Should You Go 1099 as a CRNA? The Honest First-Year Math

Every recruiter pitch for 1099 CRNA work starts with the same line: "you'll make more." And every W2 CRNA who flipped to 1099 mid-career has a 6-month period where they weren't entirely sure that was true.

Here's the honest first-year math.

The setup

We'll compare two realistic offers for the same provider:

W2 offer: $210,000 base, 6 weeks PTO, employer-paid malpractice (occurrence), employer covers 70% of family health insurance premium (~$14,000/yr employer contribution), 5% 401(k) match up to $14,000, $4,000 CME allowance.
1099 offer: $125/hr, averaged across 1,920 hours ($240,000 gross), you pay everything.

The 1099 offer looks like a $30K raise. It isn't.

What comes out of the 1099 gross

Self-employment tax — ~$22,000

As 1099, you pay both halves of FICA: 15.3% on the first $168,600 of self-employment income (2026 Social Security wage base), then 2.9% Medicare on everything above. On $240K: roughly $22,000–$23,000 in self-employment tax.

A W2 employee pays only their 7.65% half. The employer pays the rest. In the 1099 scenario, you are the employer.

If you set up an S-Corp (and your income is high enough to justify one — typically $150K+), you can reduce this. Taking a reasonable salary of $140K and the rest as K-1 distributions cuts your self-employment tax liability to roughly $11,000. Savings: ~$11,000/year. But S-Corp setup adds ~$1,500–$3,000/yr in payroll processing, bookkeeping, and accounting costs. Net savings: ~$8,000–$9,000.

Health insurance — ~$18,000–$28,000

The W2 employer was contributing ~$14,000/yr to your family health insurance. As a 1099 provider, you have three options:

Spouse's employer plan. Often the cheapest path, $4,000–$8,000/yr family contribution.
ACA marketplace. Typical family silver plan in 2026: $20,000–$28,000/yr premium for a high-income CRNA household (no subsidies at this income level).
Direct purchase + DPC model. Variable; not a replacement for catastrophic coverage.

For this comparison, assume ACA at $22,000/yr. The 1099 offer is net $22,000 poorer than the W2 offer before you write the first check.

Retirement — you self-fund, but with higher limits

W2: $14,000 employer match on your 401(k) plus your $23,500 employee contribution.

1099: You can open a Solo 401(k) and contribute up to $70,000/year ($77,500 if 50+). The employee side is your own salary deferral; the employer side is profit-sharing up to 25% of net self-employment income.

This is a big lever. But it's your money, not a match. You're shifting $14K of employer contribution into your own ledger as a cost.

PTO — zero

No PTO means every day you're not working is a day you're not paid. A W2 CRNA earning $210K with 6 weeks PTO is getting $24,000/yr of paid non-work time.

A 1099 CRNA wanting the same 6 weeks off is giving up $24,000 of gross earnings (at the $125/hr, 1920-hour baseline).

CME, license, disability insurance

W2 employer covered $4K CME and disability. As 1099:

CME courses, conference travel: $3,000–$6,000/yr out of pocket
State license renewals, DEA, NBCRNA: $1,500–$2,500/yr
Own-occupation disability insurance policy: $3,500–$6,000/yr
Professional liability / malpractice (occurrence): $2,500–$5,000/yr

Total self-funded insurance + CME: ~$12,000/yr.

Quarterly estimated taxes

Your federal, state, and self-employment tax burden on $240K gross, assuming standard deductions and no S-Corp, is roughly $65,000–$75,000 in combined tax. The IRS expects 100–110% of prior-year liability paid through quarterly estimates (April 15, June 15, September 15, January 15) or you owe penalties.

This isn't a cost — it's a cash-flow burden. A W2 provider has tax withheld from every paycheck. A 1099 provider has four large checks to write per year. If you don't discipline yourself to set the money aside, you will find out what the IRS penalty interest rate looks like.

The actual take-home comparison

Scenario A: W2 at $210K

Gross: $210,000
Employer benefits value (health, match, CME, disability): +$19,000 (in-kind)
Federal + state + FICA tax: -$58,000
Net cash take-home: ~$152,000
Net value including benefits: ~$171,000

Scenario B: 1099 at $240K, no S-Corp, ACA health, 6 weeks off

Gross: $240,000
ACA family insurance: -$22,000
Disability, malpractice, CME, license: -$12,000
Federal + state + SE tax: -$72,000
Net cash take-home: ~$134,000
Net after retirement (you fund your own $23K): ~$111,000 liquid

Scenario C: 1099 at $240K, S-Corp structure, spouse-employer health

Gross: $240,000 (as S-Corp revenue)
Spousal health insurance: -$6,000
Disability, malpractice, CME, license: -$12,000
S-Corp payroll tax savings: +$9,000 (vs sole prop)
Federal + state + SE tax (with S-Corp structure): -$55,000
Accounting/payroll costs: -$2,500
Net cash take-home: ~$173,500
Net after retirement (max Solo 401(k) $70K): ~$103,500 liquid + $70K pre-tax retirement

When 1099 actually wins

From the math above, the 1099 scenarios pencil out in specific circumstances:

Spousal health coverage available — biggest single lever. Closes most of the gap.
Income high enough for S-Corp ($150K+ net). Major SE tax savings.
You'd max retirement anyway. The Solo 401(k) ceiling is materially higher than W2 403(b)/401(k).
You'd work the hours regardless of PTO. If you'd naturally work 1900+ hours, the PTO gap disappears.
You have reliable 3+ months of living expenses in savings. 1099 income varies; assignments get canceled; W2 stability has real option value.

When 1099 loses

You need ACA insurance without spousal backup. $22K/yr premium drowns most of the gross advantage.
You value PTO and won't work 1900+ hours. You're paying for time off out of gross.
Your effective tax rate in your state is high (CA, NY, NJ, MN, OR) — 1099's deductibility advantages partially offset by high state income tax on pass-through income.
You're new to practice (under 2 years). Clinical mentorship and the benefits of being embedded in one group outweigh the money.

The decision framework

Run the numbers in the 1099 vs W2 Calculator with your actual offer, your actual insurance situation, and your actual projected hours. Do not use recruiter gross-hourly math. The gap between gross hourly and true net is usually 35-45% once all the costs are in.

If you want a structured read on your specific situation, try the Should I Go 1099? decision tool. It scores you across 9 factors and tells you what to fix before making the switch.

The one-sentence summary

1099 wins when you have spousal health insurance, enough income for an S-Corp, and the discipline to set aside quarterly taxes — otherwise the W2 with benefits is usually a narrower gap than the recruiter suggested.

None of this is legal or financial advice. Talk to a CPA who specializes in healthcare 1099 practice before you make the jump. It's a $500 consult that will save you $10,000 over the first year.