Social Safety Nets' Effects on the Level of Entrepreneurship : a study focused on the role of healthcare acting as a safety net, within an entrepreneurial ecosystem

Social Safety Nets' Effects on the Level of Entrepreneurship.

A study focused on the role of healthcare acting as a safety net, within an

entrepreneurial ecosystem.

1

st

_{reader: Tsvi Vinig}

2

nd

_{reader: Roel C W van der Voort}

2

nd

_{Final Draft}

of July, 2018

Sinan Bence Erdal

Masters in Entrepreneurship

Student # 11424052

Table of Contents

Introducton...1 AutomatonnandnthenJobnMareet...1 ArgumentsnfornSafetynNets...3 StatenofnEntrepreneurshipninnthenU.S.A...5 SafetynNetsnandnEntrepreneurship...8 TheoretcalnInsightsnofnthenEntrepreneurialnEcosystem...10 ThenEntrepreneurialnEcosystemsnandnPoliciesnfornEntrepreneurship...13 HealthcarenasnanSafetynNet...17 ThenStatenofnHealthcareninnthenU.S.A...18 Hypothesis...19 Methodology...22 EntrepreneurialnEcosystemsninnFocus...26 HealthcareninnMassachusets...26 HealthcareninnKentucey...28 HealthcareninnTexas...29 Boston-Cambridge-QuincynMSAnasnannEntrepreneurialnEcosystem...31 Louisville-JeffersonnCountynMSAnasnannEntrepreneurialnEcosystem...34 Dallas-FortnWorth-ArlingtonnMSAnasnannEntrepreneurialnEcosystem...37 DatanAnalysis...39 FindingsnfromnData...43 Conclusionn&nDiscussion...45

Introduction

Therenhasnbeennannongoingndebatenamongnscholars,nwhetherngovernmentnspendingnonnpublic goodsnaffectsnthenlevelnofnentrepreneurshipnpositvely,ninnangivenneconomynoverall.nnInnansense, thisndebatenextendsntonthenrootednandnwell-enownnKeynesiannvsnthen(Neo)Liberalnviewsnonnthe rolenofngovernmentnspendingninnanneconomy.nContemporaryndiscussionsnhowevernrequirensuch debatesntontaeenplace,ntonbenablentonstartnworeingnonnthenchallengesnofnthennear-future.nThese challengesnInmentonednwillnarisenasnthendirectnand/ornindirectneffectsnofnrapidntechnological developments n wen facen as n humans n around n then Globe. n Although n the n rapid n advancement n of technology,nglobally,nisnmeantntonincreasenproductvity,nincreasenqualitynofnlives,ncreatenimmense amountnofnvaluenandnopportunitesnfornpeoplenallnover,ntherenwillnbennaturallyn'losers'ntoonofnthis process.nOnenaspectnofnthisndevelopmentnisnpotentallynpartcularlynworryingnfornordinarynpeople aroundnthenWorld,nthatnisnthenrisenofnautomaton.nAutomatonncannbenexplainednasnannatural process,nbynwhichnorganizatonsnmaeeninvestmentsninnnewncapitalntonincreasenproductvityninnthe longntermnandndisplacenthenmoreninefcientnhumanncapital.nInnthisnstudy,nInproposenthatnto combatnthendisplacementnofnemployeesnduentonrapidntechnologicalndevelopments,npublicnsafety netsnneedntonbenimposed.nThesenarenneededntonfosternentrepreneurshipnandnself-employment, whichncanncombatnmassnunemploymentnandnfurthermore,nincreasenproductvitynandnthenlevelnof creatvityninnangivennentrepreneurialnecosystem.

Automation and the Jo Market

DisruptventechnologiesnarennothingnnewntonusnHumans.nItnhasnbeennannessentalnpartnofnour economicnandnsocialndevelopmentnovernthencenturies.nInn18th_{ncenturynEngland,nangroupncalled}

thenLudditesnhadnprotestednthenincreasingnusenofnmachinesninnthenwool-producingnindustry.nThey werenworriednthatnthenownersnofnfactoriesnwouldnreplacenthemnwithnmorencost-tmeneffectve machinery.n Naturally nthesen peoplen fearedn hownthisn wouldn affectn theirn livelihood n andn their chancesnofnputngnbreadnonnthentable.nNowncenturiesnlaternwenarenexperiencingnthendawnnof another n disruptve n innovaton n cycle, n but n with n the n difference n that n now n we n live n in n an highly globalizedncivilisaton.nTonsomenextentnthenadverseneffectsnofnautomatonncannbenfeltnacross

severalnnatonsnofnthenWorld.nnAn2014nReutersnanalysisnlooeednatnseveralnlargencorporatonsnin thenUSAnandnfoundnthatnalthoughntheirnproftsnhadnrisenninnthenperiodnofn2001-2013,nthennumber ofnpeoplentheynemployednhadndecreased.nFromnthisnitncannbenconcludednthatnhumannlabournisnno longernansignifcantndrivernofneconomicngrowthn(Stevens,n2016).n Asnautomatonninnthenworeforcenexpandsnacrossnmanynindustries.nSonwillnitsneffectsnbenfeltnacross differentndemographics.nCampan(2017)npredictsnthatn"byn2025,ntensnofnmillionsnofnjobsninnboth developingnandnadvancedneconomiesncouldnbenaffected".nThenquestonnisnhowngovernmentsnwill be n able n to n deal n with n the n masses n people n displaced n from n their n woreplace. n Technological unemploymentnisnlieelyntonbenhighlyndecisiveninn21st_{ncenturynpolitcalnandneconomicnlandscape.nAs}

populistnviewsninnthenUnitednStatesnpressurencompaniesntonproducendomestcally,nhopingnthat the n losses n of n jobs n could n be n reversed, n there n is n evidence n that n companies n are n motvated n to advancenthenratenofnautomaton.nReutersnfoundnwithnthengreaternpushnforneeepingnfactoriesnat home,ncompaniesnarenincreasinglyninvestngninnautomatonnprocesses,ninnorderntonbenablentonstay compettveninnthenglobalnmareet.n

In n 2013, n McKinsey n Global n Insttute n publishes n a n report n named n "Disruptiv Tvchnoeloegivs: Adiancvs that Will Transfoerm Lifv, Businvss, and thv Gloebal Ecoenoemy".nHerentheynproposenan overhaulnofntheneducatonnsystemsntonbeternpreparenfuturengeneratonsnfornthenjobnmareetsnof thenfuture.nTheynstatenthatneducatonnhasntonbenfocusednonnraisingnhighlynseillednindividuals,nwith adequate n enowledge n to n compete n in n a n high-tech n environment. n There n are n worrying n signs however, n that n educaton n alone n can't n solve n the n problem n of n woreers n being n replaced n by automaton.nAnrecentnPwCnstudynnamedn"Willnrobotsnreallynstealnournjobs?nAnninternatonal analysisnofnthenpotentalnlong-termnimpactnofnautomaton"npredictsnthatntherenwillnbenthree wavesnofnautomaton.nAccordingly,nthenthirdnwavenwillnbenfeltnbynthenmidn2030'snandnwillnput overn10%nofnjobsnthatnrequirenhighneducatonnundernthenrisenofnautomaton.nThenratenisneven worsenfornmediumneducatonnjobs,nwherenovern35%nwillnbenundernrise.nFinally,novern45%nofnlow seillednworenwillnbensubjectedntonautomaton.nOthers,nincludingnAutorn(2014)nproposesnanslightly differentnpossibility.nHenarguesnthatntheneconomynwidenadoptonnofnautomatonnwillnresultninna phenomenon n called n 'job-polarizaton'. n He n believes n that n the n jobs n that n are n the n most n easily automatednarenthenmiddle-wagenandnmediumnseillednoccupatons.nFurthermore,nhenarguesnthat

"computerizatonnofnroutnenjobntasesnmaynleadntonthensimultaneousngrowthnofnhigh-educaton, high-wage n and n low-educaton, n low-wages n jobs n at n the n expense n of n wage, n middle-educatonnjobs".nNevertheless,nthenscenario,nitncannbeneasilynpredictednthatnthendistributonnof incomenwillnbenevennlessnequalninnthenfuture,nleadingntonfurthernsocio-economicntensions,nand distrustsninnthenelitesnresponsiblenfornorganizingnthenunitsnofnproducton.nnIfnwenarenfacingnsuchna scenario,nthennwhatncannangovernmentndontonensurenthenwell-beingnofnitsncitzens?

Arguments for Safety Nets

In n1964,nPresidentnL.B nJohnson n initated nansoncallednBluenRibbonn'Natonal nCommissionnon Technology, n Automaton n and n Economic n Progress' n to n identfy n the n potental n impact n of technologicalnadvancementnonnemploymentnandnthenlevelnofndisplacementninnthenlabournforce. Thenconclusionnwasnthatnautomatonndidnnotnposenannimmediatenthreatnatnthatntme,nhowevernit didnencouragenpolicymaeersntonthinenaheadnandnimposenpublicnbeneftsnthatnwouldnaidnthose affected. n Overall n the n report n embraced n technological n advancement n as n an n essental n part n of economicnprosperity,n"Automatonnisnnotnournenemy.nOurnenemiesnarenignorance,nindifference, andninerta",nwarningnthatnpreparednessnisncrucialnfornfuturenwelfare.nThenadversenconsequences ofnautomatonnwillnbenrelatvely-longnlastng,neffectngngeneratonsntoncome.nHowever,nitnisnnot somethingnthatncan'tnbenovercome.nJ.M.nKeynesnarguablynforesawnthatnthensoncalledn'technical unemployment'nwillnbenannissueninnthenfuture,nwhilenemphasizingnthatnitnwillnbenonlynantemporary phase.nStevensn(2016)narguesnthatninnthencasenofntechnologicalnunemployment,n"Theneeynis determiningnhowntoneffectvelyndealnwithntheneconomicnandnsocialndisruptonsnthatnnaturallynand historicallynfollownperiodsnofntechnologicalngrowth".nThus,nthenquestonnarises.nWhatnpolicies shouldngovernmentsnadoptntoncombatnthisnmountngnchallenge? PaulnKrugmannarguesninnonenofnhisncolumnsnpublishesninnthenNYTnthat,n"thenonlynwaynwencould havenanythingnresemblingnanmiddle-classnsociety...wouldnbenbynhavingnanstrongnsocialnsafetynnet, onenthatnguaranteesnnotnjustnhealthncarenbutnanminimumnincome,ntoo".nRecently,nseveralnpeople fromnthenso-callednTechnElitenhadnbegunntonadvocatenfornUniversalnBasicnIncome.nInnfact,nUBInas referredntonfromnnownon,nhasnbecomenanhotntopicnforndebatenamongnscholars,nbusinessmennand policymaeersnaroundnthenGlobe.nExperimentsnofncashntransfernprogramsnhadnbeennconductednin

