The Survival of Small Businesses Purchasing Health Insurance under the Affordable Care Act

Grounded in the theory of strategic organizational change (SOC), the purpose of this multiple case study was to explore the strategies small business owners use to provide health insurance coverage under the ACA and remain in business. Semistructured interviews were conducted in Northeastern Ohio with 3 business owners in the physical and mental health care industry. The da-ta-collection process included semistructured interviews and business documents. Data analysis involved cluster and coding analysis. Member checking was crucial for strengthening the trustworthiness and credibility of interpreting the responses obtained from participants. The themes that emerged from the study included the importance of cost associated with health care plans, high employee turnover rates, and significant insurance company participation. Specifically, for the small business owner to purchase affordable health care required decisions that encompassed resources and employee reactions to change. The study results may contribute to social change, with information benefiting small business owners in providing health insurance coverage to full-time employees. In addition, the study results may reduce the number of uninsured individuals. Small business owners could use the data from this study to help small business owners reduce health care insurance costs.


Introduction and Background
President Obama signed the Patient Protection and Affordable Care Act (ACA) into law on March 23, 2010, and extended until 2016 the mandate for business

Purpose Statement
The purpose of this qualitative multiple-case study was to explore strategies small business owners in the physical and mental health care industry use to implement health insurance sustaining business. The targeted population will include three small business owners working in physical and mental health facilities in Northeastern Ohio. The owners were appropriate for the study because they staff approximately 50 to 100 employees while implementing health insurance under the guidelines of the ACA. In addition, positive social change implies that successful small business owners' insights might help other small business owners provide health insurance coverage for employees who otherwise could not obtain health insurance, reducing the rising cost of health care. Finally, small business owners might use the findings of this study to chart a path for small business owner to decrease the number of uninsured Americans.

Research Question
The overarching question was: what strategies do small business owners in the physical and mental health industry use to implement health insurance sustaining business?

Assumptions, Limitations, and Delimitations
Assumptions are statements acknowledged as facts without supporting evidence for validation (Leedy & Ormrod, 2013). Without the assumptions, the problem of the research was not plausible. One assumption in this proposed study was small business owners operating as care provider agencies in Northeastern Ohio have concerns about possible financial hardships resulting from the implementation of the ACA. Owners of small businesses who fail to prepare early for the implementation of the ACA may face difficulties regarding sustainability. Another assumption was that small business owners in the physical and mental health care industry in Northeastern Ohio were not ready to meet the mandates of the ACA, even though they received an extension until 2016 to comply with the law. Employers not prepared to phase in the provision of health care will face the need to decide to provide full-time employees with health care, downgrade full-time employees to part-time employees, or pay fines for noncompliance (Hossain et al., 2019). The assumption in the study was that participants would respond to the questions with honesty and integrity, providing substantive, detailed feedback.
A limitation was the process of limited procedures identified in a case study (Yin, 2015). Yin (2015) indicated that the lack of systematic strategies for multi-case research was a concern for a researcher because of methodological guide-Open Journal of Business and Management posited that small business owners' knowledge about the ACA would increase over time. Health care guidelines are critical in the understanding implementation of the ACA. Some employers have a negative view of the Affordable Care Act. Blavin et al. (2014) asserted that the ACA threatens employer-sponsored health care coverage. Blavin et al. claimed that employer-sponsored health care coverage should benefit low-wage employers and their employees. Blumenthal and Collins (2014) reported that lawmakers intend to expand the ACA to employer-sponsored health care coverage. Small business owners have concerns about compensation packages and penalties for failing to provide affordable coverage. Buchmueller et al. (2013) expressed concern that employers might drop health care coverage because of the ACA. Employers might have to conduct complex calculations that consider local regulations, taxes, and wages (Buchmueller et al., 2013). Therefore, the cost that small business owners consider must combine positive and negative costs associated with health care.
Cost is an important factor for small business owners. Diaz (2015) indicated that providing health care coverage would be an expensive undertaking for employers. Health care costs average between $1.79 and $2 per hour for full-time employees, depending on the state (2015). Depending on the hours worked and the number of employees requiring coverage, health care costs can appear substantial. The changing business environment requires small business owners to keep pace with competition (Behara & Gunderson, 2015). The commitment of small business owners to health care, whether voluntary or mandated, causes an increase in financial and administrative burdens (Krizan et al., 2014). Insurance rates were unpredictable, which increased the problem for business owners.
The decision that small business owners make relates to their sustainability. Fusch and Ness (2015) indicated that the role of a researcher is to explore a subject until saturation. In my role, I will explore the ACA from many different angles. Many scholars considered the influence of the ACA regarding small business viability and SOC. Many who studied the ACA focused on how small business owners will implement the ACA and not on their strategies to offer health care coverage while remaining sustainable. Blumenthal and Collins (2014) are one of few that addressed how the ACA affects small businesses and health care systems. Hossain et al. (2019) stressed that most researchers focused on how small business owners address ACA enactment instead of the strategies that small business owners will use to accommodate the ACA. In my role, I will explore SOCs that coincide with the passage of the ACA because small business owners lack effective strategies to implement the ACA while sustaining a business.
The affordable care act includes various legislative layers. Talwalkar (2014) explained that the ACA contains two separate pieces of legislation: the ACA and the Education Reconciliation Act. The government agency overseeing the ACA calls for providing health care coverage to full-time employees under laws al-Open Journal of Business and Management ready outlined in health care coverage (Moran, 2013). Talwalkar noted that some legislators agree that the implementation of the ACA will cause a change in health care coverage for some patients because the ACA requires health insurers to allow all individuals to obtain health care coverage. Under the ACA and Education Reconciliation Act, all small business owners must provide their employees with health care coverage. Members of Congress allow specific changes to the original ACA, including a process for allowing the United States to remain on a budget by increasing the number of individuals paying for their health care insurance (Talwalkar, 2014). Admittedly, even though the numbers include rising individuals in health care, employers must make staffing decisions that work for their business.
Business owners weigh each employee's cost to determine their benefit to the company. Baker and Jorgensen (2015) expressed that employer might react to the ACA by changing hiring practices. For example, Baker and Jorgensen noted that the ACA might cause employers to cap employee hours at 30 per week or decrease the number of full-time employees. However, full-time employment remained relatively constant since 2013 and showed no signs of reduction (Baker & Jorgensen, 2015). Baker and Jorgensen also indicated that cuts in employment did not occur because many small business owners did not know about the mandate delaying implementation for small businesses until 2016. As a result, small business owners made educated guesses on ACA's impact on their company.
Despite many lawmakers expressing fears that the ACA would undermine job growth, these fears have remained unfounded to date. Ogundipe et al. (2015) noted that the ACA could result in a 70% reduction of uninsured adults because of the expansion of Medicaid to individuals 133% below the poverty line. Lowry and Gravelle (2013) indicated that the ACA is an economic issue because small business owners need to sponsor health care coverage by offsetting wage costs. Employers who fail to provide insurance face $2000 per full-time worker; however, the penalty does not apply to employees who work 30 hours per week (Baker & Jorgensen, 2015). Opponents of the ACA feared that the ACA would cause employers to demote full-time employees to permanent, part-time workers to avoid the penalty and pay for health care insurance.
The ACA is necessary to address the increasing costs of health care. The law has guidelines to address the failing health care system. For example, suppose small business owners provide health care coverage to their employees. In that case, they should claim the tax incentives under the ACA to balance against the cost of providing health care coverage and to remain sustainable. For example, for employees who earn less than $50,000 per year, an employer can receive a 50% tax credit for two years; this incentive is higher than the 35% tax credit allowed to tax-exempt organizations (Hossain et al., 2019). The ACA evolves with several vital elements to ease the burden on small business owners paying for the cost of health care.

