Still, there's evidence that publicly provided health insurance prompts more people to start businesses. A 2015 Harvard Business School study found that after the Children's Health Insurance Program was started in 1997, the self-employment rate for parents of CHIP beneficiaries jumped 23%, and the ownership rate of incorporated businesses increased 31%.
A 2013 study found that after the ACA provision took effect allowing young people ages 19-25 to stay on their parents' health plans, they were more than twice as likely to start their own businesses.
That's what Chicago public relations consultant Alyssa Conrardy did. At age 24, she co-founded Prosper Strategies, staying on her parents' plan for two years while she got the company off the ground. It now employs eight people and provides them with group health insurance.
“I don't think we could have gotten here without the security the ACA provided,” she said. “If the ACA is repealed, there are so many young people for whom entrepreneurship will no longer be a feasible financial option.”
Trump and other GOP leaders say they'll keep that popular ACA provision allowing young people to stay on their parents' plan until age 26. But it's not clear what kind of health plans the replacement system will offer or what the out-of-pocket costs will be.
How the GOP's alternative model addresses annual and lifetime benefit limits and maximum out-of-pocket costs is a huge concern for Namir Yedid, 35, of San Diego. He left a job with health insurance in 2014 to develop several technology products.
Soon after buying a plan on the California exchange, he was diagnosed with a rare cancer. His medical bills totaled about $150,000. Without the ACA's annual cap on out-of-pocket costs, he would have been on the hook for tens of thousands of dollars.
Yedid's cancer is now in remission, and he's preparing to bring his first product to market. He currently employs five people. “There are plenty of talented people in the tech scene who couldn't take the risks I did and go out on their own without the ACA,” he said.
Ryan and HHS secretary nominee Dr. Tom Price have proposed putting people like Yedid into high-risk pools. Yedid notes that these state pools generally did not work well in pre-ACA days in providing affordable coverage for those with pre-existing conditions.
He's angry that the Republicans are rushing to repeal the ACA without telling the public exactly what they're going to put in its place, making it impossible for people to plan their business lives.
Lisa Martin, 35, of Cambridge, Mass., expresses similar frustration. She left a job with health insurance in 2014 to start her own website consulting business, made possible by the availability of ACA coverage. Soon after leaving her job, she suffered a minor stroke. Even though she recently switched to her partner's employer-based health plan, she hates the uncertainty of not knowing for several years what the GOP plan will look like and how it will address pre-existing conditions.
“What am I supposed to do in the next two to four years?” she lamented. “Why create anxiety and replace something that's meeting people's needs?”
Asked what he would advise people considering self-employment during the uncertain interim period following repeal of the ACA, Holtz-Eakin said: “I'd make the leap. There are policies available now. If you like them, you can have them. They have more to look forward to in the replace plans. I don't think they should be worried.”
But Elmendorf disagrees, arguing the Republicans have not put out nearly enough details for the CBO to determine how good and affordable the plans under a replacement package will be and how it will affect the nation's uninsured rate. There's no evidence, he added, that Republicans are willing to spend the large amount of federal money or impose the rules necessary to ensure good coverage.
“These self-employed folks should be quite concerned,” he said. “I don't know how they should proceed.”