Brazil,nMexiconandnChina.nFurthermore,ntherenarenUBInexperimentsncurrentlynundernprogressnin Finland,nOaeland-California,nItalynandninnthenNetherlandsntoo.nPainternetnaln2015,nfoundnthatnUBI has n the n potental n to n be n viable n and n"would n beter n underpin n human n creatvity". n They n have concludedntheirnresultsnbasednonnUBInexperimentsnundertaeenninnIndianandninnNamibia,nwhere thengrantsn"ledntonsmallnscaleninvestments...establishmentnofnlitlenshops"nandnpercentagenof self-employednrosen11npointsnrespectvely.n UBInisnanhighlyncontroversialntopicnandnitsneffectsnneedntonbenstudiednonnanwidernrange,ninnboth developednandndevelopingneconomiesnbeforenjumpingntonconclusions.nExtensivenstudiesnand experimentsnonnUBInarencurrentlynbeingnconductednarenstllninconclusive.nWenwillnonlynenowntheir trueneffectsninnthennearnfuturenasnthenevidencenbecomesnmorenconvincing.nHowever,ntheneffects ofnhealthcare,nanothernimportantnsafetynnetncannbenmoreneasilynstudied.nOldsn(2014)narguesnthat "access n to n public n health n insurance n increases n business n ownership n by n reducing n the n rises n of enteringnentrepreneurship".nHisnresultsnwerenbasednonnanstudynofnmigrantnfamiliesnwithnno previousn healthn insurancen and n found n that n government nprograms naimedn at n providingn them coveragenincreasednthenchancenofnthenhouseholdsntonbenself-employednbyn20npercentnandnthe lieelihoodnofnowningnannincorporatednbusinessnbyn28npercent.n

On n the n other n hand, n others n have n claimed n contradictory n effects n of n safety n nets n on entrepreneurship.nSchreinernandnWollern(2003)narguenthatnansafetynnetnreducesnthennumbernof micro-enterprisesninnfvendistnctvenways.nFirstnitnputsnfoodnonnthentable,nsecondnitnrequiresnless effortnandnhasnlessnrise,nthirdnitnreducesnthenrewardsnforntaeingnonnrises,nfourthnitnreducesnsavings andnfnallynthenfihnpointnisnthatnitndiscouragesnreceiversntonthinenaboutnself-employmentnasnan alternatve.n Itnisnlieelynthatnthesendifferencesninnviewpointsnstemnfromnthencontradictngneconomicnschoolsnof thought, nwhichntaeesn usnbacentonthenKeynesiannvsn(Neo)nLiberalndivisionnonntheneffectsnof governmentnspendingninnanneconomy.nOnnthenonenhand,nAidisnetnaln(2012)narguenthatn"Total governmentnspendingnhasnnegatveninfuencenonnentrepreneurship",nwhilenAsifnIslamn(2015) claimsnthatn"Annincreaseninnthensharenofngovernmentnspendingnhasnanpositveneffectnonnthenrate

ofnentrepreneurialnactvity".nHowever,nlet’snhavenannactualnlooenatnthencurrentntrendsnregarding entrepreneurshipninnthenUnitednStates.n

State of Entrepreneurship in the U.S.A.

MarenZandi,nchiefneconomistnatnMoody'snstatednthenfollowingnwhenndescribingntheneconomynin 2015:n" Inthinentherenarenthingsntonbenworriednabout,nandnthenstatenofnentrepreneurshipnisnonenof thosenthings".nItnappearsnasnifnthenentrepreneurialnspiritnofnAmericanisnnowninnsomenformnofncrisis. Harrison,nreportngnfornthenWashingtonnPostninn2015nhadnidentfednmanynpointsnofnconcern whennhenlooeednatnthenstatenofnentrepreneurshipninnhisncountry.nEvennthoughntheneconomy seemedntonbensteadilynrecoveringnaiernthenimpactnofnthenFinancialnCrisis,nthenratenofnbusiness formaton n could n not n recover n to n pre-depression n levels. n He n identfed n that n the n decline n in entrepreneurshipnfollowednantrendnthatnhadnstartedndecadesnagonandnbeganntonhitnall-tmenlows. Thenratenatnwhichnbusinessesnarenbornnhavenbeennslowingndown.nThenstatsnhenputnforwardnwas thatnjobsncreatednbynnewnventuresnwerenaroundn5.2nmillionninn2014,ncomparednton6nmillionnjust beforenthencrisis.nEvennmorenworryingnthatnnewnjobsncreatednbynstart-upsninnthen1990'snwerenat aroundn7nmillion.nIfnwenconsidernthatnhenstatesnthatnyoungnbusinessesncreatenalmostnallnnewnnet jobsninnthenUnitednStatesnannually,nthennwencannseenthatnthisntrendnposesnanseriousnemployment problemnfornthenfuture.nn Hathawaynetnal.ninn2014npublishednanworenenownnasn"DecliningnBusinessnDynamismninnthenUnited States:nAnLooenatnStatesnandnMetros"nandnraisednfurthernconcernsnregardingnthendecliningntrend innentrepreneurship.nTheynidentfednthatnthenslowingndownnisnconsistentnthroughoutnthenwhole ofnthencountry,nfollowingnancontnuousndipnforndecades.n

Chart 1

Chartn 1nshowsn thatnthendeclinenhasnbeennannongoingnprocessnsincenatnleastn thenlaten 70's. Furthermore,ntheynhavenalsonprovednthatnthenphenomenonnisnnotnlimitedntoncertainnregions,nbut indeednfollowsnannatonalntrend.nThisncannbenobservedninntheirnfollowingnchart.n Chart 2 Asnseennabove,nthenstatenofnentrepreneurshipninnthenUnitednStatesnisnannatonwidenconcernnfor businessndynamismnasnanwhole.nThenreasoningntheynprovidenisnthatnpeoplenarenmorenreluctantnto launchnnewnventuresnduentonchangingnperceptonsnofnthenrisesninvolved.n ThenUnitednStates'nBureaunofnLabornStatstcsnhasnsharednsimilarlynconcerningnviewsnwithnthe generalnpublic.nInntheirnreportnonn'BusinessnEmploymentnDynamism'ntheynpublishednthatnthe numbernofnjobsncreatednbynventuresnyoungernthann1-year-oldnhasndroppednfromn4.1nmillionnin 1994nton3nmillionninn2015.nTheirnresultsncannbenseennasndisplayednonnthenchartnbelow.

Chart 3

AsncannbenseennonnChartn3,nthentrendnalsonpointsntonthenfactnthatnnotnonlynthennumbernofnnew venturesncreatednannuallynisninndecline,nbutnthesenventuresnemploynlessnandnlessnpeople.

Onnthe npositvennote,nthenKauffmannFoundaton'sn'2017nStatenofnEntrepreneurshipnAddress' identfednannupwardntrendnthatnhadnstartedninn2015nandncontnuedntonincreaseninnthenyearn2016 too. n Alongside n with n growth n in n two n consecutve n years, n they n also n found n that n the n share n of businesses n created n by n entrepreneurs n out n of n opportunity n rather n than n purely n necessity n had increasednton84npercentn innthenyearn2015.nIsnitnpossiblenthatnthisnrecentnclimbnisnanresultnofna governmentninitatednpublicnsafetynnet?n TherenisngrowingnevidencenthatnsuggestsnthatnthenintroductonnofnthenAffordablenCarenActninnthe UnitednStatesninn2013nhasnbeennpositvelyncontributngntonthenrebuildingnofnthenentrepreneurial spirit.nMichanKaufman,nCEOnofnFiverrnandnguestnwriternfornthenEntrepreneurnarguesnthatnthe healthcarenbilln“freednmanyntoncreatennon-employernbusinesses...providingnthenentrepreneurial ecosystemnwithnfexible,nseillednworeersnwhonrunntheirnownnbusinesses.”nHengoesnonntonsupport thenreform,nasnitnremovednthenincreasinglynwell-enownnphenomenonnofnthen‘job-loce’,nallowing individualsntonpursuentheirnbusinessnambitonsnwithoutnthenfearnofnloosingntheirnhealthncare coverage.nAnUnitednNatonsnstudynfornitsnEconomicsnandnSocialnCommissionnfornAsianandnthe Pacifc n (UNESCAP) n has n identfed n that n “gaps n in n social n safety n nets n for n entrepreneurs, n for example...health n coverage, n were n the n main n obstacles n for n women n in n establishing n their businesses”ninnthenselectednentrepreneurialnecosystems.n

Safety Nets and Entrepreneurship

Politcians,nlawmaeers,nthine-tanesnandnresearchncentresnacrossnthenUnitednStatesnlieentonheavily emphasizenthenrolenthatnsmallnbusinessesnplayninntheneconomy.nTheynpraisenthenentrepreneurial spiritnofnAmerica,nrepresentngnannessentalncomponentnofnthensoncalledn'AmericannDream'.nThey arguenthatnthenpowernofnthenhard-woreingnandndeterminednindividuals,neithernlivingnorncomingnto America, n drivesn innovaton, n growth n and n competton. n Then Kauffman n Foundaton n intensively studiesnentrepreneurshipnandnhasnbaceednthenideanthatn"Entrepreneurshipnisnthenenginenof economic n growth n and n the n primary n source n of n net n job n creaton n in n the n United n States". n The followingnchartnwasnpublishednbynthenKauffmannFoundaton,ninnonenofntheirnartclesnonnthe "ImportancenofnYoungnFirmsnfornEconomicnGrowth".

Chart 4

Chartn4ndemonstratesnthenimportancenofnnewnbusinesses,ninntermsnofnthennumbernofnjobsnthey createn inn thenU.S. n economy. n An studyndonen bynHaltwanger,n etnal. ninn2010,nfndsn that nnew businessesnaccountnfornalmostnthenwholennetnnewnjobsncreatednandnnearlyn20npercentnofngross job n creaton. n They n further n argue n that n since n these n businesses n are n either n innovatve n and successful,nresultngninngrowthninntermsnofnjobsnandnvalue,norngonbustnrelatvelynquice,nenabling capitalntonbenallocatednmorenefciently.nn

Entrepreneurshipnrequiresnmanynsacrifcesnonnthenbehalfnofnannindividualnundertaeingnannew venture.nAnnentrepreneurnrisesncapital,nvaluablentme,nreputatonnandnthenopportunityncostnof notnworeingnfornanfxnwagenifnhe/shenhasnanregularnjob.nHowever,ninnancountrynlieenthenU.S.,nwithna limitednsocialnsafetynnetnsystem,nwould-benentrepreneursnalsonrisenlosingntheirnhealthninsurance policiesnthatncomenwithnwagenemployment.nConsideringnthenfactnthatnhealthcarenisnatachednto one'snjob,nentrepreneursninnthenU.S.narguablynfacenandecisivenuncertainty,nonenthatnisnnotnpresent forntheirncounterpartsnlivingninncountriesnwithnmorenadvancednhealthcarensystems.nWiensnand JacesonnofnthenKauffmannFoundatonnarguenthatnthenavailabilitynofnsocialnbeneftsnoutsidenof someone'snemployment,nresultsninnhim/hernhavingnangreaternwillingnessntontaeenonnthenrisenof becomingnannentrepreneur.n AnphenomenonnidentfedninnthenU.S.nthatnderivesnfromnthenrisesnandnuncertaintesnofnleaving and/ornchangingnemploymentsnisnenownnasnthen'Job-Loce'.nThenjobnlocenisnusedntonpartally explain n immobility n across n the n labour n mareet n and n the n lace n of n dynamism n it n creates n in n the economy.nItncausesnemployeesntonbenstucenwithnoccupatonsnthatndon'tnmatchntheirnpotental seillsnand/ornambitons.nAcademicsnarguenthatnthisnphenomenonnalsoneffectsnthendecisionnfor individualsntonleaventhenrelatvensafetynofntheirnjobsnandnstartnannewnventurenonntheirnown. Evidencenfromnliteraturenpointsntonthenexistencenofnthen'EntrepreneurshipnLoce'.nWellingtonnet al.nfndsnthatn "coveragenthroughnone’snspousenincreasednthenprobabilitynofnself-employment betweenn2.3nandn4.4npercentagenpointsnfornmennandn1.2nandn4.6npercentagenpointsnfornwomen", when n looeing n at n the n line n between n healthcare n coverage n and n entrepreneurship. n In n another research, n DeCicca n looeed n at n the n state n of n New n Jersey's n 'Individual n Health n Coverage n Plan' implementedninn1993.nThisnreformnwasnintendedntonprovidenhealthninsurancenonnannon-employer basis.nHenhadnfoundnthatnthen"lawnincreasednself-employmentnbynaboutn15-25%".nFurthermore, Fairlie n et n al. n looeed n at n whether n employer-based n health n insurance n was n a n barrier n to entrepreneurshipnandnfoundnthatnifnanmemberninnanfamilynsufferednfromnbadnhealthnandnhadnno accessntonhealthcarenthroughnanspouse'snemployment,nitnlednton"tonbothnmarriednmennand womennbeingnlessnlieelyntoncreatennewnbusinesses".nTheynalsonidentfednthatnbeingneligiblenfor Medicaren(anhealthninsurancenprogramndedicatedntonpeoplenwhonaren65nornolder,nfornpeoplenwith disabilitesnandnfornpeoplensufferingnfromnESRD)nsignifcantlyninfuencednone'snentrepreneurial