Theory of Strategic Organizational Change
Social scientists tried to define SOC challenges and address organizational needs, such as small business owners' obligation to implement ACA while sustaining a business. Sanchez and Heene (1997) contended that the theory of SOC represents an open system of properties that motivates an organization to change. Bloodgood and Morrow (2003) indicated that another explanation of the SOC is the need for organizational change using structures, strategies, operational methods, and technologies to effect changes in corporate culture. These changes require minor modifications to resources to help the organization compete.
The implementation of ACA was not perfect (Pasek et al., 2015). Auster et al. (2005) asserted that business owners would need to make minor modifications to change their business implementation of health care. To compete, business owners must make their businesses increasingly more complex. Business owners must create multiple capabilities to implement strategic change. The owner must build commitment and leverage the new change using what is already working (2005). Putting new practices into place requires leaders to use a new organizational mission (Appelbaum et al., 1998). Small business owners who wish to satisfy ACA mandates must plan and prepare what works best for their small business. SOC influences organizational learning, motivation, productivity, and opposition to leadership (Appelbaum et al., 1998). Business owners who plan to make changes in their businesses must create a new system to sustain a business. The owner must build a commitment among employees and leverage the recent health care change by using what is already working versus what is not working. SOC includes strategies to help business owners meet organizational challenges (Rashford & De Figueiredo, 2011). Strategic organizational change is the foundation of this study.

History of U.S. Government Programs
Government officials remain in a long battle trying to expand health care. In 1932, President Franklin D. Roosevelt worked with the U.S. government to have businesses provide health care (Cooper, 2016). In 1945, President Roosevelt announced the earliest form of nationalized health care, Medicare. Medicare was an amendment to Social Security and gave lawmakers the authority to provide health care to children and individuals with disabilities, even those under 65 years (Blumenthal & Collins, 2014). Medicare and Medicaid are for older adults and individuals who are poor or have physical disabilities (Fuchs, 2012).
Health care cost has many factors. The Omnibus Act of 1989 led to a change in providers' healthcare fees and billing (Gallman, 2016). Changes in government legislation had a direct influence on controlling health care expenditures.
Since the 1980s, administrators of hospitals that serve large numbers of under or uninsured patients have felt the pressure to increase profit margins because of Medicare payments (Cooper, 2016). In the 1990s, private payers caused markets to move away from negotiating, which increased the gap in billing prices. Health Open Journal of Business and Management care costs reflect a system and the administrators within a hospital (Cutler & Sahni, 2013). Out-of-touch pricing (e.g., aspirin at the U.S. $5 per dose) is one contributor to increased health care costs. As a result, many components exist that reflect the cost of healthcare.
Lawmakers in North Carolina implement health care successfully. Health care costs continue to increase, even though U.S. mortality rates for individuals 50 years and older are among the lowest of all nations (Randolph & Morrow, 2013).
The cost of health care in the United States does not translate to a better health care system. North Carolina legislators sought to change health care programs in their state by targeting chronic diseases with preventive care. Government officials disbursed 7.4 million per year through competitive grant programs for 5 years to invest statewide (Randolph & Morrow, 2013). This process resulted in health care savings of 4.8 million simply by putting preventative health care in place. Randolph and Morrow (2013) asserted that improvement to healthcare is a direct effect of the ACA, similar to the gains resulting from the preventive care of Medicare and Medicaid. North Carolina legislators' implementation of ACA improved the health care system in North Carolina (Randolph & Morrow, 2013).
By targeting people with chronic health problems, North Carolina officials succeeded in applying the ACA.

Small Business
Many small business owners were reluctant regarding the ACA mandate. Hossain et al. (2019) found that 56.7% of U.S. small business owners did not make plans for instituting ACA mandates. Lahm (2015) contended that some small business owners attempting to meet the demands of ACA noted financial concerns with the cost of health care coverage. Gallman (2016) acknowledged that health care coverage costs are a burden for employers. Controlling costs and benefits may appear difficult for small business owners who seek to provide health care coverage for the first time. Gallman (2016) captured the difficulties by outlining the rules of the 1099 form. A 1099 form that reflects earnings of $600 or more requires reporting.
Small business owners providing health care to employees can reap benefits by reporting healthcare costs. Small business owners may be eligible for health care tax credits, depending on the size of the organization and the volume of wages paid to employees (Hossain et al., 2019). Hossain et al. (2019) also stated business owners who pay full-time employees less than $25,000 per year could receive tax credits up to 50% of their health care premium. In addition, employers with a tax-exempt classification may receive a 35% tax exemption (Hossain et al., 2019).
Government officials had deadlines for having health care in place. Owners of small businesses ACA mandate was January 2015 (Moriya et al., 2016) that makes employers responsible for health care coverage for 70% of employees in 2015 and 95% of employees as of January 2016. Employers who fail to meet these D. W. White Jr., C. Needham Open Journal of Business and Management responsibilities will incur financial penalties (Dillender et al., 2016). The goal of the government officials was to have the largest group of small businesses providing employees with health care.
Small business owners must create a brick-and-mortar establishment to qualify for the health care insurance exchange. Developmental service providers can shop for insurance under the Small Business Health Care Options Program, which is the exchange for small businesses (Hossain et al., 2019). Services providers categorize as small businesses must offer health care coverage to their employees. The provider's overall sustainability links to their provision of coverage.
Health care exchanges are a source for small business owners to buy health care policies. Federal government policymakers funded health care exchange programs to intend that these health care exchanges would be self-supporting in 2 years, which was in 2015 (Hossain et al., 2019). The funding of health care exchanges was temporary (Hossain et al., 2019). Federal funding is at the heart of the ACA. Health care exchanges have a two-pronged effect on health care coverage. First, health care exchanges control costs and reduce resources, from which small businesses have to search to purchase health care coverage. Compared to buying health care coverage directly from an insurance carrier, health care coverage purchased through the exchange provides less expensive health care. The exchanges will benefit small business owners who understand how to use the exchange Exchanges are a health care source for operating alongside small business owners. Blavin et al. (2014) asserted that the most significant advantage of the ACA is its tax credits for businesses. Small business owners use tax credits to provide coverage without compromising their ability to remain sustainable. Many small businesses owners expressed concerns regarding the levels of coverage available and their costs (Lahm, 2014). Owners of small businesses with moderate to low revenues shoulder costs of $4824 per employee to provide health care coverage for individuals and $13,375 for individuals with families (Warnsley, 2015). Eligible individuals who enroll in exchanges make the exchanges successful (Collins & Garber, 2013). However, only a small percent of state officials took advantage of federal funding to set up their exchanges (Hossain et al., 2019). The exchanges are valuable to employers because they include competition among insurance providers resulting in lower costs.
U.S. governmental leaders spend 250 billion annually to compensate and incentivize employers to provide health care coverage to employees (Hossain et al., 2019). Medicaid is an insurance program that includes care for lower-income individuals and families, focusing on children before the ACA. Business owners do not have a legal obligation under the ACA to offer health care benefits to part-time workers (Hossain et al., 2019). Still, they must provide health care coverage to full-time workers or face penalties in 2016 (Blavin et al., 2014).
Some experts have argued that the cost of health care coverage for full-time Open Journal of Business and Management employees will result in job losses (Moran, 2013). However, no supporting evidence exists to document the fears. Busom et al. (2014) noted tax subsidies associated with employee growth or reductionists. Some naysayers asserted the ACA had increased the taxes employers must pay (Lahm, 2014). The cost of providing health care coverage to each employee is $3000 per year (Strobel, 2014). The failure of employers to provide health care will result in a $100-per-day penalty for each full-time employee who does not have coverage (Blavin et al., 2014).
The ACA legislators fear the reduction of small businesses (Hossain et al., 2019).
Small business owners may not believe they can benefit from legislators' efficiency and cost savings in passing the ACA. Bailey and Chorniy (2016) concluded that the ACA results in a different dynamic for employees locked in a specific workforce because of health care. Before implementing the ACA, some employees remained in their jobs for fear of losing health care coverage (Cutler, 2014). Individuals' willingness to retire or move to another employer because of flexible health care coverage is a primary benefit to ACA (Bailey & Chorniy, 2016). As health care coverage is portable, the workforce dynamics may change. Based on the ability to carry insurance outside of small businesses, employees can make decisions concerning employment without health coverage.
The ACA is a complex system, and its many components must function correctly for the entire system to perform as expected. Multiple groups and individuals must work collaboratively to implement the ACA (Stewart et al., 2014). Stewart et al. (2014) stated that officials license commercial insurance agents and brokers to sell insurance. Medicaid brokers provide independent counseling to individuals enrolling in a Medicaid-managed care program. In addition, certified application counselors are specialists in ACA regulations and help enrollees with the marketplace for Medicaid health care. Health center outreach and enrollment assistance workers determine the eligibility of individuals living below the poverty line and who cannot afford coverage (Arnold, 2013). Some consider the regulations to move toward universal health care coverage (Collins & Garber, 2013). The ACA has many different components.

