Health care costs and the economy are the top factors affectingboth employers' business decisions and their vote in the upcomingpresidential election, according to a survey released today by thePrincipal Financial Group.

More than half of employers (57%) say health care costs are topof mind in regards to their business decisions, while slightly less(54%) cite economic growth. Other top issues include uncertainty oftaxes (45%), gas prices (43%), unemployment (37%) and inflation(36%). The Principal group surveyed 604 business owners incompanies of 10-500 employees.

American business owners say both the economy and health carereform will impact their votes in the presidential election, butthe economics matter slightly more.

President Obama's Patient Protection and Affordable Care Act hasbeen controversial, while many reports have attempted to understandthe impact it will have on employers, all to different results.Challenger Mitt Romney has said he will repeal and replace thehealth reform law. Both candidates have very different views on howto best handle the struggling economy.

[Also see "Reform isn't impacting employer-sponsored coverage"]

The main trouble with health reform is the looming uncertaintyaround it, employers say. In addition to worrying about managingthe cost and administrative responsibilities of health care,employers say understanding the impact of health care reform ontheir business is their top concern for their well-being in theupcoming year.

Though the economy is a concern, businesses say they are doingfine, mainly because they are being frugal in their strategies.

Roughly half of those surveyed say their business financialsimproved compared to a year ago and more than half (58%) believetheir financials will improve in the next 12 months. But when itcomes to the broader picture, nearly half of those surveyed (46%)are cautious about the economic outlook for 2013, and two-thirdsare holding off on making long-term financial commitments becauseof the current state of the economy.

“While owners of small to medium-sized businesses report growingconfidence in what they can control—their own companies—they do sowith a healthy dose of caution in the context of the overalleconomy,” says Amy Friedrich, Principal vice president. “As theseowners prepare for Election Day, the economy will not onlyinfluence their vote, but also their long-term plans forspending.”

In an attempt to take control of the future of health care whilecurbing costs, more employers are turning to wellness programs.Nearly two-thirds of those surveyed (64%) offer some form ofwellness benefit to their employees. Among those that do, almostone-third (32%) have experienced lower health insurance costs. Theyalso say the programs have made their employees more productive atwork, increased employee retention and caused them to be away lessfrom work.

“With lingering ambiguity around health care reform, thechallenge of managing health care costs can be overwhelming forowners of small and mid-sized businesses,” Friedrich says.“Business owners are seizing opportunities to take action amidstthis uncertainty and experiencing positive results.”