decisions.nnThenauthorsnhadnfoundnansmall,nyetnsignifcantnincreaseninnbusinessnownershipnfrom 24.6nton28npercentnwhennsomeonenbecameneligiblenfornthenhealthninsurancenprogram.n Itnisnimportantntonnotenthatnmeasuringnentrepreneurshipnisnanhighlyncomplexnundertaeing.nIn orderntonbenablentonidentfynansignifcantnrelatonshipnbetweennthenintroductonnofnuniversal healthcarencoveragenasnansafetynnetnandnthenlevelnofnentrepreneurship,nthenscopenofnthenanalysis willnbensetnonnanmicro-economicnlevel.nOnenpartcularlynusefulntheorynthatncannhelpnlimitnthe scope n of n the n research n is n enown n as n the n Entrepreneurial n Ecosystem. n It n aims n to n construct n a comprehensive n framewore n of n local n conditons n that n together n contribute n to n fostering n new businessncreatonninnangivennarea.nOnenelementnofnthenframewore,nthenrolenofngovernmentnpolicy willnbenannessentalnvariableninnthisnthesis.nThen2014nstudynbynMasonnetnal.nfornthenOECDnLEED programnidentfednthatnlawnmaeersnandngovernmentnrepresentatvesnwithnanclearnunderstanding andnfocusnonnthencorenissuesnarencrucialnfornthensuccessesnofnthenecosystem.n nFurthermore Carvalho n 2017 n argues n that n a n global n rethineing n of n the n healthcare n systems n is n necessary n for achieving n sustainable n ecosystems. n n The n relatonship n between n an n efcient n entrepreneurial ecosystemnandnhealthcarenreformnhasnnotnbeennthoroughlynresearchednbefore.nHowever,ngiven thensignifcancenofnthatnsafetynnetnfornpeopleninngeneral,nitnwouldnbenbenefcialntonhavenanbeter understanding.nAiernallnthenEuropeannCommission’snSmallnBusinessnAct’snverynfrstnprinciplenisnto “Createnannenvironmentninnwhichnentrepreneursnandnfamilynbusinessesncannthrive”.nArguablynin anpre-AffordablenCarenActnUSA,ngivennthenintensen‘job-loce’neffect,nsuchnconditonsnwerennot alwaysnadequate.n

Theoretical Insights of the Entrepreneurial Ecosystem

Thennotonnofnentrepreneurshipnasnanvehiclenforninnovatonnandngrowthnhasnbeennadoptednby many n governments n as n a n policy n for n economic n development. n The n extent n of n which n however governmentsnand/ornregionalnpolicymaeersnunderstandnthencomplexitynofnthenphenomenonnisna highlyndebatablentopic.nThentheorynofnentrepreneurialnecosystemsnhasnarisenntonhelpnexplainnthe success n of n some n cites/regions n and n teach n us n lessons n on n how n to n implement n policies n for supportng n entrepreneurship n locally. n The n theory n also n emphasizes n that n conditons n in n each

ecosystemnarenuniquenandnsimplyncopyingnandnpastngnpolicynwillnnotnworeninneachnandnevery setng.nIsenbergn(2010)nstatesnthatnentrepreneurialnecosystemsnshouldnbenftedntonthenlocal conditonsnandnthatntherenisn'tnanynprecisenrecipentoncreatensuch.n Thentermn'ecosystem'nwasnfrstnusednbynthenBritshnbotanist,nandnpioneernofnhisnfeld,nSirnArthur Tansleyninn1935.nHendescribednitnasn"anpartcularncategorynofnphysicalnsystems,nconsistngnof organismsnandninorganicncomponentsninnanrelatvelynstablenequilibrium,nopennandnofnvarious sizesnandneinds",nessentallynancommunitynofnlivingnorganisms,nwhoninteractnwithneachnothernto formnansystem.nMooren(1993)ndefnednannecosystemninnbusinessnasninterdependentnactors,nwho evolven"throughnrelatonshipsnandninteractonnwithnsuppliers,nfnanciersnandncustomers".nSince thenemergencenofnthenviewnthatnangeographicnlocatonncannpossessnuniquenelementsninnthe fosteringnofnnewnventurencreaton,ngrowthnandninnovaton,nseveralndefnitonsnhadnarisennfrom different n academics. n Stam n (2015) n defnes n the n entrepreneurial n ecosystem n as n "a n set n of interdependentnactorsnandnfactorsncoordinatedninnsuchnanwaynthat ntheynenablenproductve entrepreneurship".nMooren(2006)narguesnthatnsuchnannecosystemnisnan"collaboratonntoncreatena systemnofncomplementaryncapabilitesnandntonsupportninnovaton",ninnanwaynthatnactorsnpractce andegreenofnself-determinatonnandnself-organizaton.nStamnandnSpiegeln(2017)nproposenthat entrepreneurialnecosystemsnarenan"setnofnindependentnactorsnandnfactorsncoordinatedninnsuchna waynthatntheynenablenproductvenentrepreneurshipnwithinnanpartcularnterritory".

Looeing n at n the n different n defnitons n given n to n the n entrepreneurial n ecosystem, n we n see n that academicsnemphasizenthenimportancenofnthenactorsnbeingnindependentnofneachnother.nYet, withinnthenboundariesnofnthensystem,ntheynengagenwithnallnothernactorsntonachievenanstatenof dynamic n equilibrium. n In n this n state, n individual n entrepreneurs n maee n use n of n the n regulatory, fnancial,nlegal,nsocio-economicnenvironmentnandnutlizenallnavailablenresourcesntoncreatenvalue, which n in n turn n enriches n the n system n as n a n whole. n Thus, n independent n actors n form n an interdependent n networe, n in n an n environment n that n is n as n ideal n as n it n gets n in n nurturing entrepreneurship.

Thenreasonnwhynentrepreneurialnecosystemsnhavenbecomenrelevantnisnduentonthenchangenin perceptonsnofnthenrolenofnentrepreneurshipnbynpolicymaeers,ncombinednwithnanshiininnacademic

perspectve.nThisnshiinmovesnawaynfromnfocusingnonn"thenrolenofnthenindividualntonthenrolenof social,nculturalnandneconomicnforcesninnthenentrepreneurialnprocess"n(Spiegelnetnal.n2016).nnStayer &nKatzn(2004)nwentnonntonarguenthatnthenclassicalnviewpointnofnthenentrepreneurnisngivingnaway tonannew,nmorendistnctnviewnofnentrepreneurshipnasnpartnofnsocialnmechanismsninnanbroader context.nThisnbroaderncontextnentailsnthenactonsnofnpeople,nnetworesnandninsttutonsn(Spiegelnet al.n2017).nThisnthoughtnofnschoolnrepresentsnanmorencomprehensivenunderstandingnofnthenfactors infuencing n the n entrepreneurial n phenomenon n and n brings n us n closer n to n understand n the n eey dynamicsninvolved.nItnisnalsonimportantntonnotenthatnevennthoughnthenfocusnhasnshiiednfrom solely n the n entrepreneur, n the n signifcance n of n the n individual's n actons n within n the n ecosystem remainsnancrucialnelement.nSomenviewnthenemergencenofnentrepreneurialnecosystemsntonlimit thenrolenofnthengovernmentnandnhighlightnthenimportancenofnthenentrepreneurnasnan"central playern/leader"ninncreatngnandnmaintainingnthensystemn(Feldman,n2014).nAccordingntonSpiegelnat al.n(2017)nhowever,nthengovernmentnretainsnitsnrolenasnan'feeder',ncreatngnthenrightneconomic and n social n conditons n for n the n ecosystem n to n taee n shape. n It n is n important n to n recognise n that academicsnmainlynseenthatngovernmentsnshouldnplaynanfacilitatve,nenablingnrole,ninsteadnof imposingnthenstandardsnandnthentypenofnentrepreneurshipntheynwantntonsee.nFurthermore,nthe governmentnretainsnitsnrolenofnsetngnupnpolicyndirectedntowardsngrowthnandndevelopment throughnentrepreneurshipnandninnovaton.nThisncomprehensivenpolicyninitatvenhasntoninclude setngnupnthenidealnregulatory,nlegalnandninsttutonalnframeworentonencouragenindividualsnto launchnnewnbusinesses.nFurthermore,naccordingntonIsenbergn(2010)nthengovernmentnneedsnto invitenthenprivatensectorn"tondevelopnanself-sustainingnandnproft-drivennmareet"nwhichnare essentalnfornthenbirthnofnannecosystem.nThenearliernitnisndone,nthenlargernthenchancenofna successfulnentrepreneurialnecosystemnfourishingninnanstatenofndynamicnequilibrium.n Thencomprehensivenframeworenofnsoncalledn'EntrepreneurialnEcosystems'nwasnputnforwardnby DanielnIsenbergnofnthenBabsonnEntrepreneurshipnEcosystemnProject.nIsenbergnenvisionednthat thensuccessnofncertainnEEsncannbenexplainednbynthensixndomainsnthatninteractnwithneachnother within n the n ecosystem. n These n domains n are n powered n by n mareet n forces n and n government initatves.nHenpredictednthatnultmatelyn thesenecosystemsnwouldnbecomenself-sustainingnas

successnwouldnbreednfurthernsuccessnandnsonon.nThendomainsnofnthenEEnmodelncannbenseenninnthe followingndiagram.