Small Business Viability
Small business owners' strategies for successfully implementing the ACA mandates have implications for their overall sustainability. Industrial-organizational economists have offered numerous organizational change strategies that allow businesses to remain competitive in small businesses. Shapiro (1989) contends that an approach involving game theory is ineffective in the competitive market. Fisher (1989) and Shapiro (1989) postulated that the business strategy theory does not correspond with any single theory, but the theory of business is a collection of various business models.
Medical insurance costs have a history of changing as benefits change (Fuchs, 2012). Increased health care costs contributed to the worldwide economic crisis. D. W. White Jr., C. Needham Open Journal of Business and Management Fuchs (2012) contended that predicting increases in health care costs is essential. Gallman (2016) indicated that the reimbursement costs of specialists such as orthopedists are a growing primary concern for privatized Medicaid and Medicare insurance. Members of the international community recognize health care as a human right, and the United States is moving in the same direction (Blumenthal & Collins, 2014).
The owners of small businesses with 50 or more employees must provide health care coverage for full-time employees (Hossain et al., 2019). Employers who do not offer health care coverage could find implementation a challenge that requires a strategic change in business operations (Collins & Garber, 2013).
The U.S. Supreme Court justices ruled that ACA is constitutional and made provisions for insurance exchanges and federal subsidies to reduce the number of uninsured Americans by 30 million, but not until 2019, which means insuring people remains a focus (Geslison & Jacobs, 2013). Businesses that operate with seasonal workers are not exempt from implementing the ACA unless the season extends past 120 days per taxable year (Hossain et al., 2019).
The owners of small businesses with 50 -100 employees must fund health care coverage for full-time employees. Still, employers are unsure if providing health care for full-time employees is detrimental to the profitability of their business (Colla et al., 2013). Insurance markets have numerous options for employers to purchase coverage for their employees (Giaimo, 2013). However, business owners might struggle to help their businesses remain profitable when they begin paying for health care coverage for employees, mainly if those businesses are small (Blavin et al., 2014).
Small business owners are essential to the success in health care success. The decision by a small business owner to provide health care coverage to employees can affect profitability (Krizan et al., 2014). In turn, financial burdens from funding coverage increase for small businesses, which necessitate reductions in the number of employees receiving health care coverage (Blavin et al., 2014). Furthermore, the ACA includes assistance provisions for small businesses to reduce the financial burden of health care coverage but offers no control over increasing insurance rates. In conjunction with funds allowed through government agencies, owners' decisions are critical factors in how small business owners sustain in business.
The owners of businesses with 50-one hundred employees did not need to offer health care coverage until 2015 (Hossain et al., 2019). Hossain et al. (2019) also stated the owners of businesses with 50 -100 employees could provide insurance for their employees through exchanges. However, depending on the insurance market, the entrance of small businesses and their employees into the exchanges could harm the success of insurance providers (Pauly & Harrington, 2013).
The ACA will profoundly affect future generations (Hossain et al., 2019). However, affordability is the primary concern of small business owners implement-Open Journal of Business and Management ing ACA. Tax incentives may alleviate some small business owners' fears about remaining profitable while simultaneously paying for employees' health care coverage (2014). Small businesses are eligible for tax incentives that range from 35% to 50%, depending on the income range of their employees (Blavin et al., 2014). For example, an employer with 25 or more employees who receive an average salary of $40,000 will receive up to 35% in tax credits (Moran, 2013).
Business owners can use the tax credits to balance payments with employees who earn more than $200,000 and pay taxes at a rate of 3.8% (Pauly & Harrington, 2013).
Health care exchanges do not amount to a simple sign-up service for employers to offer health care coverage; instead, exchanges are an alternative for employers to sponsor health care coverage programs for their employees (Hossain et al., 2019). Employers' lack of understanding of the health care marketplace can result in increased overhead for an employer. Employers will not receive a tax subsidy if they provide employer-sponsored health care coverage (2014).
In 2014, small business owners could purchase private health care coverage through the exchanges . The ACA process prevented insurance companies from completely controlling rates and determining whether they would provide coverage (2014). As a result, the owners of insurance exchanges do not have autonomy over their services. The ACA includes an adjustment method that incorporates demographics to determine risk .
In 2014, government officials set a tax credit for small business owners who offer health care coverage to their employees through the exchanges (Dillender et al., 2016). As a result, small business owners received an offer of significant tax benefits (Cordova et al., 2013), which made the 2010 health care reform the most significant modification to health care in over 45 years (Hossain et al., 2019). Even though small businesses are eligible for tax credits under the ACA, small business owners recognize the viability of their businesses is contingent on maintaining a solid workforce (Cordova et al., 2013) and containing the cost of supplying insurance. Between 1999 and 2009, insurance rates for small business owners increased by over 123% (Blavin et al., 2014).
Some small business owners may not know how to navigate the tax savings associated with the ACA for success (Amato & Schreiber, 2013). Government officials created the ACA with the intent of small businesses to reduce the number of uninsured people in the United States (Blumenthal & Collins, 2014). As Rak and Coffin (2013) explained, the ACA changes the historic landscape of health care and makes health care a right rather than a privilege. Small business owners must navigate through regulations set in the ACA to assist in the reduction of uninsured people in the United States.
In addition, the influence of the ACA, when considered an extension of Medicaid, is an uncertain generational change to health care (Blumenthal & Collins, 2014). However, the current small business health care systems have flaws (Lahm, 2015). Government officials intended the ACA to serve as a primary source of D. W. White Jr., C. Needham Open Journal of Business and Management health care coverage in the United States (Blumenthal & Collins, 2014). A primary goal of government officials designing the ACA was to reduce the number of uninsured individuals by providing affordable insurance for small businesses and individuals (Giaimo, 2013). Unfortunately, insurance costs continue to rise, which causes employers to eliminate health care coverage (Blavin et al., 2014). Stulberg (2013) expressed uncertainty about whether the ACA can eventually stabilize or reduce costs.
The ACA includes a mandate that small business owners with 50-one hundred employees must provide health care coverage to full-time employees by 2016 (Buchmueller et al., 2013). Therefore, small business owners must determine the long-term influence of implementing employee health care coverage. For example, business owners might need help to understand the ACA because they do not know its effects on their business. Buchmueller et al. (2013) contended that business owners to meet the expectations of providing health care requires the same expectancy from insurance providers. Zentner (2015) noted this assertion warrants additional research to confirm that leadership is a pivotal component of any change initiative.

