When Theresa Bixby, 63, learned that she had breast cancer four years ago, she reacted as many Americans do. “One of my first thoughts was, ‘Will they pay?’ ” she said. But she wasn’t talking about a conventional insurance plan. She lost hers when she left her full-time position for part-time work at her church in Greenville, S.C. She was worried about the program that she had joined six months earlier: Christian Healthcare Ministries.
Christian Healthcare Ministries is not an insurance company. It is a nonprofit “health care sharing ministry” based in Barberton, Ohio. The cost of membership is far lower than the rates of traditional insurance policies – $45 a month for the cheapest plan – but the ministry makes no guarantees of payment. Members send their monthly “gift” to an escrow account, which disburses payments for eligible medical bills, excluding costs like routine physicals, continuing treatment for pre-existing conditions or procedures that members have voted to exclude, like care for pregnancies outside wedlock.
Each time Bixby visited her hospital for tests or chemotherapy, she explained that she was a self-pay patient and a member of a cost-sharing ministry. Sometimes the receptionist nodded; sometimes she got a blank stare. The hospital never denied her treatment, but “I was getting a 2-inch stack of bills every month, and threats that they would take me to collections,” she told me.
Christian Healthcare Ministries assigned her case to a “member advocate,” who negotiated discounts on her fees. These counted toward Bixby’s $5,000 deductible, so she paid out of pocket only for office visits. In the end, the ministry persuaded the hospital to lop $220,900 off a bill of $301,540 and reimbursed or paid directly the remaining $80,640.
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Despite stories like this, organizations such as Christian Healthcare Ministries claim a modest membership. The four main cost-sharing ministries in the United States have about 340,000 members. Regulators in several states have raised concerns that these ministries offer the illusion of insurance while sidestepping the Affordable Care Act’s baseline standards of coverage and skirting requirements that apply to conventional insurance companies, like minimum cash reserves. Nonetheless, membership in the ministries has been growing, particularly since the act granted them an exemption as one of the only ways to avoid the law’s mandate to buy insurance without paying a fine.
But the debate over consumer protections may disguise a more interesting question: Could this model scale up? These ministries seem to achieve a remarkable level of member satisfaction, even if they sometimes must portion out reimbursements when the bills outstrip monthly contributions.
The ministries’ appeal lies partly in their low fees, but also in their ideological boundaries. “This isn’t something that’s for everyone,” said Tony Meggs, the CEO of the Florida-based Christian Care Ministry, which runs a health care sharing program called Medi-Share.
Christian cost-sharing ministries have been around for about 30 years. They claim that their true origins lie in the Book of Acts, the biblical account of how the first Christians “had everything in common” and “gave to anyone as he had need.” The ministries “show the world something that works, and works well, and is a reflection of the commandments of Christ,” Meggs said.
The resemblance to apostolic Christianity is debatable: After all, Jesus’ healing ministry didn’t take pre-existing conditions into account, and the early church offered aid to nonbelievers. The real precursors are the mutual aid societies of the 19th and early 20th centuries. In their heyday, organizations like the Odd Fellows and the Loyal Order of Moose pooled fees to provide insurance for huge numbers of working-class Americans. It is no accident that in our new Gilded Age, the model that prevailed during the first Gilded Age is enjoying a second life.
These aid societies did more than provide relief from doctors’ bills, lost wages or funeral expenses. They also divided the “deserving” poor from miscreants who suffered through their own fault. Their bylaws stressed “thrift, leadership skills, self-government, self-control and good moral character,” the historian David Beito has written. Lodges required members to hold an “honorable” job, banned women of “immoral or questionable behavior” and limited the use of alcohol and drugs.
Today, Medi-Share requires members to “live by biblical standards”: no tobacco or illegal drugs and no sex “outside of traditional Christian marriage.” Samaritan Ministries, with headquarters in Peoria, Ill., requires a pastor’s approval of medical expenses (and refuses to cover treatment for STDs unless “contracted innocently”). Liberty HealthShare, based in Independence, Ohio, is the only Affordable Care Act-exempt ministry open to people of many faiths. It asks them to affirm that “it is my spiritual duty to God and my ethical duty to others to maintain a healthy lifestyle.”
Members say these rules are marks of the kind of community that government programs undermine. “This is a solution for those of us who see the ACA as a problem,” said Daniel Alders, 28, a Samaritan member who lives in Nacogdoches, Tex., and has turned to the ministry to pay for the births of his two children. Samaritan members send their monthly share directly to another member with medical expenses. “When we receive money, nine times out of 10 there’s a note attached saying they’re praying for us and the health of the baby,” he told me.
“A community is an organically grown organism, so it can’t succeed if it’s pushed and enforced from the top level down,” he said. “You have to have a moral foundation, a reason to trust those whose needs you’re sharing.”
In a recent interview with NPR, President Obama acknowledged that many white working-class voters felt no such trust in the government. “They think: ‘I’m being left out. Nobody seems to be thinking about how tough it is for me right now,’ ” he said.
He’s not the first liberal to hope that publicly funded health insurance could win that trust. More than a century ago, the Progressive reformer Jane Addams admired the parades of mutual aid societies in Chicago’s Italian quarter, where members marched “with a brave showing of banners, celebrating their achievement in having surrounded themselves by at least a thin wall of protection against disaster.” She longed “to pour into the government of their adopted country all this affection and zeal, this real patriotism. A system of State insurance would be a very simple device and secure a large return.”
In fact, mutual aid societies fought compulsory insurance legislation that Progressive activists proposed in the World War I era, fearing that such laws would endanger Americans’ “spirit of self-reliance.” The legislation failed, but the societies’ days were numbered, too. The financial burdens of their aging membership sometimes became crushing. And they were no match for the growing political power of commercial insurance companies and organized medicine, or the IRS’s ruling in 1943 to grant tax breaks to employers who paid for workers’ insurance.
In a way, Addams still got her wish. Persuaded by a new vision of solidarity, many of those Italian immigrants joined the New Deal coalition. In 1941, Franklin Delano Roosevelt advocated for the right to “security for those who need it,” including “adequate medical care.” Roosevelt wanted to surpass the model of the voluntary aid society by turning the social contract into a covenant that bound people who otherwise had little in common, that granted a basic level of economic security to people excluded by the market or mutual aid.
For a small, self-selected group of Americans, cost-sharing ministries make our broken health care system bearable. There is much to admire in their nonprofit structure and their tireless advocacy for members. The problem is that too often their proponents take them as proof that it’s “in the DNA of Americans to assist and help one another” and success comes “when the marketplace is given the opportunity to produce solutions on its own,” as Dale Bellis, Liberty HealthShare’s executive director, put it.
The truth is that Americans never enjoyed a golden age when local communities came together to solve social problems. In Colonial times, villages “warned out” the aged, disabled and unmarried pregnant women, deporting their neediest residents to other towns.
The great insight of the New Deal reformers was that fetishizing a romantic idea of community is as perilous as making a false idol of the free market. Cost-sharing ministries nurture one kind of community, but only by opting out of the broader obligations of society. To make the Affordable Care Act stick, and to make it work, means convincing more Americans that they are not just their brother’s keeper.
The New York Times
Molly Worthen is an assistant professor of history at the University of North Carolina at Chapel Hill.