Isenberg n states n that n to n create n such n a n breeding n ground n for n successful n start-ups, n inital governmentninvolvementnisncrucial,nhowevernitnshouldnbenlimitedntonconceptualizatonnandnthe executonnofnthencorrectnframewore.nItnisnfurthernarguednthatnthengovernment'snrolenisnsolelynto providentheninfrastructure,nwhichncreatesnthenrightnconditonsnfornentrepreneursnandnisnnotnto tellnthemnhowntonconductntheirnbusinesses.nThendiagramnportrayedninnImagen1,nisnmeantnto portraynhownentrepreneursnperceiventheninfuencenofnthenoutsidenworldnonnthendecisionsnthey maee. n Isenberg n describes n the n constructon n of n such n an n EE n as n a n "virtuous n cycle n of entrepreneurship"nandntheneasiestnwayntonachievenitnisnton"directlyncreate,nenhance,ncultvate, evolven–nangeographicallynconcentratednecosystemnthatnisnconductventonentrepreneurshipnand itsnsuccess".n

The Entrepreneurial Ecosystems and Policies for Entrepreneurship

Initatvesnbynthengovernment,ninvolvingnactorsnfromnthenprivatensectornandnpublicninsttutons suchnasnuniversitesnisnnecessaryntonestablishnanlocalnculturenthatnembracesnthenentrepreneurial mind-set. n Besides n the n main n public n and n private n bodies, n the n availability n of n resources n by entrepreneursnisnanotherncrucialninputnofnthenecosystem.nFirstnofnall,nhumannresourcesnarenof

utmostnimportance.nItnisncrucialnthatnthenlabournforcenincludesnanwidenrangenofnseillsnandnindustry sectors,nrangingnfromntechnicalntonmorenbusiness-orientednones.n nBesidesnhumanncapital,nthe availabilitynofnfnancialncapitalnisn alsoncrucialnfornansuccessfulnstart-upnscene.nVCs,nbusiness angels,nseednfnancersnandnothernnewnventurenrelatednfnancingnmethodsnshouldnbenreadily available,naccessiblenandnenownnbynall,nnotnjustnbynselectnfewn(Spiegelnetnal.n2017).nHavingnansolid basenofnhumannandnfnancialncapitalnisnanpromisingnstart.nHowever,ntherenisnmorentonwhatnmaees ansuccessfulnentrepreneurialnecosystem.nAsnmentonednearlier,nentrepreneursnplaynancentral, leadingnroleninnthen system.nGivennthat npotentallynsuccessnbreadsnmorensuccess,n successful entrepreneurs,nornserial-entrepreneursncanngivenbacenuniquenenowledgenandnenow-howntontheir communites.nTherefore,nthenrolenofnexperiencednadvisorsnandnmentorsnisntonteachnandnguide newnventurencreatorsninnthenformnofnstart-upnacceleratorsnandnincubators.nSpiegelnatnal.ngoes ontonarguingnthatnprofessionalnservices,nsupportvenlargenestablishednfrms,nfrequentneventsnand overalln an high n networe ndensity nare nalso n then buildingnbloces n maeingn upn an n entrepreneurial ecosystem.n Academicsntryntonemphasizenandnwarnnpolicymaeersnthatnthensuccessnofncertain,nestablished entrepreneurialnecosystems,nsuchnasnSiliconnValleynarennotnreplicableninndifferentnsetngs.nThe ideanthatnancertainnmixnofnelementsnwithinnangeographicnregionnhasnthenpotentalntoncradle innovatve,nandnhighngrowthnbusinessesnthatncatalysenfurtherngrowthnmaynseemntoonatractve fornsomentonfallnfornit.nIsenbergnhimselfnwarnsnagainstnthen"copy-and-pastenapproach",ninnanworld wherenentrepreneurshipnisnseennincreasinglynasnthencurenfornourncurrentnandnfuturensocialnand economicntroubles.nJustnbecausenentrenecosystemsncannotnbenreplicatednandnsetnupnsomewhere else,nitndoesn’tnmeannthatnwencan'tnlearnnfromnthensuccessn(ornfailure)nofnexistngnexamples. Certainnaspects,npolicies,nenow-hownetc.ncanncertainlynbenimplementedninndifferentnregionsnwith relatve n successes. n Even n tough, n there n is n no n precise n recipe n for n creatng n an n entrepreneurial ecosystem,nIsenbergn(2010)nhasnidentfednninenprinciplesntontaeenintonaccount.

1. StopnimitatngnSiliconnValley

2. Framenthenecosystemnaccordingntonthenlocalnscene

3. Getnthenprivatensectornengagednfromnthenverynbeginning

5. Insteadnofnoverthineingnthem,nletnecosystemsnarisenorganically 6. Allocatenresourcesntonventuresnwithnhighnpotentaln 7. Getnanbignwinnonnthenboardnandninsttuton 8. Tacelenculturalnchangenheadnon 9. Reformnthenlegal,nbureaucratcnandnregulatorynframeworesn AccordingntonIsenberg,nifnthesenstepsnarenfollowednthrough,nthenntheyncannleadnton"venture creaton...,necosystemncreatonnandnanvibrantnbusinessnsector".nnItnisnonlynnaturalntonwondernif socialnpolicies,nservingnasnansafetynnet,ncannbenalsontaeennintonaccountnasnanbasicndomainnofna thrivingnecosystem.nn

There n are n countless n government n initatves n aimed n at n fostering n entrepreneurship, n either natonwide, n statewide, n region-wide n or n municipal n efforts n specifc n to n a n city n or n town. n These initatves,nornrathernprogramsnarenaimednatnincreasingnjobncreatonnandnpromotngneconomic growthninngeneral.nnHowever,ntheneffectvenessnofntheseneffortsnisndebatable.nTheseninitatves burnnscarcenpublicnresourcesnonnprogramsnthatnarenbelievedntonharbornentrepreneurship.nOne studynconductednbynFairlienetnal.ninn2012nlooesnatnthenresultsnofnthenso-callednprojectnGATE (Growing n America n Through n Entrepreneurship), n which n was n initated n by n the n Small n Business Administraton n and n the n Department n of n Labor. n People n interested n by n the n noton n of entrepreneurship n were n randomly n assigned n to n partcipate n in n classes n at n the n Small n Business DevelopmentnCenters.nOutnofnthenfournthousandnpartcipantsnhalfnreceivedntrainingnandnthe othernhalfnremainednwithoutntrainingnasnancontrolngroup.nThenprojectnaimedntoninvestgatenthe effectvenessnofnfacilitatngnentrepreneurshipntrainingnton'potentally'nwould-benentrepreneurs. Thenstudynfoundnthatnthenprogramnfailednbynlargentonfacilitatenlongnlastngnentrepreneurship. Individualsnwhontooenpartninnthentrainingnwerenmorenlieelyntonhaventheirnownnventureninnthe short-term.nInnthenlong-term,ntheynwerenasnlieelyntonbenentrepreneursnasnthenothernhalfnofnthe groupnwhonhadnreceivednnontrainingnwhatsoever.n Theneffectvenessnofnstatensponsoredninitatvesnaimednatncreatngnmorenentrepreneursnandntheir abilityntondriveneconomicngrowthnisnquestonable.nMorenresearchnshouldnbenconductedninnorder tonseenclearlynwhethernsupportnprogramsnarenwastngnmoneynandnpublicnresourcesnwithout

effectvely n producing n long-term n positve n results. n If n the n aim n is n to n create n a n self-sustaining EntrepreneurialnEcosystemninnwhichnsuccessnbreadsnmorensuccessnandnsonon,nthennitnmustnbe clearnwherenandnhownpublicnresourcesnshouldnbenused.nGarethnOlds,nwritngnfornthenKauffman Foundatonnurgesnothersntonconcludentypesnofnrisesnthatnconcernnenterprisingnindividualsnthe most. n Furthermore, n he n questons n " n whether npublic n goods n that n can n be n provided n only n by governments n or n whether n some n policy-driven n mareet-maeing n can n coordinate n the n efforts n of privatenactors".nAtnthisnpointnitnisnonlynbutnnaturalntonwondernifngovernmentnprovidednpublic goods,nactngnasnansafetynnetncannhavenanneffectvenplaceninnannEE.nThenideanthatnsocialnsafety netsncouldnbenincludednasnonenofnthendomainsnofnannEEnisncurrentlynexcludednfromnIsenberg's model.nGivennthenlabournmareetnandnemploymentnchallengesnlayingnaheadnfornmany,nifnnotnmost natons,nitnwouldnbenhighlynbenefcialntoninvestgatensuchnanmater.nIfnitncouldnbenconcludednthat publicngoods,nsuchnasnsocialnsafetynnetsninteractnwithnthenoriginalnEEnmodel,nthennitnwouldnbena greatninitatvenfornsocialnreforms.nnDevelopingnanmoreninclusivensocialnsystemnwouldn'liberate' labournmareetsnfromnitsngripnandnincreasendynamismninnannEE. Therenisnsomenevidencenfromnsocialnsafetynnetnreformsninntwondevelopedneconomies.nTwo initatves,nonenthatnwasnundertaeenninnFrancenandnthenothernoneninnGermany.n nInn2001,nthe FrenchnMinistrynofnLabournintroducednannewnreformnwhichnaimedntonboostnentrepreneurship amongnitsnunemployednpopulaton.nThenreformnallowednpartcipantsntoncontnuentonreceiventheir unemploymentnbeneftsnfornthreenyearsnaierntheynhadnbecomenentrepreneurs.nThisnreform arguablynprovidednanmuch-needednsafetynnetnfornindividualsnoutnofnwore.nAnstudynconductednin 2014nbynHombertnatnel.nconcludednthatnnewnbusinessesnformednbynthesenindividualsnmadenupna largenpartnofnthen25npercentnincreaseninnthenratenofnnewnfrmsnformed.nFurthermore,ntheynfound thatntheninitatvencontributednaroundn350nmillionneurosntonthenFrenchneconomy,nwhilencostng aroundn100nmillionninnthenfrstnplace.n Caliendonetnal.nlooeednatntwonprogramsninnGermanynthatnhadnbeennaimednatnassistngnthe unemployed n launch n their n businesses. n Both n programs n provided n subsidies n to n unemployed individualsnifntheynundertooenentrepreneurialnactvites.nAiernstudyingnthenpartcipantsnforntwo andnhalfnyears,nanlargenmajoritynwerenstllnself-employed.nFurthermore,nthenauthorsnstatenthat thesenstart-upsnformednwerenmorenthannjustn'bornnoutnofnnecessity'nventuresnandnwentnonnto

"playnanmajornroleninnboth,nthenlabournmareetnandntheneconomicnpolicynatnlarge".nIfnthesenreforms provedntonbenefcientlynfosteringnentrepreneurshipnandngrowth,nthennperhapsnhealthcarentoo hasnthenpotentalntonactnasnansafetynnetnfornwould-benentrepreneurs.nIfnsuchnanreformnisnbeing considered,nitnisnimportantnfromnthenverynbeginningntonconsiderntheirnbroadernimpacts.nInnour case n the n impacts n in n queston n is n whether n universal n healthcare n provides n the n sustainable conditons nforn individualsn to n begin n interactngn with nthe n actorsn within ntheirn Entrepreneurial Ecosystem.

Healthcare as a Safety Net

Sincensafetynnetsnhavenbeennusedntonsupportnnascentnentrepreneurs,nitnwouldnbenbenefcialnto enownwhetherncommonnpublicnprogramsnalsonhavensuchnanfacilitatngnrole.nAnwidelynadopted safetynnetnamongnOECDncountriesnisnuniversalnhealthcare.nOnensignifcantnoutliernwithinnthese natonsnwhennitncomesntonhealthcarenisnthenUnitednStates,nwhonhasnonlynrecentlyn(2013,nvianthe AffordablenCarenAct,naeanObamacare)nintroducedncompulsorynuniversalncoveragentonallnofnits citzens.nTondefnenhealthcarenasnansafetynnetnlet’snhavenanlooenatnthenbasicnprinciplesnbehindnthe currentnsystemninnthenNetherlands.nn  Itnisnandemand-drivennservice.n  Allncompaniesnprovidingnhealthninsurancenarennot-fornproftncooperatvesnthatneither reallocatenanynproftsngeneratedntonreservesnthatntheynarenrequiredntonmaintainnornreturn themninnformnofnlowernpremiums.  nPeoplenarengivennthenchoicentonswitchnhealthcarenprovidersnannually.n  Thenhealthcarensystemnisninnthenhandsnofnprivatenorganizatonssnwhilenthengovernment facilitatesnthenrolenofnprotectngntheninterestsnofnthengeneralnpublic.  Thengovernmentnactsnasnannagentntonguaranteenthensocialnnaturenofnthensystem.  Healthninsurancesnarenrequiredntoncarenasntheirndutynandnmaeensurenthatnservicesnwithin thenbasicninsurancenpaceagenisnavailablentonallntheirnpolicyholders.n

(HealthcareninnthenNetherlands,nThenMinistrynofnPublicnHealth,nWelfarenandnSportsnofnthe Netherlands,nThenHague)n

The State of Healthcare in the U.S.A.