Costs Associated with ACA
The increasing costs of health care coverage may directly connect with an individuals' choice of health care. Cutler and Sahni (2013) noted that health care costs have risen to appease providers and ensure cooperation. Even though the ACA is the law for employers meeting the appropriate criteria, proper implementation remains to reduce the unsustainable costs of providing health care and health care coverage to all residents of the United States. As Foran et al.
(2012) indicated, economic factors caused some health care practitioners to withdraw from the Medicare system. The implication of economics on the health care system is that some medical reimbursement payments will decrease and continue to decline until 2020 (Belatti et al., 2014).
Rationing health care is a common strategy for reducing care costs (Mariner, 2014). The idea of rationing is consequently a better option than allowing an independent payment advisory board to make health care decisions. The advisory board members make decisions based on necessity reducing fraud and abuse.
Given that health care costs in the United States have become a severe problem, determining who gets insurance remains a topic of debate (Hirsch & Lyman, 2014). The Oregon health plan, which includes rationing health care as an option, came under scrutiny by doctors who saw the practice as an unethical change to established treatments (Mariner, 2014).
The implementation of ACA will lead to 32 million people in the United States having access to health insurance by 2019 (Hossain et al., 2019). The increased number of entrants into the health care system may reduce the cost of health care by 1 trillion over 20 years (2014). The reduction may not occur if ACA legislation strays from the health care model designed to deliver services Open Journal of Business and Management (Chrikmaitov et al., 2014).
Although the Supreme Court justices decided the ACA as constitutional (Mariner, 2014), they agreed to review challenges to subsidies identified in the law (Choi, 2016). The political nature of the ACA continues to change the landscape of health care, and the decision to revisit the ACA continues to feed uncertainties about the direction of health care. Hartman et al. (2012) noted the cost of health care coverage has increased 3.9% to more than 2.7 trillion and may continue to rise. Based on the recession and high employment rate, the increase leaves private-sector health insurance at a loss. In contrast, Cutler and Sahni (2013) indicated the cost of health care coverage has decreased by more than 500 billion, which represents a move toward more savings than predicted. An eight percent decrease is prevalent in private-sector health care: however, a 55 % of the spending slowdown is unexplained. United States government officials expect to spend 19.6% on health care coverage by 2021, 19.6% of the gross domestic product (Randolph & Morrow, 2013). The U.S. physicians' opinions are essential in the political decision-making that controls health care costs (Tilburt et al., 2013).
Health care insurance providers typically offer different plans to small businesses and large businesses regarding individuals to address needs and cost constraints. Giaimo (2013) noted that obstacles faced in implementing group and individual insurance differ from small to large businesses. Giaimo also stated owners of small businesses must calculate premium amounts associated with actual health care obtained, which is a daunting task. Small business employers must also address premium increases that routinely involve significant cost increases (Stulberg, 2013). Health care cost increases affect smaller businesses more than larger businesses because of the risk imposed on small businesses. Blavin et al. (2014) estimated that 8 -9 million employees of small businesses were at risk of losing health care coverage. States officials develop and operate their health care exchanges to monitor the quality of services provided to establish a healthier workforce (Stulberg, 2013). Randolph and Morrow (2013) noted the ACA enactment emerged to improve the U.S. health care program. U.S. government officials must keep pace with life expectancy for more than 30 years to measure the effectiveness of the health care system (Finberg, 2012). On average, U.S. government officials spend twice as much money on health care than government officials in other nations (2012).

ACA Mandates
The money spent by U.S. government officials is a cause for concern because they failed to improve the system. Medicare payments represent approximately 20% of the payments made to health providers (Burwell, 2015). An increase in Medicare recipients eases the burden on private sector insurance companies.
Government officials designed the ACA so small business owners could provide health care coverage for employees (Dillender et al., 2016). As a result, tax D. W. White Jr., C. Needham Open Journal of Business and Management credits subsidize the cost of coverage. Before the tax credit for small business owners, little change occurred to the overall small business (Moriya et al., 2016).
As a result, the cost to provide quality health care should increase by 759 billion (Zigrang & Bailey, 2014). Employer-based insurance will eventually cover 27 million individuals (Moriya et al., 2016).
Despite concerns that small business owners will reduce staff sizes and stop hiring, insuring a larger group of employees will lead to lower costs (Blavin et al., 2014). Small businesses can benefit by purchasing coverage exchanges that make insurance competitive (Francis, 2013). The costs associated with providing health care insurance for small business employers require tactical decisions by small business owners (Francis, 2013). A tactical strategy is the best way for small business owners to receive lower healthcare costs.
The ACA intends for industries leaders to continue providing changes to the most significant healthcare reform in 45 years (Hossain et al., 2019). When government officials implemented the ACA, insurance exchanges were available to state agencies that offer coverage through employers. In 2016, the executives of the health care exchanges began providing coverage for individuals, thereby changing the dynamics of competitive insurance providers (Francis, 2013). In addition, by the mandate for all residents of the United States to have health insurance, individuals can obtain coverage through private insurance, employer insurance, or extended Medicaid-eligible programs (2013).
The decision to determine whether the ACA is suitable for small businesses remains debatable. Many people believe insurance companies will benefit from the ACA because of the mandate (Dillender et al., 2016). The higher the number of covered individuals will decrease cost, including those with preexisting conditions who could not obtain coverage before ACA (Angell, 2013). Although insurance company decision-makers will cover more individuals than ever before and premiums might increase to cover the cost of these policies, small businesses with 50 or more employees should face no increased expenditures .
In discussions of small business owners' strategies for implementing the ACA and enhancing profitability, one controversial concern is whether the ACA mandate negatively affects small business-based health care. Hossain et al., (2019) contended that the ACA is a new experience for small business owners worried that it would affect their profits. However, the tax credits available through the ACA should offset small business owners' profit losses and help to pay for employees' health care coverage (Gallman, 2016).

Research Method and Design
The qualitative method includes open-ended interview questions (Yin, 2015). Kahn (2014) noted that qualitative research is a method of looking into life's experiences; therefore, a qualitative research method is suitable for this study. Leedy Open Journal of Business and Management and Ormrod (2013) contended that researchers use multiple sources in qualitative research to create a complex reconstruction of real-world phenomena. Harvey (2015) noted that qualitative analysis could include nonverbal clues, whereas the quantitative method includes only statistical data and mixed methods.

Research Method
The qualitative research method involves aligning with the dynamics of exploring the successful implementation of ACA among small business owners from practical insights. Harvey (2015) noted that qualitative research is a tool for participants to express understanding. Yin (2015) contended that the qualitative method includes an opportunity to ask open-ended interview questions. Participants can express their personal experiences when responding to open-ended questions posed in an interview format (Chan et al., 2013). Yin (2015) noted that conducting a study on small businesses requires soliciting information from the owners through their experience. Merriam and Tisdell (2015) pointed out that researchers of qualitative studies could capture and understand in-depth human experiences, which is why a quantitative method is not suitable for this study. Yin (2015) proposed that a researcher achieve a comprehensive understanding in a qualitative case study. Moreover, selecting the research design was essential for ensuring the effectiveness of a study. A qualitative, multiple case study and the exploratory design were appropriate to understand how small business owners use strategies to implement the ACA into their businesses. I conducted one-on-one interviews with study participants to answer ten open-ended questions. Then I explored how small business owners implement the ACA law. Case study research is a multifaceted tool more appropriate for understanding circumstances and relationships (Yin, 2015). The case study design is suitable for exhaustive exploration; moreover, Smith (2015) contended that participants could provide in-depth knowledge with a qualitative case study.

Research Design
Furthermore, a case study is most suitable for conducting evaluations, studying natural phenomena, and exploring why an event happens (Yin, 2015). Yin (2015) noted that the case study design is an excellent choice to extend a program's exploration. The case study was a sound process for evaluating what strategies small business owners use to implement the ACA in their respective businesses. The study involves collecting data by conducting semistructured interviews. Participants will respond to semistructured interviews with in-depth information without limitations or boundaries. Chan et al. (2013) contended that the semistructured interview approach is the most efficient method for obtaining an in-depth understanding of individuals. Additionally, Koelsch (2013) stated that researchers are the primary instruments in studies involving interviews, and the interview guide is a secondary instrument.
Case studies can appear exploratory, explanatory, or descriptive (Yin, 2015). A multiple exploratory case design study was the most appropriate option because D. W. White Jr., C. Needham Open Journal of Business and Management this study intended to explore the small business owners' strategies for implementing organizational change. The exploratory case study design included uncovering the challenges of implementing organizational change (Baker et al., 2013). A feature of the exploratory case study design was to explain the advantage of exploration into a complex research question (Yin, 2015). To understand the complex relationships of participants in a short period using a multiple case study design was the most appropriate option. Vernon-Dotson (2013) recommended using numerous case explanatory design studies to explore all aspects of a system, process, or phenomenon. Yin (2015) noted that case studies are appropriate for investigations of daily practice, and Vernon-Dotson (2013)  The most appropriate design for this research was exploratory because the intent was to explore how small business owners implement a government mandate.
The purpose is to identify common traits and patterns better to understand the subject (Yin, 2015). The advantage of a case study design, as opposed to other designs, was to understand complex relationships among the participants quickly.

