Despite the growing ranks of voluntarily uninsured Americans, 55 percent of small business owners have never directly asked employees if they want healthcare coverage, according to a survey of 1,046 U.S. small business owners by management consulting firm George S. May International.

"Small business owners can no longer afford to assume their employees want healthcare coverage," said Paul Rauseo, managing director of the George S. May International. “An increasing number of people are voluntarily uninsured because they want to invest those healthcare dollars in other ways. Small business owners need to recognize this trend and have an honest talk with their employees about benefits that make sense."

While the U.S. Census Bureau categorizes 47 million Americans as uninsured, a study by the Employment Policies Institute revealed that 43 percent of those in the 18–64 year-old age group can be called "voluntarily uninsured." These predominantly younger workers have incomes at or above 2.5 times the poverty line, indicating they have the means to obtain coverage.

At a time when 45 percent of small businesses aren’t profitable, both the employees and company win when small business owners talk openly about benefits, according to Rauseo. "We’ve found that the top three employee complaints include salary size, internal pay equity, and the benefits program," he said. "If employees don’t want full healthcare coverage, businesses can drive profitability and employee satisfaction by using that savings to fund performance-based incentive programs that address these complaints."

But small businesses aren’t quite there yet. The George S. May survey also found that while 31 percent of respondents have increased employees’ contributions to healthcare coverage, only 28 percent have used the savings for performance-based incentives, including bonuses and pay increases.