The n healthcare n system n in n the n US n is n different n than n of n other n industrialized n natons. n When comparedntonthenrestnofnthenOECDncountries,nthenAmericannsystemnappearsnasnanhybridnone. Therenhasnnevernbeennuniversalnhealthncarencoverageninnthencountry'snhistory,nhowevernsincenthe introducton n of n the n ACA n (Affordable n Care n Act, n aea. n 'Obamacare') n in n 2013, n there n has n been mandatoryncoveragenfornallncitzens.nThenhealthcarenfundsninnindustrializednnatonsnarengenerally describednasnsingle,nornmult-payernsystems,nwhilenthenoneninnthenUSncombinesnbothnthese elements. n Spendingn is n covered n byn private n funds, n households n and n businesses. n Even n though healthcarenisnfnancednbynpublicnbodies,nthenservicenisnactuallyndeliverednbynprivatenmedical insttutons.nOutnofnthenOECDnmemberncountries,nthenUSA's,ntogethernwithnMexico'sngovernment interferesnthenleastninnthenhealthcarensystem.n HealthcarencostsnarenenownntonbengenerallynhighninnthenUS.nAccordingntondatancollectednbynthe OECD,nhealthcarencostsninnthenUSnwerenthenhighestnamongnthenmembernstates,natn$9892nper capita,ncomparednton$5385nperncapitaninnthenNetherlandsninnthenyearn2016.nAnnexplanatonnof thenhighncostsnisngivennbynBeamesderfernetnal.n2012nwhenntheynarguenthatnthenresearchnand developmentnofnthennewestnhealthcarentechnologies,ntreatmentsnandndrugsndriventhendemand for n these n state-of-the-art n solutons n and n thus n pushing n costs n ever n higher. n Other n major n cost inefciencies n are n due n to n level n of n chronic n diseases n and n obesity n in n the n US n and n to n the n high administratvencostsninvolvednthroughoutnthensystem.nCaringnfornpatentsnsufferingnfromnchronic diseasesninnthenlastntwonyearsnofntheirnlifenaccountntonaroundn32%nofnallnhealthcarencosts. Inevitably,nhighncostsndrivenhighnpremiumsnforncustomers.nAccordingntonresearchnconductednby thenKaufmannFamilynFoundaton,naveragenpremiumsnfornfamilyncoveragenrosen5npercentnannually betweennthenyearsn2005nandn2015.n

Notnhavingnancomprehensivenandnuniversalnhealthncarensystemncanncausenanheavynburdennonnthe economy. n According n to n the n Center n for n American n Progress n in n 2009, n the n cost n of n not n doing anythingntonfxnthensystemnhasnantollnofnbetweenn$124nbillionnton$248nbillionnpernyearnonnthe economynoverall.nUniversalncoveragenisnrequiredntonprotectnthosenwhonlivenunder,nornclosentonthe povertynline,nprovideninsurancenfornpeoplenwithnpreexistngnconditonsnandntonaddressnthenlacenof jobnmobilityninnthenlabournmareet.nThenlacenofnhealthcarenhasnaffectedndifferentndemographics unevenlynthroughoutnthennaton.nMinorites,nchildrennandnyoungnadultsnhaventhenhighestnun-insurancenrates,nwhichncannaffectncertainncommunitesnespeciallynhard.nTonthrivenfornanbeter, fairernandnmorenequalnsociety,nitnseemsnthatnhavingnuniversalnhealthncarencoveragenwouldnbena signifcantnmilestone.n SincenthenintroductonnofnthenACA,nthenuninsurednrateninnthenUSnfellnfromn17%ninn2013nton11%nby thenendnofnthenyearn2016.nThenlegislatonnenforcesnallncitzensntonhavenhealthninsurancenfrom eitherntheirnemployer,ngetnanpersonalninsurancenplannfromnthencompaniesnavailablenornbeneft fromnprogramsnsuchnasnMedicaid/Medicare.nTheneffectsnofnthenACAninntermsnofncoveragenrates howevernvaryngreatlynbetweennstates.nAccordingntonthenWell-BeingnIndex'snreport,nthenstatesnof AreansasnandnKentuceynexperiencednthenlargestnincreaseninnhealthcarencoveragencountrynwide. Thesenstatesnsawnandecreasenofnaroundn12%ninnthenratenofnuninsurednbetweenn2013nandn2016.nIn 2016,nMassachusetsnhadnthenlowestnratenofnuninsurednamongnitsnpopulatonnfornthen9thnyearnin anrow,nwhilenthenstatenofnTexasnhadnthenhighestnratenatnaroundn20%.n

Hypothesis

Thenimpactnofnsocialnsafetynnetsnonnindividualsntonundertaeenentrepreneurialnactvitesnisnanvery complexnmater.nYetnitnwouldnbenofngreatnvaluentonenownwhethernsuchnpoliciesnhavenanyneffect onnindividuals’nchoicesnofnbecomingnentrepreneurs.nAsneconomists,nscholars,nthenbusinessnelite andnpolitciansnarenworeingnonndevisingnpolicyntonprotectnthosenwhonwillnendnupnbeingnadversely affectednbyntechnologicalndevelopment,ntheyncouldnusenallnthenhelpnthatntheyncannget.nInnthis thesis,nInintendntoninvestgatenwhethernthenadoptonnofnhealthncarenreformninnthenUnitednStates ofnAmericanhadnannimpactnonnpeoples'nactonsninnfollowingntheirnentrepreneurialnambitons.nThe investgaton'snfocusnwillnbenonnthenmicronrathernthannthenmacronlevelnofntheneconomy.n nThe

thesisnwillnfocusnonncertainnEntrepreneurialnEcosystems,ninnorderntonanalysenwhethernsafetynnets asnanpublicngoodnprovidednbynthengovernmentnhaventhenpotentalntonbenonenofnthendomainsnin Isenberg'snproposednmodel.nFurthermore,nbyncomparingnstate-levelnhealthcarencoveragenrates tonthenratenofnentrepreneurshipninnthenecosystems,nInaimntonproventhatntheynarennotnonlynshaped bynlocalnconditons,nbutnalsoninfuencednbynstatenpolicies. nn n Ifnthenrelatonshipnprovesntonbe signifcant,nthennitnmaynbecomenapplicablenfornothersntonconsidernhealthncarenasnannessental publicngoodnthatnhelpsnfacilitatenentrepreneurshipninnannecosystem.nInhavenchosenntonfocusnon thenadoptonnofnhealthncare,nsincenitnisnansignifcantnandnthusnhighlyndebatedntopic,nwhere partsannbeliefsnimposenangreatnbiasnonnthenactualnresults.nItnisnalsononenofnthengreatestnpublic safetynnetninitatvenundertaeennbynandevelopedncountryninnrecentnhistory.nTherenisnalready evidencenfromnresearchnthatnthenintroductonnofnformsnofnhealthcarencoveragenasnansafetynnet cannincreasenthenlevelnofnentrepreneurship.nnnnnnTherenisnalsonangrowingngroupnofnpeoplenwhonhave identfednhealthncarencoveragentonbenplayingnsomenroleninnentrepreneurialnecosystems,nhowever nononensonfarnhasnincorporatednitnasnpartnofnthenframeworenconditons.nFurthermorenthendirect relatonshipnbetweenntheneffectsnofnthenhealthcarenreformnonninsurancencoveragenwithinnanstate andnthenlevelnofnentrepreneurshipninnannentrepreneurialnecosystemnhasnnotnbeennspecifcally investgatednbefore.n ThenWorldnHealthnOrganizaton'snconsttuton,nwritenninn1946,nenvisionsn"thenhighestnatainable standardnofnhealthnasnanfundamentalnrightnofneverynhumannbeing".nThirty-two,noutnofnthenthirty-three n developed n countries n have n some n form n of n universal n healthcare n coverage, n with n the exceptonnofnthenUS,ninnwhichnapproximatelyn30nmillionncitzensnremainnuninsured.nThenUS,nbeing andevelopedneconomy,nhasnalreadynbegunnthentransitonntowardsnindustryn4.0,naccompanied withnlowernproductvitynlevelsnandnthenadoptonnofnautomatonntechnologiesnacrossnindustries. Whilentheneconomynisnalreadynundergoingnthisntransiton,nsocietynasnanwholenremainsnuterly unprepared.n Thereforenthenaimnofnthisnthesisnisntonidentfynansignifcantnrelatonshipnbetweennhealthcare coveragenandnthenratenofnentrepreneurship.nIfnthenresultsnproventonbenconclusive,nthennuniversal healthcare n will n be n able n to n be n considered n as n a n facilitatng n node n within n an n Entrepreneurial Ecosystem.nFurthermore,nthenresultsnmayngivenconclusivenanswersnonnhowntontargetnpublicnpolicy

andnresourcesnmoreneffectvely.nIfnhealthcarenplaysnanfacilitatngnrolenasnpartnofnanpublicngoods domainninnIsenberg'snmodel,nthennitnwouldnreinforcenthenrolenofngovernmentninitatednsocial safety n nets n as n a n boost n to n entrepreneurship. n Given n the n current n declining n trend n in entrepreneurshipninnthenUnitednStates,ntogethernwithnthendisruptvenforcenofnrapidntechnological developmentsnonnthenlabournmareet,nconclusivenresearchncouldnaidnlawmaeersnatnallnlevelsnof governance.nn

Thenthesisnworenwillnbeninvestgatngnthenvaliditynofnthenfollowingnhypothesis:

H0: 'Thv ratv oef hvalth insurancv coeivragv (statv-widv) signifcantly coerrvlatvs with thv lvivl oef

svlf-vmploeymvnt in an Entrvprvnvurial Ecoesystvm.'