Population and Sampling
The population for this study involved small businesses owners in the physical and mental health care industry delivering health care services to clients with disabilities in Northeastern Ohio. Potential participants met the following criteria: the owners operate a business with 50 to 100 employees in Northeastern Ohio, manage day-to-day operations, and ensure that the small business complies with all laws and a sustaining business. I recruited participants through purposeful sampling. Purposeful or snowball sampling was appropriate for identifying participants with experience in the topic of interest. (Yin, 2015) contended that incorrect data might come from multiple sources, such as documents, direct observation, and interviews, and participant observation may require a large sample. (Yin, 2015) noted that snowball sampling means contacting a hard-to-reach population. Purposeful sampling can lead to rich information through individually identified resources related to a study (Duan et al., 2015). Mellor et al. (2015) noted that emerging interpretations must remain in the original data to achieve saturation. I narrowed the scope of owners to participants currently implementing the ACA, then conducted follow-up member-checking interviews and obtained in-depth data to reach saturation. Purposeful sample size was appropriate to determine the point of saturation (Fusch & Ness, 2015).
A sample can adequately report the research question (Fusch & Ness, 2015). Fusch and Ness (2015) also stated that saturation levels would vary based on study design. Marshall et al. (2013) indicated that researchers achieve data saturation when data becomes redundant.
The sample size is adequate for the participants to reach saturation (Fusch & Ness, 2015). Griffin (2013) noted that scholars conducting small studies with a Open Journal of Business and Management modest claim would achieve saturation expeditiously. I addressed the fair share of how small business owners in Northeastern Ohio in the physical and mental care industry were implementing the ACA. Yin (2015) contended that if a study involves a single organization to explore the nature of the organization or a program within the organization, a holistic design is appropriate. A unique set of circumstances will encompass small business owners in Northeastern Ohio in the physical and mental care industry who implemented the ACA mandate and addressed the research question. Thematic saturation occurs when no new themes or patterns emerge from the data (Kavalieratos et al., 2015). Depoy and Gitlin (2015) described the investigator as the primary data collection instrument. Chan et al. (2013) stated the researcher is primarily the data collection instrument. Data collection involved using an existing instrument (Leedy & Ormrod, 2013). I used eight open-ended questions in a semistructured interview that reflected strategic organizational change strategies (SOC) of participants who implemented the ACA. Yin (2015) stated that every participant should receive the same interview protocol to maintain consistency. The semistructured was a process for collecting in-depth information regarding business strategies. Using the specific protocol will ensure reliability, consistency, and validity.

Data Collection Instruments
Using an adopted instrument was appropriate for the interview questions. Merriam and Tisdell (2015) surmised the researcher is the primary instrument for collecting data. The interview questions align with the SOC theory. Five sources of data collection identify evidence of triangulation: 1) interviews, 2) business documents, 3) archived, 4) direct observations, and 5) participants observations. Morse (2015) stated that a designed process collects participants' experiences. The interview format should include flexibility for posing probing questions to elicit detailed answers (Seidman, 2013). Sanchez and Heene (1997) provided strategies for implementing SOC conceptual framework. I used the eight questions to address the implications of ACA. After receiving IRB board approval in conjunction with the signed consent forms from all participants, conducting data collection started. Yin (2015) outlined guidelines for analyzing qualitative data. Chereni (2014) noted that making sense of data is a two-fold process involving primary participants and the researcher.
As the primary data collection instrument, I ensured the instrument's reliability before implementing the study. Integrating bracketing techniques and following case study protocol was appropriate to improve reliability and validity.
The additional data collection instruments comprised of 1) semistructured interview questions, 2) a Livescribe pen audio recorder, 3) literature review, and 4) a journal documenting data collection. The semistructured interview consisted of eight open-ended questions to encourage participants to understand the overarching question in-depth. The overarching research question was the basis for Open Journal of Business and Management the interview questions. An audio recorder was appropriate to help with reliability during the face-to-face interview sessions with participants at their office. Koelsch (2013) stated the opportunity for participants to ensure the interpretation of the answers to ensure accuracy is mandatory. The participants can agree or disagree with the interpretation to correctly mirror their views (Marshall & Rossman, 2016). Measuring how small business owners in Northeastern Ohio's physical and mental health care industry was appropriate for measuring the SOC strategy to implement the ACA while sustaining business. The literature review was suitable for exhaustive background information on the study. I documented the participant's data process for implementing the Affordable Care Act. Reliability in qualitative research relates directly to dependability (Morse, 2015).
To increase dependability, participants must provide a 24-hour opportunity to approve or disapprove of any data (Yin, 2015). In qualitative research, validity is the relationship between the data and the constructs. Yin (2015)  The study participants were provided the opportunities to member check my data interpretation to ensure the correct explanation of the information in the interview. Yin (2015) indicated that researchers must share all the findings with the participants to complete member checks. Using multilayered methods at different stages of the study can enhance validity and reliability.

Data Collection Technique
The case study must involve semistructured interviews (Cairney & St Denny, 2015). Onwuegbuzie and Byers (2014)  Semistructured interviews include probing additional responses related to the study (Merriam & Tisdell, 2015). Participants' answers to open-ended questions provide a richer understanding of a topic and help to uncover additional insight (Kahn, 2014). If the participant does not fully answer the question, the question could receive rephrasing to obtain an adequate answer. Semistructured interviews were face-to-face interactions. E-mails requests were sent to the participants in advance of the interview. I requested e-mail consent from the participants before conducting a face-to-face interaction in advance of each interview.
While conducting the interviews, participants may feel reluctant to offer personal experiences (Seidman, 2013). Seidman (2013) noted interviews are time-consuming and expensive. The advantage of a qualitative research study is gaining an in-depth understanding of a phenomenon of the individual conducting the study (Yin, 2015). Merriam and Tisdell (2015) also confirmed that a qualitative research study is appropriate for exploring a greater understanding of a topic. Most importantly, qualitative research is a process of experiencing real-time events. During the interview, I used a simultaneous Microsoft transcription using a Livescribe Echo Pen and written notes. The ability to locate areas in the interview with the touch of a pen was better than a handheld recorder. I linked my Livescribe pen to my computer and downloaded the notes recorded during the interview. Immediately for transcription. The Livescribe Echo pen is an instrument for recording written notes into a Microsoft Word document. The Livescribe Echo pen is an electronic device appropriate for using handwritten notes alongside the recording. The Livescribe was to record data uncovered in the study; therefore, checking the Livescribe pen's green indicator light after every question was necessary to ensure the operation and prevent data loss.
Qualitative research must include an accurate transcription of the interviews (Kavalieratos et al., 2015). Vernon-Dotson (2013) noted that data consists of a continual interpretation, which is different from other forms of research. I interpreted what the participants shared and provided my understanding to maximize reliability and validity by conducting member checking. Member checking method of sharing is appropriate for participants' interpretation to increase validity. By providing participants with the opportunity to review, my interpretation of their responses supported data completeness and accuracy. In addition, the study participants were allowed to check the data interpretation to ensure the information uncovered during the interview was accurate.
A multiple exploratory case study was appropriate for collecting data from various sources (Vernon-Dotson, 2013). Small business documents and archival records helped conduct an investigation. I interpreted and shared the data with the participants. The data collection and interviews are in the protocol Da Silva et al. (2014) suggested. The participants will have access to the interpretation of the data. The process of using multiple lines of evidence confirms validity (Yin, 2015). Merriam and Tisdell (2015) deduced interviewing face-to-face is necessary, although face-to-face is often difficult to surmise the participants' behavior.

D. W. White Jr., C. Needham Open Journal of Business and Management
A face-to-face interview was an excellent opportunity for uncovering information. Frohmader et al. (2016) noted that participants like questionnaires sent by e-mail, as the e-mailed questionnaire is often more feasible for participants who have demanding schedules. Merriam and Tisdell (2015) stated member checking is appropriate for paraphrasing the participant's responses for each question into the researchers' own words. Merriam and Tisdell indicated that the researcher then could ask the participant to ensure that the researcher accurately interpreted their intended message for each question. The data verification was for accuracy with participants during member checking. Yin (2015) noted that researchers should compile data, disassemble the data, reassemble the data, interpret the meaning, and make conclusions. The member checking process does not encompass all data, but member checking is a tool for analyzing credibility (Andraski et al., 2014). Clarifying ensures correctness during an interview process (Frohmader et al., 2016). Participants received a succinct synthesis of each question. Member checking serves to ensure internal and external validity (Morse, 2015). The data received verification, and no changes were necessary to interpret the data.

