Only 25.1% of North Carolina Small Businesses Offer Health Coverage, Down From 33.8% in 2009

Rising healthcare costs have put increasing pressure on small businesses across the United States. For firms with fewer than 50 employees, offering health insurance has become significantly more expensive over the past decade, forcing many to reevaluate or eliminate this once-common benefit. While employer-sponsored insurance remains a key component of the U.S. healthcare system, small businesses—facing limited bargaining power and narrower profit margins—have struggled to keep up with premium growth. More than a quarter of the U.S. workforce is employed by firms with fewer than 50 employees, yet only 30% of these businesses offer health coverage.

A new analysis by Take Command—a SaaS company that helps businesses provide Health Reimbursement Arrangements (HRAs)—uses data from the Medical Expenditure Panel Survey (MEPS) to examine how rising costs and policy changes have reshaped the small group insurance landscape. The report tracks changes in insurance premiums and overall coverage rates since before the Affordable Care Act (ACA) was passed. It also highlights geographic disparities, identifying which states have seen the steepest declines in small business coverage and which continue to maintain higher levels of employer-sponsored insurance at small firms.