Ifntherenisnansignifcantncorrelatonnbetweennthentwonvariables,nthennitnwillnbensafentonassumenthe following. n Universal n healthcare n coverage n as n a n public n safety n net n positvely n contributes n to entrepreneurship. n Second, n state n (or n naton)-level n policies n can n also n play n a n facilitatng n (or preventng)nroleninnentrepreneurialnecosystems.n

To n measure n the n relatonship, n we n need n two n sets n of n data. n One n that n refects n the n state n of entrepreneurshipnwithinnanneconomicnecosystem,nbyndisplayingnthenpercentagenofnpeoplenwho claimntonbenentrepreneurs,nagainstnthosenwhonhavenregularnjobs.nThensecondnsetnofndatanhasnto measurenthenratenofnpeoplenwhonhavenobtainednhealthcarencoveragenwithinnanstate.nThentme periodnhasntoncovernprior-to,nduringnandnaiernthenintroductonnofnthenAffordablenCarenActnand thenfollowingnMedicaidnnon/expansionsnundernthenstatenlegislatves.nMostnimportantly,nthentwo datansetsnhaventonrepresentnthensamentmenperiod.n SafetynnetsnalreadynplaynannimportantnsocialnroleninncountriesnacrossnthenWorld.nSincentherenis evidencenthatntheyncanneffectvelynfosternentrepreneurship,nitnwouldnbenofngreatnvaluentonhavena beter n understanding n of n the n role n of n universal n healthcare n coverage n within n entrepreneurial ecosystems. n Since n it n is n safe n to n argue n that n well-directed n initatves n can n result n in n successful entrepreneurnbreedingnprograms,nthennpotentallynthenrightntypenofnpublicnpolicyncannbeneft entrepreneurship.nDanielnIsenbergnhimselfnstatednthat" nEntrepreneurshipnisnnonpanaceanfor society’snills,nbutnitnhasnenoughnspill-oversnandnisncausalnenoughnthatnitnshouldnbenanpublicnpriority onnparnwithneducaton,nsecurity,nwelfare,nenergy,nandnhealthnasnanbasicnsocialngood."n

Methodology

Healthcarenisnancomplicatednmaterninnmostncountries.nInnthencasenofnthenUnitednStates,nitnis arguablynevennmorentroublesome.nDuentonthenongoingnendlessnpartsanndebatesnonnthentopic, thengeneralnpublicnhasnalsonbecomenpuzzled,nunawarenwhethernsuchnanreformnwillnbeneftnornhurt them.nThenpolitcalnlandscapenthroughoutnthenmanynstatesnrefectsnbiterndivisionsnbetweennpro-andncontra-nhealthcarenviews,noiennleavingnordinarynpeoplentonbearntheneffectsnofnthisnfght.nIn annenvironmentnsurroundednbynconfusionnandnmistrustnofncontradictorynopinions,nitnisnmore benefcialntonmeasurenindividuals’nactonsninnorderntonbenablentondrawnrealistcnconclusions.nThat isnwhyntheninvestgatonnisnfocusednonnthenmicronlevel,nallnthenwayndownntonthenperson’sndecision tonabandonnwhatntheynarendoingnandnstartnanventurenbynthemselves.n Theninvestgatonnwillnbenconductedninnorderntondetectnansignifcantnimpactnthatnthenintroducton ofnthenhealthcarenreformnhad non nentrepreneurship.n Asndiscussednearlier,nthenscopen ofn the researchnisneeptnonnthenmicronlevel,nspecifcntonthenentrepreneurialnecosystem.nThentheorynofnEE impliesnthatninnordernfornannodentonbecomenannactorninnthensystem,nitnhasntonbenembeddednas part nof,nand nfurthermore,naddn tonthenprocessnofndynamicnequilibrium.nIn willnbenlooeingnat people’sncareernchoicesnofnbecomingnself-employedninnthenchosennEntrepreneurialnEcosystems. FornthenanalysisnInwillnbenlooeingnatntwondifferent,npubliclynavailablendatasets.n KIEAnMicrodata KauffmannIndexnData StartupnIndexnData RatenandnOpportunitynSharenofnEntrepreneurs Years:n  1996n–n2015

Variables:n  Age  Classnofnworeer  Totalnfamilynincome  Female  Educatonalnatainment  Home-ownership  Totalnhoursnworeednlastnweee  Immigrant  Industrynfornmainnjob  Maritalnstatus  Monthlynlabournforcenrecode  surveynmonth  Metropolitan area  Centralncitynstatus  Countrynofnbirth  Personalnidentfcatonncode  Race  Regionnofnthencountry

 Self-employed with 15+ hours worked  Spanishnethnicity  State  Veterannstatus  Surveynyear ThenKIEA MicroedatanisnmetculouslyncollectednovernthenyearsnbynthenKauffmannFoundaton.nThis comprehensivenarchivencontainsndatanonnentrepreneurshipnindicatorsnfromn1996nton2015ninnthe UnitednStates.nThenindexnisnbroadlynusednbynfederalnandnstatengovernmentnagencies,nthenWhite House,nasnwellnasnacademicsnandnrespectednnewsnpublishers.nEachnmicrodatanflenrepresentsn650 thousandnobservatonsnofnadultsnpernyear.nThenvariablesnofninterestninnmynanalysisn(highlightednin thenabovenlist)narenthenpercentagenofnrespondentsnwhonclaimntonbenself-employedn(15+nhours pernweee)nperneachnofnthenchosennmetropolitannstatstcalnarea.

U.S.nCensusnBureaun AmericannCommunitynSurvey HealthnInsurancenCoveragenStatusnbynSexnandnAge Civiliannnonninsttutonalisednpopulaton Years:  2012–2016n Variables:  fornMalesnandnfornFemalesn(pernstatenforneachn52)n ◦ 0<6nyearsnold ▪ Withnhealthninsurancencoverage ▪ Without ◦ 6-17nyearsnold ▪ Withnhealthninsurancencoverage ▪ Without ◦ 18-24 years old

▪ With health insurance coverage

▪ Without

◦ 25-34 years old

▪ With health insurance coverage

▪ Without

◦ 35-44 years old

▪ With health insurance coverage

▪ Without

◦ 45-54 years old

▪ With health insurance coverage

▪ Without

◦ 55-64 years old

▪ With health insurance coverage

▪ Without ◦ 65-74nyearsnold ▪ Withnhealthninsurancencoverage ▪ Without ◦ 75n+nyearsnold ▪ Withnhealthninsurancencoverage ▪ Without

ThenAmericannCommunitynSurvey’sn‘Hvalth Insurancv Coeivragv Status by Svx and Agv’ndataset isnbroeenndownnbynsexnforneachnstate.nThenACSnisnconductednandnitsnresultsnarensummarizednby thenU.S.nCensusnBureauneverynfvenyears.nOutnofnthisndatasetnthenanalysisnwillnbenlooeingnatnthe uninsurednratesnamongnthenadult,nworeingnpopulatonn(18-64nyearsnold)ninnstatesnwherenthe selectednEntrepreneurialnEcosystemsnbelongnto.nAlthoughnthisndatanrepresentsnvaluesnatnanstate level,nitnwillnservenasnannappropriatenestmatonnofnthenpopulatons’nhealthninsurancencoveragenin each n entrepreneurial n ecosystem. n Due n to n the n different n politcal n climates n in n each n state, n the adoptonnofnhealthcarencoveragenaiernthenintroductonnofnthenreformsndiffersnaccordingly.nThe investgaton n seees n to n unveil n whether n the n change n in n state-level n coverage n effects n people’s decisionntonbecomenentrepreneursnwithinntheirnecosystem.n

Tonmeasurenthenrelatonnbetweennthentwonselectedndatasets,nInwillnusenthenratenofnthenuninsured as n the n independent n variable n and n the n percentage n of n the n self-employed n as n the n dependent variable.nUponncompletonnofnthendatananalysis,nInhopentonobservenancorrelatonnbetweennthe percentage n of n respondents n claiming n to n have n become n self-employed n and n the n rate n of n the uninsured,nthusnindicatngnthenrolenplayednbynthenintroductonnofnanuniversalnhealthcarenreform.n Ultmately,ntheninvestgatonnseeesntonestablishnthenfollowingnrelaton.nFirstnthenintroductonnofna universal n healthcare n system n results n in n less n uninsured n people n within n the n state. n This n new healthcarensystemnthennactsnasnansafetynnet,npositvelyninfuencingnindividuals’ndecisionsnto become n entrepreneurs n within n their n ecosystems. n For n the n saee n of n the n research, n the n term entrepreneurshipnwillnbeninterpretedninnanrelatvelynbroadernsense,nwhichnisnbecomingnself-employed. n To n prove n the n existence n of n such n an relatonship, n I n have n chosen n to n analyse n three different n MSA’s n (Metropolitan n Statstcal n Areas) n actng n as n the n entrepreneurial n ecosystems. ThesenthreenarenBoston,nDallasnandnLouisville,nlocatedninnthreendifferentnstates,nrepresentng threensignifcantncasesnofnhealthcareninnthencountry.nOnenstatenalreadynimplementednhealthcare reformninn2006nandnhasnthenhighestnratenofninsurancencoverageninnthencountry.nThensecondnstate sawnamongnthenhighestnincreasesninncoveragenratesnsincenthenintroductonnofnthenACAninn2013, whilenthenthirdnstatenwillnservenasnancontrol,nsincenitnonlynpartallynimplementednthenreformnand has n the n highest n rate n of n uninsured n in n the n naton. n The n three n MSA’s n were n chosen n for n the complexitynofntheirnentrepreneurialnecosystems.nWhennselectngnthencites,nInfocusednonnhaving

annengagednstartupnscenenandnnetworenofnactvenstaeeholders.nFurthermore,ntheynwerenchosen becausenofntheirneconomicnsignifcance,nnotnjustninntheirnstatenbutnfornthencountrynoverall.n

Entrepreneurial Ecosystems in Focus

Fornthensaeenofnthisnthesis,nInhavenselectednthreenmetropolitannstatstcalnareasn(MSA),nservingnas the n entrepreneurial n ecosystems n undern investgaton. n Then threen ecosystemsn aren fromn three differentnstatesnthatnrepresentncontrastngnviewsninntermsnofnhealthcarencoverage.nThenstates thatnInhadnidentfednforntheninvestgatonnarenKentucey,nMassachusetsnandnTexas.nThenstatenof Kentuceynhadnexperiencednthenlargestnfallninnthenratenofnthenuninsurednsincenthenintroductonnof thenAffordablenCarenActn(togethernwithnthenstatenofnAreansas),natnaroundn12npercent.nThenstate ofnMassachusetsnhadnthenlowestnuninsurednratenfornthen9th_{n yearninnanrowninn2016.nAnother} interestngnfactnaboutnMassachusets,nthatnitnhadnitsnownnstate-widenhealthcarenreform,nbacenin 2006,nwhichnbecamenthenmodelnfornnatonwidenimplementatonnundernthenpresidencynofnBarrace Obama.nThenthirdnstatenisnTexas,nwhichnhadnthenhighestnratenofnuninsurednofnaroundn20npercent inn2016nandnonlynpartallynimplementednthenreform,nleavingnmanynofnitsncitzensnun-eligiblenfor coverage.n Withinnthosenstates,nInhadnselectednBoston-Cambridge-QuincynMSAninnMassachusets,nDallas-FortnWorth-ArlingtonnMSAninnTexas nandn Louisville/JeffersonnCountynMSAninnKentuceynasnthe entrepreneurialnecosystemsninnfocus.nInnthenupcomingnchapternInwillnfurthernelaboratenonnthe healthcareninneachnstatenandnexploreneachnecosystemninndepth.n

Healthcare in Massachusets

InnthenstatenofnMassachusets,nMedicaidnandnCHIPn(Children'snInsurancenProgram)narencombined intonone,nenownnasnMassHealth.nMedicaidnhadnbeennintroducedninnthenlaten1960'sntonprovide medicalnassistancenfornthosencitzensnwhonnormallyncouldnnotnaffordnhealthcarenservices.nUnder thenPatentnProtectonnandnAffordablenCarenAct,npassedninn2010,neligibilitynofnindividualsnto receivenMedicaidnwasnexpanded.nAlthoughnansupremencourtnrulingnstatednthatnstatesncould choosenwhetherntonimplementnthenexpansion,novernhalfnofnthenUnitednStatesnwentnfornitnanyway.