Data Organization Technique
Data organization is a component for analyzing and interpreting data. Davies et al. (2013) stated a multiple exploratory case study is a method that consists of continuing an organization, examination, and interpretation of data. Data organization was a component for analyzing and interpreting data. A multiple exploratory case study continues the process that consists of organization, examination, and interpretation of data (Davies et al., 2013). I organized the data using an alphanumeric code to maintain the confidentiality of participants. The data will remain secure in an electronic form and hardcopy-filing system for data access. The use of generic codes achieves anonymity and confidentiality (Gibson et al., 2013).

Data Analysis
The triangulated data collection comes from face-to-face interviews, business documents, and records received at the meeting (Cronin, 2014). I analyzed and summarized the results based on the interview transcription and company documentation. Methodological triangulation was the process used to identify themes, aid interpretation, make assessments, and develop conclusions (Devotta et al., 2016). Triangulation analyzes participants of the same set (Rittichainuwat & Rattanaphinanchai, 2015). A reflection on data to classify and interpret information obtained from the interview is crucial (Doody & Noonan, 2013). The participants' comments were categorized to make comparisons and to uncover patterns. The themes emerged based on the answers to questions connected to the research question (Yin, 2015). Coding leads to categorizing data into different classifications (Morse, 2015). Morse (2015) reported that researchers should categorize, classify, sort, and Open Journal of Business and Management arrange data in the most resourceful manner. The objective of preparing data for analysis is to facilitate uncovering themes and patterns (Bishop & Lexchin, 2013). My role was crosschecking multiple sources. Depoy and Gitlin (2015) indicated that triangulation from numerous perspectives would lead to a comprehensive understanding. Data analysis is an essential component in research (Smith, 2015). An audio recorder captured information collected during my face-to-face interviews. Data from the Livescribe pen was transcribed into a Microsoft Word document and verified for accuracy with participants using member checking.
No alteration occurred to the transcription. Yin (2015) noted that researchers should compile data, disassemble the data, reassemble the data, interpret the meaning, and make conclusions. I ensured that the data was sequential.
Data analysis aimed to uncover themes, patterns, and descriptions that address the research question. Merriam and Tisdell (2015) noted the most significant step in qualitative research is the process of data analysis. Strategic organizational change theory and process of implementing ACA into a small business applied to address the conceptual framework data. The data analysis involves coding recovered information to ensure reliability, validity, and creditability (Yin, 2015). The data consisted of SOC strategies categories. The data receive analyzing and categorizing using a data analysis method.
The data will include information that relates to ACA implementation. Analysis of the data revealed central themes (Anderson, 2013). Noble and Smith (2015) stated common themes must occur. Once a common theme emerges, a thorough analysis will take place. Borrego et al. (2014) noted that researchers should ensure a connection exists between the literature, methodology, and study results. I explored the implementation of the new ACA law from Sanchez and Heene's (1997) theory of SOC. Research rigor improves coding the participants' data (Kaefer et al., 2015). The conceptual framework of SOC was appropriate as a guide to categorize how small business owners adapted to internal and external strategies of the SOC. The data recovered from physical or mental disabilities of small business owners align with themes of how owners address the operational challenges of implementing the ACA. Smith (2015) noted two critical components of the research process: data analysis and data interpretation. The method of data analysis is the most significant step toward quality research (Yin, 2015).
Methodological triangulation was essential for collecting in-depth interviews, company documents, and member checking data.

Reliability and Validity
A primary concern in a study is achieving the highest possible quality (Cope, 2014). Reliability and validity could affect the relevance of analysis if the individual conducting the study fails to meet timeline boundaries (Fusch & Ness, 2015). Assessing the quality in qualitative research through imagination, expression, and the invention is paramount for reliability and validity (Houghton et al., 2013).  (Carlson et al., 2014). I implemented member checking as a critical component of reliability that included case study protocol to ensure reliability. After the interview, the participant will receive the interpretation. Participants had an opportunity to member check by contributing new or additional perspectives and explaining validation. Participants provided no further details; therefore, transcript remained in the original form. Member checking is a way to establish reliability in qualitative research (Leedy & Ormrod, 2013). Avoiding threats in the data collection phase was necessary to ensure procedural reliability. Failing to take precautions such as note-taking and recording the interview increases the possibility of errors in a study. Data collection stages were a process done in specific stages. Following the same steps during an interview helps decrease issues during the data collection (Onwuegbuzie & Byers, 2014). Documented steps will ensure the ability to replicate the study (2012).

Validity
The validity test between qualitative and quantitative studies was a topic of debate because qualitative studies do not involve measurement. A detailed explanation of relevance is within the study (Cope, 2014). Yin (2015) noted that the link between the relevant literature and the conceptual theory is essential to establishing validity in a qualitative study. The goal is to capture participants' experiences to understand the case (Potter et al., 2013).
Bias and insufficient data were threats to the validity of a qualitative study. Yin (2015) noted that data saturation occurs when the results of the data analysis show no new or different information. Ensuring validity is essential for avoiding personal bias and incompleteness (Noble & Smith, 2015). I used methodological triangulation to enhance validity, including ACA plans, business implementation plans, or policies and procedures on healthcare changes. Yin (2015) indicated that researchers use a study design to avoid threats to contextual validity by ensuring correct data interpretation and analysis (Potter et al., 2013). Cope

Dependability
In qualitative research, dependability indicates consistency within the study. I provided a trail of memos and field notes to ensure trustworthiness. Study results are dependable when an audit trail is available for others to replicate the study (Charach et al., 2014). Dependability enhances if other scholars agree with Open Journal of Business and Management the results found in the study (Cope, 2014). An agreement to achieve dependability must occur in each research process. Member checking was a tool to increase data dependability, external validity, and warrant transferability. Member checking involves testing data with the participants who provide the data to ensure credibility and authenticity (Reilly, 2013). Member checking is the process of data clarification (Onwuegbuzie & Byers, 2014). The participants received an interpretation of the interview to safeguard against misrepresentation.

Credibility
A test that determines audibility and trustworthiness is necessary (Cope, 2014). Data must exhibit high quality and high reliability even at the most basic level.
The use of a rigorous approach to the study will justify the findings. The member checking follow-up interview enhanced academic rigor through data saturation. This process continued until no new data occurred. Leedy and Ormrod (2013) noted that the construct of qualitative research credibility is judging validity. Cope (2014) indicated that credibility in a qualitative study includes the human experience. Houghton et al. (2013) stated research must consist of a believable process.

Transferability
Cope (2014) stated that transferability is the basis for the scholars conducting the subsequent study; therefore, I provided a framework for future scholars to continue the study through my ability to generalize or transfer research results. Transferability is the degree to which results relate to other settings (Black et al., 2013). Transferability can revert to future researchers planning their subsequent study. The proposed study coincided with other studies. Houghton et al. (2013) noted that qualitative research includes an incentive, expressive, and imaginative methodology. Houghton et al. also stated researchers conducting qualitative research could obtain an extended interview that can support the ability to obtain validity through patterns of behavior. My study included an unbiased viewpoint, and I avoided scholarly bias toward any topic by using a combination of interviews and office data addressing the ACA. The process of sharing personal bias at the beginning of a study establishes trustworthiness (Black et al., 2013). Obtaining the highest possible quality is necessary for reversing the view that qualitative research is a soft science (Cope, 2014). Reliability and validity affect the relevance of research if researchers fail to ensure they meet the guidelines of conformability (Fusch & Ness, 2015).

Presentation of the Findings
To develop the research question, I used semistructured interviews and member checking to obtain the strategies small business owners use for sustainability. I Open Journal of Business and Management reviewed small business owners' documents and qualitative data obtained from the interviews. I also analyzed the participants' key concepts. Depoy and Gitlin (2015) indicated that triangulation from multiple perspectives would lead to a comprehensive understanding. Three significant themes included in the research question emerged from the data analysis. Small business owners addressed: 1) increasing cost, 2) reducing high-cost premiums, and 3) high staffing turnover.
The conceptual framework for the study was a strategic organizational change (SOC). The SOC theory includes concepts of management reactions, human resources management with human resource development, employees' reactions, perceptions, and attitudes toward an employee (Anderson, 2013). The SOC was appropriate to explore my business owners' strategies for successful ACA implementation. In addition, the SOC was useful in aligning the process for implementing ACA and sustaining business. Small business owners are cognizant that providing health insurance is costly (Lahm, 2015).

