Businesses with 50 or more full-time employees face employer mandate penalties. This mandate gives employers a motive to stay below 50 employees, such that the employers that want to continue to grow their businesses must either outsource more work, or replace their own full-time employees with part-time employees. In addition, since the employer mandate penalties depend on month-by-month changes in the number of full-time and part-time employees, this leads to a requirement for small business owners to engage in time-consuming monitoring and paperwork.

The additional benefits required by the PPACA, such as bans on annual and lifetime payout limits, and an extensive list of free preventive services, have increased the cost of insurance. As such, insurance purchased by the individual and small-group markets are becoming more expensive, because they must cover these additional benefits. In addition, according to the NFIB, "In 2016, the Secretary of Health and Human Services will have virtually unfettered power to add items and costs to the package."

The PPACA also imposes a health insurance tax (HIT) on insurers, and insurers tend to pass the tax along to businesses and consumers. In fact, over the first decade of PPACA (2014 to 2023), according to the NFIB, this provision increases taxes by $102 billion. As a result, the NFIB estimates that the HIT will reduce private sector employment by 146,000 to 262,000 jobs, with 59 percent of the losses coming from small businesses.

In addition, owners of unincorporated "pass through" businesses report business income on their household 1040 tax forms. Pass-throughs are vulnerable to PPACA's 0.9 percent "Medicare" surtax on wage and salary income above $200,000 for individuals ($250,000 for joint filers). This surtax is paid on top of the long-existing 1.45 percent Medicare payroll tax. The NFIB added, "Despite the name, the proceeds of the new tax will not go to Medicare."

Employees can no longer use flexible spending accounts (FSAs) and health savings accounts (HSAs) to purchase over-the-counter (OTC) medications without a prescription. As such, unless businesses increase employee compensation to offset what amounts to an increase in taxes, employees lose spending power.

A number of PPACA's provisions, such as essential health benefits requirements and the HIT, apply only to the full-insured market (most small businesses and individual policyholders), but not to the self-insured market (most big businesses, labor unions and governments). The NFIB also noted that, "The Secretary of HHS has granted thousands of waivers to certain PPACA provisions without specifying the criteria for approval or disapproval. The result is to saddle some, but not all, employers with large expenses, and do so in an unpredictable manner."

PPACA has left many of the most important operational details to regulators. The result is that businesses are required to devote considerable resources to monitoring and navigating regulatory changes. Few small businesses have human resources, legal, or account departments to track these changes.

Finally, research conducted by the NFIB over the last two years has found that 62 percent of small business owners reported that their premiums had increased, while only eight percent said their costs had dropped. "One in ten small businesses had their policies cancelled, under the law," said Danner. "Almost no one is using the SHOP exchange, according to the government's own enrollment data, and to the extent that there are subsidies available in the form of tax credits, they are complicated, temporary, and too small to offset the costs."