CHIPnwasnimplementednasnannexpansionnofnitsnpredecessornSCHIP,nwhichnisnessentallynanfundnto covernhealthninsurancenfornchildren,novernwhichnstatesnhavenfullnfexibilityninnitsndesign.n ThosenqualifedntonMassHealthnhavenaccessntonvisitngndoctors,nreceivingnprescriptonndrugs, stayingninnhospitalsnandnsonon.nAnnualnaveragenhealthcarencostnpernpersonnisn$8441nandncosts contnuentonriseninneverynsectornofnthenindustry.nThenriseninnthenpricesnofnprescriptonndrugs contnue,nwithnnonendninnsight.nHealthcarenisnbothnstatenandnfederallynfunded.n

In n 2006, n under n the n then n governor n Mitn Romney, n the n state n of n Massachusets n adopted n a signifcantnhealthcarenreform.nThenaimnofnthenreformnwasntonprovideneveryncitzennofnthenstate withn"affordable,ncomprehensivenhealthninsurance".nThennewnbillnmandatedneachnindividualnto obtainnhealthninsurance,nsonthatnideallynthenyoungnandnhealthynwouldnbensubsidizingncarenfornthe elderlynandnthensice.nThisnwaynthenstatenhopedntoneeepnpremiumncostsnmanageablenandnthus eeepingnhealthcarenaffordablenfornall.nFurthermore,ninnreturnnfornlowernpremiums,neveryone becamenobligedntonpurchasencoveragenfromntheninsurancencompanies.n Asnmentonednearlier,nMassachusetsnhasnthenhighestncoveragenrateninnthencountry,nanstaggering 98npercent.nEvennthoughnpartsanntensionsnremainnhighninntermsnofnthenhealthcarendebate, majoritynofnMassachusets'npopulatonnfavoursnthenbill.nAccessntonhealthcarenhasnbeennimproving andnnownitnisnfarnaboventhennatonalnaverage.nCoveragenratesnwerennotnsignifcantlynaffected duringnthenrecessionnyears.nEmployernrelatedncoveragendroppednfromn68%ninn2001nton60%nin 2009,nbutnthanesntonthenhealthcarenreform,npeoplencouldnsafelynrelynonnpublicncoverage.nThe state n also n launched n an n initatve n to n help n small n businesses n with n lower n premiums n for n their employees.nThensupportnfornsmallnbusinessesnwasnfurthernenlargednwithnthenSmallnBusinesses WellnessnIncentvenProgram,nwhichnoffersntaxnbreaesntontheneligiblenfrmsnifntheirnemployees partcipateninnonenofnthendedicatednwellnessnprograms.nCoveragenofnpeoplenworeingnfornsmall businessesnisnrecognizablynhigher,nstandingnatn72npercent,nwhenncomparedntonthennatonal averagenofn60npercent.nThisnisnarguablynanresultnofnthenpenaltesnimplementednfornbusinesses thatndon'tnoffernsubstantalnhealthninsurancenoptonsnforntheirnworeers.n Despitenthenfearmongering,nthatnhealthcarenreformnwouldnhurtntheneconomynbynputngnthe fnancialnburdennonnbusinessesnandndepletngnthenstate'snresources,nMassachusets’nexperiment

stllnstandsnonnsolidngrounds.nAccordingntonanstudynconductednbynthenCenternfornHealthnLawnand EconomicsnofnthenUniversitynofnMassachusets,nthenfnancialnburdennisnproportonallynshared betweennbusinesses,nemployeesnandnthengovernmentnofnthenStatenandnthendistributonnofnthe pienhasn'tnchangednsincenpre-reformnyears.nnThenMassachusetsnhealthcarenreformnendures,nwith nonevidencenofnitnruiningnthenstate'sneconomyninnthennearnfuture.n

Healthcare in Kentucky

KentuceynisnansignifcantlynimportantnstatenwhennitncomesntontheneffectsnofnthenAffordablenCare Act.nAsnmentonednearlier,nthenstate,ntogethernwithnAreansasnexperiencednthenbiggestndecrease innthenratenofnuninsurednbetweennthenyearsn2013nandn2016.nKentuceynhadnbeennamongnthe groupnofnstatesnthatnhadnvotednfornMedicaidnexpansionnundernthenACA.nUponnthenhealthcare reform,nKentuceyninitatednthenestablishmentnofnanhealthninsurancenexchange,nenownnasnKynect. Thenexchangenisnofciallynanhealthninsurancenmareetplace,nwhichnwasnintroducednintonlawnbynthe ACA.nItndemandsnthatnallnstatesnhaventhisnexchangenwhichnenablesntheirncitzensntonfairlynpice amongnprivatenandnpublicninsurers.nBesidesnhavingnadoptednthenMedicaidnexpansion,nthenstate alsonrunsnitsnownnChildren'snHealthnInsurancenProgramn(CHIP).n Thenimplementatonnofnthenmareetplacenexchangenhowevernwasnnotneasilynacceptednbynthe generalnpublic.nAtnthentme,nKentuceynhadnangovernornfromnthenDemocratcnparty,nwhilenthe majoritynofnthenstate'snpopulatonnhadnopposednPresidentnObamanandnhisnreform.nGovernor BeshearnintroducednthenKyntectnvianannexecutvenorder,nfearingnthatninactonnonnthensidenofnthe legislatvenbodiesnwouldnleadntondismantlingnofnthenintendednreform.n nKentuceynisnalonenin expandingnMedicaidnandnimplementngnanmareetplacenexchangenamongnsouthernnstates.nInnthe yearsnfollowingnthenenactment,ntherenhadnbeennansharp,nstate-widendecreaseninnthenratenof uninsured.nInnjustnonenandnanhalfnyears,nthenratenofnthenuninsuredndecreasednbyn11.4npercent accordingntonthenGallup-HealthwaysnWell-BeingnIndex.nn Polarizatonnofnthenpolitcalnlandscapenandntheneffectnofnpartsannpolitcsninnlawnmaeingnhadnmade itndifcultntonachievenlong-lastngnresults.nEvennthoughnKyntectnwasnclaimedntonbenansuccessnby many, n including n governor n Beshear n and n healthinusrance.org, n the n state's n newly n elected Republicanngovernornhadndecidedntonactnotherwise.nnDespitenKyntectnwasnarguablynonenofnthe

mostnsuccessfulnexamplesninnthencountry,nGovernornBevinnannouncednitsnterminatonnstartngnin 2017.n

Anlargenportonn ofn then populatonnofnKentuceyn reliesnonnhealthcarenprovidednbynMedicaid. Almostnanthirdnofnthenstate'snpopulatonnhasncoveragenthroughnthenprogram.nThisnisnevennhigher innthenunderdevelopednmountainnregionsnofnthenAppalachian,nwherenthenopioidncrisisnworsens thenexistngnhealthcarensituaton.nInnsomenAppalachianncountes,nthenratenofnpeoplenwhonrely solelynonnMedicaidncoveragenreach,nornevennexceedn60npercent,nwithnOwsleyncountynstandingnon thentop,natn67.5npercent.n ThencasenofnKentuceynshowcasesnthennecessitynofnhavingnuniversalnhealthninsurancenfornthe generalnpublic,nespeciallynfornthosenlivingnunder,nornclosentonthenpovertynlinenandnthenimpactnit cannhavenonntheirnlives.nAnstudynpublishedninnthenJournalnofnthenAmericannMedicalnAssociaton claimedntonhavenfoundnthatnthenimpactnofnMedicaidnfornKentucey'snlow-incomenadultsnwasnbeter access n to n healthcare n services, n increased n fnancial n stability n and n people n feeling n healthier n in generaln(Sommersnetnal.n2016).nn

Healthcare in Texas

Asndescribednearlier,nthenstatenofnTexasnhasnthenhighestnratenofnuninsuredncitzensninnthenUnited States.nThisnnaturallynpresentsnansetnofnchallengesnforntheneconomynofnthenstate,nthensocietynin generalnandnitsncommunitesnthroughout.nnTexasnisnthensecondnlargestnstateninnthencountry,nboth inntermsnofnsizenandnpopulaton.nThenUSnCensusnBureaunstatesnthatnitnhasnthenhighestnratenof populatonngrowthninnthencountry,nwithnbothndomestcnandninternatonalnmigratonndrivingnthe fgures.nAccordingntonthenreport,nmostnnewcomersnarenatractednbynitsnstableneconomynand relatvelynlownhousingnprices.n TexasnwasnamongnthennumbernofnstatesnthatnhadnnotnimplementednthenMedicaidnexpansion undern thenAffordable nCaren Act. nThisn decision ndirectlyn impacts nTexans, n especiallyn thenlower incomenresidents.nThenUniversitynofnTexasnhadnstartednpublishingnreportsninn2006,nnamednCode Red,ntonwarnntheirnstatengovernmentnaboutnthengrowingnthreatnofnanpotentalnhealthcarencrisis. Theynarguenthatnthenhealthnofnthenstate'snpopulatonnwillnhavenansignifcantnimpactnonnTexas'

standnonnthenglobalnandnnatonalnscene.nFurthermore,ntheynarguenthatn"increasingndiscrepancy betweenngrowingnhealthnneedsnandnaccessntonaffordablenhealthninsurancencoveragencreatesnthe conditonsnfornanperfectnstorm''.n Texas'nlegislatorsnarenopposedntonthenAffordablenCarenActninngeneral,nespeciallynitsnsuccessive governors.nThenstatenchoosesnnotntonacceptnfederalnfundingntonsupportnthosenwhondonnotnqualify fornhealthcarensubsidies,neithernundernthenACAnornMedicaid.nAccessntonhealthcarenfornthose alreadyninsuredncannalsonbenlimitednduentonthenhighncostsnofnthenprocedures.nThisnisnespecially truenamongnthenstate'snlowernincomencitzens.nThisninaccessibilitynisnfeltnbynsomencommunites evennmore.nnAccordingntonthenAgencynfornHealthcarenResearchnandnQualitynidentfednthatnTexas ranesnthenlowestnnatonwideninntermsnofnhealthcarenamongnitsnLatn-Americannpopulaton.nThe samenreportnhadnidentfednTexasnasnhavingnthenlowestnhealthcarenqualitynoverall.n Thisnlaggingnbehindninnhealthcarencoverage,nnaturallyncomesnwithnfnancialncosts.nThen2015nCode RednreportnwarnsnthatnthesencostsnaffectnallnTexansnbynandnlarge.nThenhealthcarenexpenditures have n to n be n covered n by n property n taxes, n higher n insurance n premiums n for n employers n and employees.nAddingntonthenproblemsnarenthenhighernpricesnassociatednwithnthentreatmentnof illnesses,nthatnwouldnhavenbeenndiagnosednandndealtnwithnatnearliernstagesnifnthosenindividuals hadnbeenninsuredninnthenfrstnplace.nnThendecisionnofnTexas'nlaw-maeersnnotntonexpandnMedicaid coveragenasnanpartnofnACA,nhadnleinaroundn1nmillionnadultsninnthensoncalledn'coveragengap'.nThis means n that n those n citzens n practcally n can't n afford n health n insurance, n but n don't n fall n into n the coverage nprovidedn byn Texas'ncurrentn Medicaidn program. n Thisnalienatonn hasn antremendous impactnonnthenlivesnofnthosenindividualsnandnwillnaffectnthenstate'snoverallnperformanceninnthe long-run.nTreatmentsnthatnarennecessarynbutnnotncoverednbynanynhealthninsurancenplannwill contnuentonburdennTexas'ntaxpayers,nthenhospitalsnandnthenstate'snbudget.nThen2015nCodenRed reportnpublishednthenopportunityncostnthatnthenstatenofnTexasnmisses,nduentonnotnexpanding Medicaid.nHadnthenstatenfollowednthroughnwithnthenwholenreform,nthennitnwouldnhavenreceived aroundn$100nbillionnfromnthenfederalngovernmentnwithinnthenfrstntennyearsnofnitsnenactment.nn

Industrynprofessionals,ncitzensnandnlegislatorsnunderstandnthenseriousnessnofnTexas'nhealthcare troubles.nWithncontnuednengagementnbynordinarynpeople,nexpertsnandnpolitciansnthisntrendncan benreversednfornthenbeternandnanpathnfornanfairernsocietyncannbencarvednfornthenlonenstarnstate.