Emergent Theme 1: Increasing Cost
A key theme to addressing the research question of what strategies small business owners use to implement the affordable care act mandates was the increasing cost of health care plans. The increasing cost of health care can determine the success of small business owners seeking sustainability while implementing ACA alternative coverage options. Increasing health care cost is apparent using strategic organizational change as a strategy for owners of organizations to meet business challenges.
The concept of controlling health care costs occurred throughout small business interviews and documentation. Lahm (2014) stated that business owners could achieve positive social change by using and sharing strategies to implement the most efficient health care. All participants reported that controlling the increasing cost of health care was a detrimental issue affecting them and their ability to stay in business. The findings revealed that the cost of health care affects the sustainability of small business owners. According to small business owners in the physical and mental health care industry who participated in this study, sustainability is in jeopardy if cost is not in control. The cost of health care is a significant concern for owners' outlook on sustainability. Lahm (2015) stated that ACA might increase 1.2 trillion, attribute cost to small business owners.
Small business owners have minimal knowledge of understanding ACA regarding employee status (Hossain et al., 2019). The study participants stated that concern about the increasing cost of health care determines their decision to provide or not provide health care to their employees. The penalties associated with not providing health care for employees are becoming a viable business solution for sustainability. Small business employers' use of human resource management was vital in health care decisions. Participants 1 and 2 stated they were advised they could use the penalty to reduce cost if necessary. Increasing cost or increasing number of employees receiving health care benefits would force own-Open Journal of Business and Management ers to use the penalty as an option to usurp high-cost health care insurance. A business owner requires a strategy to implement ACA and sustain in business.
Participant 1 stated they were advised to decline to provide health care insurance for their employees and accept the penalty because they would save money.
Participant 1 stated they decided to go against the adviser's advice and provide health care insurance to comply with the mandate. Participant 2 stated if all employees had accepted the health care, their plan owners would have had to evoke the penalty to reduce the increasing cost of health care. Participant 3 advised they were self-insured. In the literature review, Cordova et al. (2013) stated that project cost increases into total expenses by the end of the month or quarter for taxes and penalties, and premium payments determine cost viability. prices continue to increase. The cost of health care plans and accessibility was difficult because of the requirements set by significant insurers. Cutler and Sahni (2013) noted that health care costs have risen to appease insurers. Also, participants advised shopping for lower health care was a challenge.
The cost of health care coverage affects operational costs, the owners' strategic decision to provide health care coverage, to accept the penalties, and how to implement employers' hiring practices based on the expense of the health care insurance. Problems addressing ACA implementation caused changes in how lawmakers' use of ACA helps determine the cost of health care (Fry-Bowers et al., 2014). Concerns outlined in ACA additionally caused the Supreme Court justices to vote if ACA was a tax on employers (Cutler & Sahni, 2013). Participant 1 found that insurance through a large insurer was necessary to keep the cost down; however, complying with the requirements of the health care insurers was difficult. Participant 1 stated they had to pay 100% benefits to some staff to meet the criteria set by the more prominent insurer. Paying 100% of an employee's health care insurance for an overall lower rate required a strategic organizational change and attitude.
Employer-sponsor health care. Responses to this theme expressed that the cost Open Journal of Business and Management of health care plans was severe to business owners' sustainability. For example, participant 1 and participant 2 stated in the physical and mental health care industry, we do not have the option to increase rates or increase the cost of our services. Medicaid sets the price for services without the possibility of negotiation. Therefore, each increase has a direct effect on our bottom line.
In addition, all participants expressed the inability to attract high numbers of participants to enroll in their company health care plan. Small business owners who provide at least half of their employees' healthcare costs receive a 35% tax credit through the federal government (Hossain et al., 2019).
The tax incentive centers on small business owners' understanding of how the credit helps provide health care for employees. Although the tax credits subsidize the cost of health care coverage for small business owners, some owners are still unaware of the tax credits' impact on their small business (Dillender et al., 2016;Moriya et al., 2016). Small business owners that applied for the tax credit better rates (Mariner, 2014). Even though health care rates were rising at a slower pace because of ACA, the rates continue to increase, adding to the already high cost of health care. Buchmueller et al. (2013) also expressed concern that employers might drop health care coverage because of the ACA requirements. Open Journal of Business and Management Owners' insights into the sustainability of their small businesses reflect on the ACA mandate and will lead owners to make the appropriate decisions for their companies (Collins & Garber, 2013).
Moreover, despite all concerns regarding small business owners, the decisions made by the larger groups of employers will lead to lower costs (Devotta et al., 2016). Thus, the findings confirm previous concerns regarding small business owners' price for increasing the cost of health care plans. Some small business owners cannot get better insurances rates because of an inability to maintain staff.
The three participants reported going to a third-party administrator to address the cost of health care and comply with the mandates set in the ACA policy. Talwalkar (2014) noted that some legislators agreed that implementing the ACA would cause a change in health care coverage for some patients because the ACA requires health insurers to allow all individuals to obtain health care coverage. Participant 1 advised that even though owners wanted to provide health care for staff, owners could not manage to pay their share of the plan if 100% of staff signed up for the health plan. Blavin et al. (2014) stated that insurance costs continue to rise, and Stulberg (2013) expressed uncertainty about whether the cost would eventually stabilize or decrease.

Theme 2: Reducing High-Cost Premiums
The second principal theme is reducing high-cost premiums, which are a problem for small business owners. The small business owners in the health care provider industry said that they often found themselves replacing staff, forcing them to seek insurance through insurance exchanges, which results in higher cost premiums. As noted in the literature reviewed, staffing decisions are integral for small business owners who are factoring in the cost of health care.
All participants stated that the cost of health care plans increases depending on the insurer's size: larger insurers are more likely to have lower premiums. Participant 1 stated that to enroll with a large health care insurer, she had to meet an enrollment requirement of 70% of company-employee participation. As a result, small businesses had to navigate ACA strategically address Participant 1 said she had to pay 100% of a staffer's insurance to meet the requirement.
As the literature review included, increasing the cost of health care would cause small business owners to continue the process of looking for cheaper health care options (Giaimo, 2013 (Hossain et al., 2019). Therefore, small business owners who purchase health insurance may lower the rates of insurance cost.
Continue Shopping. As noted in the literature review, increasing the cost of health care would cause small business owners to continue the process of looking for cheaper health care options (Giaimo, 2013 Employers expressed concern that they may have to drop health care coverage because of cost (Buchmueller et al., 2013). Employers might have to conduct complex calculations that consider federal regulations, taxes, and wages (Buchmueller et al., 2013). Rak and Coffin (2013) (Diaz, 2015).
Additionally, Blumenthal and Collins (2014)  The participants' responses, documents, literature review, and current research provided information in uncovering SOC strategies business owners used to implement ACA. The core theme of offering incentives occurred 12 times, which revealed that health coverage was referenced 47 times when referring to increasing incentives. The offer of higher pay to employees emerged seven times from the findings that high staff turn is a problematic concern reducing small business owners' insurers' options.
The third principal theme was the large insurer's requirement. Small business owners responded to the question about their additional thoughts on the Affordable Care Act. All the owners wanted to provide health care for their employees before the ACA mandate. Participants 1 and 2 noted that the cost and requirements necessary to ensure staff were unreasonable and would cause financial burdens for their small business. Using the SOC theory for strategic and tactical implementation, small business owners made business decisions. Participant 3 stated that since 2009, health care was an option, but the cost of health care has increased 140%, and something must be done to control cost. Participant 3 also noted that staff was responsible for 100% of their coverage from the company.
Accordingly, the large insurance agency requires 70% of staff participation in their health care program. Seventy percent employee participation was a requirement for eligibility for large insurance company agencies caused concern. If owners had less than 70% employee participation in the company health care, Accordingly, Participants 1 and 2 stated that the significant insurance agency personnel require 70% of staff participation from small business owners to sign up for their health care program according to participants' 1 and 2. The 70% participation was a requirement for eligibility for large insurance company agencies was cause for concern. If owners had less than 70% participation, they were forced to purchase their plan through the health care exchanges. However, the health care exchanges do not amount to a simple sign-up service for employers to offer health care coverage; instead, exchanges were an alternative for employers to sponsor health care coverage programs for their employees (Hossain et al., 2019). In addition, the health care exchanges include higher rates. Participants 1 and 2 acknowledged that costs had increased to the extent that they now faced sustainability concerns. The participants' responses related to the literature Cordova et al. (2013) noted that small business owners receive their insurance from healthcare exchanges. The design of the Healthcare Exchange was to allow small business owners a less complex process to navigate the healthcare system.

