Medicare for all

August 26, 2017

http://amsterdamnews.com/news/2017/aug/24/medicare-all/ 

Recently we joined our friends and allies in cheering the defeat of Senate bills to dismantle the Affordable Care Act and deny health care to millions of Americans.

Throughout the torturous attempts of Senate Republicans to mutilate Medicaid, defund Planned Parenthood and transfer close to a trillion dollars to the super-wealthy, two Republican women steadfastly voted their conscience. We commend Sen. Susan Collins of Maine and Sen. Lisa Murkowski of Alaska for their refusal to be cowed by President Trump and their party’s leadership. But make no mistake, the victory for patients, caregivers and for the right to quality care was forged by those who called, marched, sat in and advocated for the human right to health care and by those in the health care community.

We must remain vigilant because the administration and its congressional allies will undoubtedly continue their assault on the ACA. The attacks will most likely focus on the troubled subsidized individual health insurance market, although the problems with these profit-driven markets predate the ACA.

The Medicaid expansion, on the other hand, is a resounding success. The more than 20 million previously uninsured who gained coverage under the ACA have no interest in giving it up, nor should they. But rather than reduce the number of uninsured, as the GOP defeated bills would have done, we need to dramatically increase coverage and continue our march toward universal health care.

And that is what the people of our country want. A recent Gallup Poll found that 73 percent of Democrats and 58 percent of all Americans favor a federal funded health care program that would include all Americans. A recent Pew report found that 60 percent of all Americans favored a federally guaranteed health care system. Such a program would put us in step with the rest of the industrialized world. Today, we are the only industrialized nation without universal health care.

And here, in the world’s wealthiest and most technologically developed country, Americans pay far more than most advanced countries for health care. Other governments are able to negotiate much more favorable terms with providers, and there are no insurance companies adding additional costs. The administrative costs for Medicare, the federal health care program for seniors and some disabled persons, is between 1 percent and 5 percent. The costs for those with private insurance is 18 percent. And as for health outcomes, the United States, despite its wealth and vast medical resources, ranks a shameful 26th in the world in life expectancy.

Supporting Medicare for all are scores of medical, national, faith-based, state and local organizations. Former President Jimmy Carter and former Vice President Al Gore also have declared support. A number of states have introduced single-payer plans. In May, a single-payer bill passed the New York State Assembly for the fourth time, but it stalled one vote shy of passage in the Senate.

Now, single payer is inching its way into the Democratic Party’s mainstream. For the first time, a majority of House Democrats have signed on to a “Medicare for all” legislation. The bill, HR676, was introduced by Rep. John Conyers, a Michigan Democrat, the dean of the Congressional Black Caucus and a longtime proponent of single payer.

Sen. Bernie Sanders of Vermont is introducing a companion bill in the Senate. The bill has the support of Democratic senatiors such as Kirsten Gillibrand of New York and Elizabeth Warren of Massachusetts. Given the makeup of the current Congress, passage of single payer is unlikely this year, but it is not too early to build a movement that can move the measure closer to passage in the next Congress.

So, while we continue to defend the ACA, it is also time to go on the offense. The only viable path to health care for all builds on—not destroys—the ACA by increasing access, improving benefits and controlling costs. Medicare for all achieves all three. As progressives put our heads together, share resources and continue to march together, we can hammer out the details of a winnable single payer plan and quality care for all. It’s past time to stop putting the profits of the few over the needs of the many.

George Gresham is president of 1199SEIU United Healthcare Workers East, the largest union in New York and the largest health care union in the nation.

Health Care in New York

August 17, 2017

https://www.nytimes.com/2017/08/16/opinion/health-care-in-new-york.html

 

Photo

A man in Miami in 2015 directed passers-by to an insurance company where they could sign up for health coverage under the Affordable Care Act. CreditJoe Raedle/Getty Images

To the Editor:

Re “How to Repair the Health Law (It’s Tricky but Not Impossible)” (front page, July 30):

The basic flaw in the Affordable Care Act is that it leaves us in the hands of insurance companies. That means rising premiums and deductibles, restricted provider networks and high out-of-network charges; huge multiple administrative bureaucracies and profits; and the costs that doctors and hospitals incur for dealing with them.