Boston-Cam ridge-Quincy MSA as an Entrepreneurial Ecosystem

BostonnisnanhistoricallynsignifcantncityninnthenUnitednStates.nItnisnonenofnthenoldestnEuropean setlementsninnthennaton,nservingnasnanbustlingnportncityninnthentmesnofnthenBritshnEmpire.nThe city n was n where n the n spare n of n the n American n War n of n Independence n got n ignited n and n spread throughout n the n colonies. n The n city n came n to n represent n the n startng n point n of n the n boldest experimentnofndemocracynandnuniversalnsuffragenundertaeenninnhumannhistory.nItnisnaccuratento statenthatnBoston'snspiritnstllnlivesnonnandncontnuesntonharbournground-breaeingnachievements, carriednonnbynpeoplenwithnthenintentnofnchangingnthenWorld.n AlthoughnthenimportancenofnthenBostonnHarbournmaynhavendiminished,nthencitynremainednasna powerhousenofnAmericanninnovatonnthroughoutnthen20th_{ncentury.nnInnthendecadesnfollowingnthe} buildingnofnthenfrstnIMTncomputerninnthen1950's,nBostonnhostednsomenofnthenmostnimportant worenonnthenfeld.nThenadoptonnofncomputerntechnologynfrstnbegannherenbynthenlongnhardnwore ofnIMTnandnrelatednresearchnfacilites.nTheirneffortsnstllnechonasnonenofnthengreatestnlegaciesnof Boston'sninnovatvenessnandnentrepreneurialnspirit.nn ThendevelopmentnofnsuchnhighnenowledgenindustriesninnBostonncouldnnotnhavenbeennachieved withoutnthencity'snworld-renownednuniversitesnandnhospitals.nThesenuniversites/collegesnare:n  BabsonnCollege  BostonnCollege  BostonnUniversity  HarvardnBusinessnSchool  MassachusetsnInsttutenofnTechnology  NortheasternnUniversity  UMassnBoston Theseninsttutonsninjectnhighlyneducatedngraduatesnintonthenecosystem,nservingnasnthentalentnfor thenallneindsnofnorganizatonsninhabitngnthencity.nBostonnhasnthenhighestnlevelnofneducaton amongnyoungnadultsninnthennaton.nAccordingntonanTechnologynOutlooenreport,nthencity'sntalent

poolnisnsecondntonofnSiliconnValley's.nAsneducatednmillennialsnmaeenupnton7.6%nofnthenpopulaton, accordingntonthenInnovatonnThatnMatersnreportnbyn1776,ncompaniesnhavenandeepnpoolntonselect from.nRenownednuniversitesnatractnpeoplenfromnallnovernthencountrynandnthenworld,nadding diversity n to n the n city's n ecosystem. n Boston, n and n Massachusets n in n general n is n viewed n as n a progressivenstate,nwhichnusuallynisnannidealnhabitatnfornyoung,neducatednadults.n However,nsomenseenthatnthentalentnraisednbynthencitynisnleavingntonothernpartsnofnthencountrynor thenworldnfornbeternopportunites.nAccordingntonthenNewnYorenTimes,nangreatnbrain-drainneffect isndamagingnBoston,nasnitnfailsntonatractnmorengraduatesnthannitnraises.nnBesidesnexportngnhighly educatednindividuals,nBostonncontnuesntonlosensomenentrepreneurs,nwhontaeentheirnventure elsewherenatnlaternstages.nAnreportnpublishednbynthenNortheasternnUniversitynstatesnthatnBoston isnan"feederncity",nthatnraisesnpeoplenwithnnewnventuresnandnbusinessnideas,nthatnarenrelocatednto placesnwithnmorenavailablenfnancesnandngreaternopportunites.n nThenbest-enownnexamplesnof thisnphenomenonnarenFacebooenandnDropbox.nBothnventuresnarenassociatednwithngreatnsuccess storiesnandnarenansomewhatnansymbolnofn21st_{n century,ntechnologicalnentrepreneurship.nBoth} venturesnhadnbeennfoundednatnMIT,naddingntonthenuniversity'snalreadyninfamousnreputaton. However,nbothnFacebooenandnDropbox,natnsomenpointnrelocatedntonSiliconnValley,ninnCalifornia. Nevertheless,nthenentrepreneurialnecosystemnofnBostonnhasnbeenngainingnquitenanreputatonnfor itself.nInn2017,nthenUSnChambernofnCommercenhadnraneednthencitynnumbernonenforndigital entrepreneurship.nAccordingntonthenKauffmannIndex,nBostonnisnthen8th_{ninnentrepreneurialngrowth} andnsecondninnsmallnbusinessnenterprising.n1776,nthenglobalnstartupnincubatornandncommunity builder n put n Boston n 1st_{n in n terms n of n readiness n for n the n much-antcipated n shiin to n the n digital}

economy.nAn2015nCompassnreportnhadnplacednthenecosystemn4th_{ninnthenWorld,nvaluednaround} $46nbillionnwithnantotalnofn400nstartupsnoperatng.n nThesenreportsnarenanresultnofnthencity's bustlingnandnhighlynconcentratedntechnscene,ntogethernwithnthenlocalngovernment'sneffortsnin boostngnentrepreneurshipnamongnitsngeneralnpopulaton.nThencity'snlawmaeersnnotnonlynvalue entrepreneurshipnasnantoolnforninnovatonnandngrowthnbutnseenitnasnantoolntoncreatenvaluenand empowermentnfornallndemographicsnpartcipatngninntheneconomy.nThencitynhowevernhasnitsnset ofnchallengesnfacingnthenecosystem.nThenBrooeingsnInsttutenfoundnthatnBostonnsuffersnfromnthe

worst n inequality n in n any n major n US n city. n Accompanied n with n a n steadily n rising n costs n of n living, partcularlynhousing,nisnanrecipenfornanpotentalnsocialncrisisninnthencity.n Boston,nisnenownntonbenroughnaroundnthenedgesnandnitsnunequalnincomendistributonnisndeeply embeddedninnthencity'snstructure.nEvenntough,nstartupsnby-and-largeninhabitnannecosystemnwith closenton'ideal'nconditons.nBostonnisnpraisedninngeneralnfornitsnhighnqualitynofnlife.n1776nraneednit 5th_{ninnthennaton.nItnhasnannactvenstartupncommunity,nformingnessentallynanhubnaroundnthenport} area.nInnthenhub,ntherenisnanbroadlynacceptednstartupnculture,nsurroundednbynansupportve infrastructure.nThenregulatorynenvironmentnisnhighlynwelcomingntonnewnventuresnandnaccessnto VCnfundingnandnlegalnsupportnisnreadilynavailable.nAncollaboratvencommunitynfacilitatesnthe exchangenofnideasnandnthenbuildingnofnnetwores.nWithinnthisnecosystem,nthentechnstartupnscene isnthriving.nWithinnthenfvenyearsnbetweenn2011nandn2016,ntherenhadnbeenn19ntechnexitsnwithin thencity,nwithnannestmatednvaluenofn$200nmillion.nOutnofnthosen19ncompanies,n3nwerenUnicorns. Withinnannecosystemnofncirculatngninnovatvenbusinessnconcepts,nthentechnindustrynisngrowing fastnthanesntonallnthennewnideas.nAlthoughnSiliconnValleynisnconsideredntonbenthenleaderninnthis feld,n1776nidentfednthatnalthoughnBostonnhasnanlotntoncatchnupnto,nthencity'sncommunity, lifestylenandnclearngovernmentnemphasisnonncreatngnannewngeneratonnofntechnentrepreneurs pushesnitntonthentopnranes.nnInnthencasenofnBoston,nitnisnevidentnthatnthengovernmentnhadnbeen actvelyninvolved,ninndeliberatelynworeingnonnatractngnactvitesnthatncreatenannecosystem.nThe aimnofnthenrecentntechninitatvenisntonatractnandncreatencompaniesnfocusingnonneducaton, energynandnhealthcarensolutons.n Collaboratonnbetweennactorsninnthenecosystemnisneeyntonachievingnitsnsustainability.nInnBoston privatenandnpublicnbodiesnengagendynamicallyntoneeepnitsnenginenrunningnatnhighnspeed.nWithin thenmetronarea,ntherenarenmorenthann40nuniversitynornindustrynincubators,nnurturingnpromising newnideas.nSomenofnthesenincubatorsnandnacceleratorsnare:n  DCUnFinTechnInnovatonnCenter  ThenEngine  GreentownnLabs  MassachusetsnMedicalnDevicenDevelopmentnCenter  MassRobotc  CogonLabs

 CybersecuritynFactory  EntrepreneurshipnfornAll  FILnLaunchpad  LearnLaunchnAccelerator  MDPnLabs  PhilipsnHealthWores Asnmentonednbefore,nthencitynhasnannactvencommunity.nThenstartupncommunitynoiennorganizes eventsntonboastnthenactvitesnwithinnthenecosystem.nThesenmeetups,neventsnandncompettons include:  BostonnBiotechn  BostonnBusinessnNetwore  BostonnEntrepreneurnThineTane  BostonnEntrepreneursnNetworen  BostonnFoodnBusinessnAssociaton  BostonnGreennTechnandnSustainablenEnergy  BostonnStartupnWeeen  HUBweeen  LearnLaunchnAcrossnBoundaries  MITnVenturenCapitaln&nInnovatonnConferencen  EdtechnPitchnCompettonn  MITn0Kn  MITnCleannEnergynPrize ThenfocusnfornBostonnfornthenfuturenisnpromotngnfemalenandnminoritynentrepreneurshipntonfght fornanmorenequalnandnfairernsociety.nThencitynwillncontnuentonfocusnonnitsncorenstrengths,nhigher educaton,nhealthcarenandnwillncontnuenengagingnthencommunityntoncreatenvaluenandnincrease compettveness.nInn2016,nGEnhadnmovednitsnheadquartersnwithinnthenBostonnMetronareanin orderntonbenlocatednwithinnproximitynwithngraduatesnandngreatninnovatvenideas.n

Louisville-Jeferson CountynMSA as an Entrepreneurial Ecosystem

Louisville,ninnthenMid-WesternnUnitednStatesnisnanuniquencityntonlooenatnasnannentrepreneurial ecosystem.nThensetlementnatnfrstnwasnfoundednaiernthenAmericannWarnofnIndependencenand began n to n serve n as n a n strategical n hub. n Being n one n of n the n few n new n cites n west n to n the n now independentncolonies,ntogethernwithnitsntransportnandntransitnadvantages,nthencitynbecamena centralnplayerninnthenpushntowardsnthenWest.nDuentonthen'rapids'nlocatednonnthenriver,nLouisville's