Applications to Professional Practice
The findings of this study clarify the strategies small business owners in the physical and mental health industry use to sustain their businesses. Based on the research question, the main themes in Section 3 are 1) increasing costs, 2) reducing high-cost premiums, and 3) high staff turnover for small business owners. Although this research provides meaningful information for small business owners in any industry, it mainly addresses small business owners in the physical and mental health industry. Randolph and Morrow (2013) stated that cost reduction in this context is related to an insurer-based system of health care.
Therefore, the findings of this research can be applied to the business practices of professional business researchers, small business owners, and stakeholders to enhance their implementation of the ACA and obtain insurance from large insurance companies.
The strategies suggested are based on the participants' interviews and can provide insights for small business owners trying to sustain their businesses after implementing the ACA. An essential element of these strategies stems from small business owners in the physical and mental health care industry. Physical Open Journal of Business and Management and mental health care agencies do not have the benefits of increasing the costs of their services. The participants' interviews suggest strategies for providing reliable information on ACA implementation and resources, such as health care costs, employee turnover rates, and large health care agency requirements. The strategy and problems uncovered during this study seem increasingly crucial because small business owners cannot sustain their businesses and the new government's official threat to repeal the ACA.
Small business owners who lack an understanding of the ACA may contribute to sustainability by providing new information. These insights leave such owners to make the best decision for their businesses (Collins & Garber, 2013). For example, lawmakers designed the ACA mandate to increase the number of individuals with health care in the United States. The problem was that the cost of health care threatened the sustainability of small business owners who had to provide health care to their employees.
Small business owners' health care insurance plan costs (Theme 1) provide evidence that supports the problem statement indicating providing for full-time employees could face financial penalties. In addition, the ACA mandate caused many small business owners to experience challenges that negatively affect their operational costs and sustainability. Therefore, providing all employees with insurance is detrimental to sustaining a small business. Themes 2 and 3 provide insights into the high staff turnover effect on health care options for small business owners. The solutions to these problems embrace the notion that an increase in the number of employees with health care plans will decrease the cost of health care (Leonhardt, 2015).

Implications for Social Change
Stakeholders can use the results of this study to share their findings with small business owners. Stakeholders can also provide insight to small business owners looking for different options to sustain the business while providing health care to their full-time employees. Additionally, stakeholders can share potential information on the number of reasonably insured employees without losing their business. These actions by small business owners follow Sanchez and Heene's (1997) recommendations for strategic organizational change. Small business owners are collectively the largest employers in the United States. Although I focused this study on small business owners and the ACA, future research should address the issue of children staying on their parent's insurance until the age of 26 and the effects of providing health care to individuals with preexisting conditions.
Small business owners who choose to follow a SOC conceptual framework could implement an alternative framework for health care, such as a business theory that could sustain their business. Giaimo (2013) indicated that for owners to sustain their businesses, researchers need to reduce healthcare costs. I propose the following strategies for decreasing the cost burdens and contributing to the sustainability of small business owners in the physical and mental health care Open Journal of Business and Management industry. Additionally, the results of this study may lead to social change by giving small business owners the information they can use to explore different options for maximum cost-saving and sustainability. Small business owners have a significant role in providing health care in the United States.

Recommendations for Action
This study showed insights into the mindset of small business owners' commerce with the increasing cost of healthcare associated with ACA. Small business owners believe that cost was spiraling out of control. For employees who work full-time, their healthcare cost ranges from $1.79 to $2.00 an hour based on the state of residence. Small business owners' awareness and creative actions were pivotal to controlling the cost of their health care and value in sustained business. The solutions for reducing health care costs could address small business owners' costs and address if providing 100% of their employee's health care coverage was a feasible goal for sustainability. Hossain et al., (2019) indicated that an increase of insured individuals across the United States will reduce health care cost. The more individual paying into the health care will bring done the cost.
Small business owners can gain knowledge from the results of this study and be their advocates for health care cost reduction. Owners of small businesses with 50 -100 employees provided the groundwork for this study. Business owners must increase their knowledge of insurance policies. Another area of knowledge owners must understand is how insurance companies categorize their employees for insurance policies. For example, spouses are not dependents in the ACA for health care, proving pivotal in cost reduction by not having to ensure the spouse, lowering the insurance policy.
Small business owners should adhere to the information gained from this study to address increasing health care costs. Health care for small business owners is a significant concern for small business owners since the implementation of ACA.
Although small business owners are experiencing high healthcare costs, owners must exhaust all avenues to address health care reduction to ensure the best product available.
The owners should conduct a tax audit to determine the strategy that provides the most efficient and lowest cost for employee health care. I would suggest small business owners look into the possibility of being a self-insurer that goes through an insurance company. A small business owner who is a self-insurer can apply stop-loss, which means the insurance company pays catastrophic needs.
By creating a budget for employee health care prepares owners for this process.
The small business must know the number of full-time employees as a starting point. If the owner accomplishes a budget, they can petition insurance vendors.
Secondly, I would recommend small business owners look into the possibility of a 401 (K) with a health care benefit that allows the employer to pay a predetermined cost for health care. Owners should also complete a comparative re-Open Journal of Business and Management view of vendor contracts. The lowest price may not be the best bargain. Additionally, checking if using one health vendor is more cost-effective than a group vendor.
Lastly, I recommend small business owners know the number of employees they can provide insurance for safely to remain sustainable. Small business owners with 50 to 100 employees are not likely to fund 100% of their employees for healthcare. Small business owners must remain aware that larger insurers require 70%, employer participation, so small business owners must expand shopping options. An owner should also look into shared health care plans that provide tax incentives.
Results of the study can provide insightful information to small business owners; therefore, small business owners who participated in the study will receive a two-page summary of the results. The study will be disseminated to several small business owners who did not participate in the study upon their request. Further dissemination of the study will include speaking engagements, consulting small business owners, training small business owners, and presenting information to government officials. I will also seek to present publication findings locally and nationally.

Recommendations for Further Research
The themes emerging from this study indicate that further research is necessary to understand the implementation of ACA by small businesses. This study intended to explore the strategy small business owners use to implement ACA and sustain their businesses. The following recommendations are for future researchers. The future exploration of different geographical locations will also provide additional insight to businesses outside of the physical and mental health care industries. The investigation of the ACA's impact on small business owners' sustainability will require further research in the future.
Small business owners believe that providing health care to 100% of their employees would cause problems for their ability to remain in business. Therefore, quantitative, or mixed methods research may provide additional insight for a formula that can determine the appropriate number of employees small business owners can provide health care to. In addition, I recommend that researchers carry out follow-ups with small business owners to obtain their views on the change in leadership in Washington D.C.

Conclusion
The study proved significant because the results provided insights into the strategies implemented by providers of health care services to individuals with disabilities in Northeastern Ohio, specifically small businesses that accommodated the mandates of the ACA.
Small business owners' strategies for health care under the ACA include tracking the increase in the cost of health care insurance. In addition, future re-Open Journal of Business and Management searchers should understand how small business owners with 50 to 100 employees in different industries strategize to implement health care for full-time employees. Beyond small business owners searching for lower health care costs, some small business owners' strategy is to act as their health care providers.
Future research could include strategies used by small business owners in different industries outside of Northeastern Ohio. Additionally, small business owners can benefit from other owners' strategic organizational strategy. Finally, further research can include small business owners who fit in the lower than 50 -100 employees and companies in the over 50 -100 range.