We should start with a basic principle: No American should be denied health care or suffer financially trying to pay for it. What makes that “tricky” — and forces health policy into contortions — is insisting on taking care of insurance companies and their hefty costs and finances.

The one way to provide all of us with health care and financial security that is most practical and least expensive is to take insurance companies out of the picture and enact improved Medicare for all.

Washington seems a long way from doing that. But progressive states like New York can create state universal public health coverage.

RICHARD N. GOTTFRIED, NEW YORK

The writer is chairman of the New York State Assembly Health Committee and the sponsor of the New York Health Act (A. 4738) to establish a single-payer system in New York.

How Over A Million Christians Have Opted Out Of Health Insurance

August 15, 2017

Oliver Munday for BuzzFeed News

How Over A Million Christians Have Opted Out Of Health Insurance

For a growing number of Christians in the US, faith-based health care sharing ministries seem like the perfect alternative to an expensive, volatile insurance marketplace. But there may be serious drawbacks for some members — and for everyone else.

Posted on 

Bet Olson was 16 years old when she realized she wanted to adopt a child someday. Bet, who was raised in a Christian family outside Chicago, was attending a youth group service at Willow Creek Community Church, a megachurch in South Barrington, Illinois. A young man started to talk about adoption. “He talked about how the story that God has for his people is to adopt them as his own,” Bet recalls. “That this is God’s character, to bring love and redemption. He talked about how he was adopted and what a difference that made in his life. I soaked up every word.”

Nearly 20 years later, Bet and her husband, Erik, live in a small green house on a quiet road in Elgin, Illinois. When I visited, it was early March, that time of year in the Midwest when you can wake up to a 70-degree day or to snow. This day was somewhere in between — overcast and in the low 40s. The Olsons’ children, Zain, 7, and Tesfa, 6 — Tess for short — had just gotten home from school and were playing in the sunroom at the front of the house. Tess was talking about her kindergarten class, where she had just been named Kid of the Week. “That means everyone’s going to say good things about me!” she said.

Bet and Erik adopted Zain and Tess from Ethiopia. “People kept telling me I would change my mind” about adoption, Bet said. “And I just said no. I felt so strongly that this was my calling.”

Bet and Erik began the process of international adoption in 2008, after three years of marriage. Following a home study and over a year of waiting, they were matched with Zain in August 2010. “For the longest time we had two pictures, and we would just look at those two pictures and we just fell in love with this kid,” Erik said. They flew to Ethiopia in November 2010 to meet Zain, and then waited six weeks in Addis Ababa for all the visa paperwork to go through in the US before they were allowed to bring him home, when he was 7 months old. They came back just before Christmas as a family.

Being adopted was akin to a pre-existing condition.

But there were complications ahead. Because the Olsons were members of a Christian health care sharing ministry, rather than a traditional insurance plan, some of Zain’s health care costs wouldn’t be covered the way a biological child’s would. Being adopted was akin to a pre-existing condition.

Since 2007, Bet and Erik had been members of Samaritan Ministries, one of a number of Christian health care sharing ministries in the US that take the place of traditional health insurance by pooling and redistributing members’ money each month. They joined when they were both working for a Christian nonprofit founded by Bet’s dad, where they had to personally raise funds from donors to cover their own salaries. Raising more than that to pay for insurance through the organization as well would have been a burden, so they started to look for creative solutions.

Some of their friends from church recommended Samaritan, which is based in Peoria; Bet and Erik looked into it, liked what they saw, and joined. “I love the idea of sharing each other’s burdens and helping each other out,” Erik said. And up to a point, Samaritan worked for the Olsons. Each month they wrote checks to the name Samaritan sent them. Sometimes they prayed for the recipient; sometimes they forgot. Outside of an incident where Erik broke his toe, Bet and Erik never submitted a need for themselves. But when their children had needs, things were different.

Before Bet and Erik could bring Zain home, in 2010, they had to show proof of insurance coverage. They got a letter from Samaritan attesting to their membership, and planned to add Zain to their Samaritan coverage once they were back in Illinois. According to its guidelines, Samaritan, like other health care sharing ministries, does not share in costs for “any physical condition which the adopted child has prior to the adopted parent being legally responsible for the child’s expenses.” Essentially, all conditions an adopted child has prior to adoption are considered pre-existing. Had the Olsons adopted a child with Down syndrome, or a neurological disorder, they would have incurred all the costs related to living with that condition.

