best possible healthcare for my team, without charging me more than is necessary? He gave me the name of a company (it doesn't matter which -- I'm not here to provide an ad for them), I called them, met their representative, and just over a week later our full-time employees were signing their new insurance paperwork. And -- fuck you, Papa John -- we've just started the process of moving our less-than-full-time employees on to the plan too. If you work for NSFWCORP, in any capacity beyond that of a very sporadic freelancer, you shouldn't have to spend a second longer than necessary worrying about the consequences of getting sick.

Yes, this is going to seriously impact our bottom line and I'm going to have to work even harder to raise more money, or to sell more subscriptions or Conflict Tower rooms to cover the additional expense. But that's my job: To ensure the company has enough money to cover the essential costs of doing business. And healthcare is one of those essential costs.

It's fair to say that, after going through the "on boarding" process with our new insurance company, I do understand the American healthcare system slightly better -- although, at best, I've moved from baffled to just confused. There's every chance I've just made a horrible business decision. It's too early to know for sure.

What I do know is that, in exchange for a few thousand dollars of our investors' money, a group of people for whom I'm responsible are now considerably less likely to get sick -- and if they do get sick, it's far less likely to cost them every penny they have.

If I made the wrong business decision, I'm an idiot but fewer people will get sick. If I made the right decision, I'm a genius and fewer people will get sick.

While we wait to see which of those scenarios plays out, I'm keen to keep learning about American healthcare, and how it affects startups. My understanding is that most of the ones who raise any decent amount of venture cash offer benefits -- the war for talent is simply too great not to. So here's my question: If you're the founder of a funded startup and don't currently offer healthcare to your employees, why not?

What is your justification? Financial? Moral? Laziness? And more importantly, when that middle-of-the-night moment hits -- when you realise that a financial decision you've made might leave a fellow human being unable to access basic healthcare -- what's your plan for being able to go back to sleep?

[Illustration by Hallie Bateman]