Luckily, Zain was healthy. But Bet and Erik took him to the doctor for a general checkup when they arrived home, and as a precaution the pediatrician ordered a panel of blood tests recommended for international adoptees by the University of Minnesota. The tests cost around $6,000, a sizeable portion of their annual income, and Erik and Bet set about submitting their need to Samaritan. “God blessed our family by giving us a beautiful boy from Ethiopia!” they wrote on their need processing form to Samaritan. “We had to have some medical testing done. All recommended international adoption medical testing came back normal and healthy. Praise God!”

Samaritan declined to share their need.

“We went to Samaritan Ministries with the need and they said, ‘This is pre-existing,’” Bet said. “We said, ‘What? What do you mean by pre-existing?’” What Samaritan meant is still unclear, because the ministry became fairly unresponsive to the couple in early 2011, when all of this was happening. The only communication the leadership provided was to explain that they would not share this cost, but that Bet and Erik could list it as a “special prayer need” in the monthly newsletter, where members could pray for them and send money if they chose to do so (six or seven people did, Bet said, all less than $50 apiece). Bet and Erik scrambled to get coverage for Zain under Medicaid in Illinois, ending up in an income-based tier where coverage would cost them $70 per month. They were able to negotiate Zain’s bloodwork costs down to about $3,000, and worked out a payment plan with the hospital.

Even through this disruption, the Olsons stayed with Samaritan, both because the price was right (around $350 per month for the two of them) and because they still believed in its mission. Samaritan was “so biblical,” Bet said, “an amazing way to show what the kingdom of God could look like.” But, she said, “it was missing this huge piece.”

For Christians looking for a way to opt out of an expensive health insurance market that they see as profit-driven, intruding on their personal freedom, and indifferent (at best) to issues of abortion and the sanctity of life, health care sharing ministries may seem like the perfect, providential solution. These ministries now legally satisfy the individual mandate of the 2010 Affordable Care Act, and have expanded rapidly since its passage. But there are serious drawbacks lurking below the surface. These ministries’ policies replicate some of the most significant problems with insurance that the ACA was intended to address in the first place, and come with their own unique risks for consumers.

Legally, ministries are not insurance providers, so there are no laws regulating who they must accept as members or which costs they cover — just a social contract between their members. Pre-existing conditions can disqualify someone from membership, while lifetime reimbursement caps and religious restrictions might mean that some members’ medical needs aren’t, in fact, reimbursed. These ministries are, to many, a straightforward blessing: a cheaper alternative to insurance and an extra assurance that their money is not going toward abortions. Many of the members I’ve spoken with are very happy with the care they receive and have found these ministries to be a source of security and community. But for others, like the Olsons, the relationship is not so simple. That’s because the stated Christian mission of these ministries doesn’t always match the reality of what they offer in the face of real, painful need.

Bet and Erik Olson sit down for a snack with their children, Zain and Tess, at their home in Elgin, Illinois.

Alyssa Schukar for BuzzFeed News

Bet and Erik Olson sit down for a snack with their children, Zain and Tess, at their home in Elgin, Illinois.

The health care sharing ministry landscape is dominated by five major players with the largest memberships and highest revenue, spread across the country and across Christian denominations. Samaritan Ministries (in Illinois), Christian Healthcare Ministries (in Ohio), and Medi-Share (in Florida) are the three large evangelical operations. (Dozens of similar ministries exist across the country, mostly smaller and more localized.) Ohio’s Liberty HealthShare is Mennonite, a denomination traditionally committed to pacifism and dialogue. Solidarity HealthShare, founded in 2015, is Catholic, and partnered with another Mennonite aid group in Ohio to be grandfathered into the ACA exemption for sharing ministries, which required that they exist before 1999. All ministries require members to sign statements of faith. Liberty’s is the broadest, and could theoretically be signed by people of varying religious backgrounds, but the others are fairly stringent. Many require regular church attendance, and Samaritan Ministries requires the signature of a pastor or church leader attesting that prospective members meet all requirements.

Each ministry operates slightly differently, but the basic premise remains the same: Every month, members pay a certain amount (their “share”) into the ministry. When a need arises — say you break your leg, or get diagnosed with lung cancer, or have a baby — you submit your bills to the ministry’s office and you receive payments for the total amount you owe, usually in the form of checks or direct deposits from various members. Some ministries hold the funds in an online escrow account; others have members mail their checks directly to the other members. Shares out are published by the ministries each month, so you can see that your $405 is going to, say, Irene in Idaho who recently had a hip replacement.

Most health care sharing ministries were born out of tragedy and frustration with the health care system in the US. Chris Faddis, the cofounder of Solidarity HealthShare, found himself at the end of his rope when his first wife was diagnosed with late-stage colon cancer in 2011. “She was so far into her diagnosis that there was not much that traditional chemo by itself would offer,” he told me. “So we found ourselves in a situation where we had to raise money.”

His connections in the church world helped them raise over $125,000, but the experience left him wondering what less connected people could rely on. “At the end of that I felt like I was supposed to be helping other people find a sustainable way that we can do health care, where people are taking care of each other,” he said. A number of the people I spoke with in reporting this story had turned to online fundraising to cover expenses that traditional insurance wouldn’t take care of, but crowdsourcing health care is the opposite of a sustainable solution. It makes sense, after an experience like Faddis’s, to want to create an entirely new system — although it is worth noting that had his wife been diagnosed and then tried to join Solidarity, her disease would have been considered a pre-existing condition, and she would have been unable to share any of her cancer-related costs.

“Financially, it was the best route for us to go. It seems to me, in some ways, like a really well-kept secret.”

These ministries are attractive to consumers for a number of reasons, but the biggest draw is likely their affordability. The individual health care marketplace can be hard to navigate, and it’s often difficult to get a clear idea of what coverage will cost, although tools like the Kaiser Family Foundation’s Health Insurance Marketplace Calculator seek to make that easier. There, we can see that a young family of five making a combined annual income of $80,000 in Cleveland would pay $608 per month in premiums; the same family making $120,000 in San Francisco would pay $1,450 per month.

Monthly costs for health care sharing ministries vary, but are relatively low: A two-person family pays $440 per month with Samaritan Ministries and a family of three or more pays $495. A Gold membership in Christian Healthcare Ministries costs $450 a month for a family, one dollar more than a family pays for a Complete membershipwith Liberty HealthShare. So, for some families, these ministries represent enormous savings — or seem to. They don’t cover everything traditional insurance would; the cost of prescriptions and preventive care is rarely shared, and lifetime caps mean that sharing won’t go beyond a certain amount per illness, usually between $125,000 and $250,000, unless a member joins a “catastrophic savings” program. Still, the low monthly cost is enormously attractive for most members.

For Becky Boggs, a retired administrative assistant who lives in Lincoln, Illinois, that made all the difference. “Huge savings for us, huge,” she told me. “I wasn’t working and my husband was working at a church and he wasn’t making a ton of money. Financially, it was the best route for us to go. It seems to me, in some ways, like a really well-kept secret.”

These ministries are generally much smaller than the biggest insurance corporations, and operate as nonprofits. Many of the members I spoke with appreciated the fact that their hard-earned money isn’t going to line the pockets of an ultra-wealthy CEO. Samaritan’s CEO, Ted Pittenger, took home just over $184,000 in 2014, the last year for which the ministry’s information is available. Dale Bellis, the executive director of Liberty HealthShare, earned a salary of $110,829 in 2015. Compared with insurance CEOs, that’s a drop in the bucket — in 2015, the CEOs of Aetna and Cigna both earned$17.3 million.

Boggs likes that her monthly Samaritan payment goes directly to the person in need. “My check never goes to Peoria,” she said.

Another big draw for ministries is that they don’t cover abortion or birth control, so members with ethical objections can be certain their money isn’t funding procedures or medication they don’t support. “Are you working and praying for abortion to end while your health insurance company is using your premiums to pay for abortion and abortifacient drugs?” asks one Samaritan Ministries brochure. “Your company’s policies may not mention abortion. They might say ‘women’s services’ or ‘reproductive treatments’ or ‘birth control.’ The result is the same, no matter what they call it.” All five of the major health care sharing ministries — Samaritan, Medi-Share, Christian Healthcare Ministries, Solidarity HealthShare, and Liberty HealthShare — make explicit statements in their promotional material about not sharing in needs related to abortion.

Ultimately, ministry members seem to find value in the human connection of sharing their health care needs with fellow Christians, often in stark contrast to the impersonal nature of traditional insurance. Boggs had to have some testing done for a heart issue, and after submitting her need, she and her husband received notes in the mail along with their checks. “There was a whole family, six kids or so, and the parents had let the kids make a little card. They all drew little pictures on it and signed it. We also get these notes from people that say, ‘Hey, we’re happy to be able to share in your medical need for the month.’”

Brandon Jones, a 38-year-old pastor from rural Herreid, South Dakota, agrees. Jones supplements his income with some online teaching. He and his wife and three children are members of Samaritan Ministries. (They also take in foster children, who are all covered through Medicaid.) It was the personal touch, along with the affordability, that attracted him to Samaritan. “I send checks out each month to people across the nation, hear a little bit about their story, pray for them,” Jones said. “And when we have a need, that’s reciprocated.”

An anti-abortion activist prays outside a Planned Parenthood clinic on February 22, 2016 in Austin, Texas.

Christian Science Monitor / Getty Images

An anti-abortion activist prays outside a Planned Parenthood clinic on February 22, 2016 in Austin, Texas.

Because health care sharing ministries aren’t legally insurance companies, they don’t technically offer “coverage,” instead shifting monies from one member to another to “share” costs. But lobbying efforts earned them protected status under the Affordable Care Act, allowing their members to remain exempt from the individual insurance mandate the ACA established — provided that the ministries existed prior to 1999, underwent annual financial audits, and retained members even after they developed medical conditions. And membership of health care sharing ministries has seen explosive growth since the passage of the ACA in 2010.

Joel Noble, Samaritan Ministries’ director of public policy and the vice president of the Alliance of Health Care Sharing Ministries, told me that its three member ministries (Samaritan Ministries, Medi-Share, and Christian Healthcare Ministries) have a total membership of just under 900,000 individuals, up from about 565,000 in February 2016. Liberty HealthShare has 145,000 members; in 2016, it grew by more than 200%. Medi-Share, the Florida-based ministry, has grown from 35,000 members in 2010 to more than 290,000 members in April 2017.

Samaritan Ministries saw its revenue increase exponentially, from $6.6 million in 2013 to over $34 million in 2015. Liberty HealthShare has seen even greater growth — its revenue was $1.9 million in 2014, shot up to $10.9 million in 2015 and, according to the ministry, exceeded $36 million in the the final 2016 audit.

That’s likely due to a combination of factors: Affordability (compared to plans available on ACA exchanges) has been a big draw for new members, as well as the appeal of belonging to a community that shares similar values. The ACA requires insurers to fully cover some forms of birth control, for example; Christian sharing ministries have no such obligation. Some people simply didn’t like feeling compelled by the government to purchase insurance. In a post about the ACA, one evangelical blogger wrote, “When we do not have the real freedom to choose if or how we want to spend our earnings and care for our own person and family, we are in bondage.” To people who feel similarly, health care sharing ministries present themselves as not only a feasible option, but a desirable alternative.

But there are significant differences between what insurance companies and sharing ministries are legally required to offer consumers. “In general, these arrangements are not regulated as insurance, and they appear to embrace many of the discriminatory practices that health insurers used to employ against sick people and that the Affordable Care Act tried to eliminate,” said Kevin Lucia, a policy analyst and professor at Georgetown’s Center on Health Insurance Reforms. “It appears to me that the health sharing ministries are designed in a way to discriminate against sick people. They typically don’t always cover pre-existing conditions and often have gaps in critical services, such as coverage for mental health services.”

A pre-existing condition was a problem for Tara Owens. A spiritual director in Colorado, Owens suffered a heart attack in April 2010. The next month, her husband lost his job and they were soon left without insurance. “I was not a high-risk patient,” she said. “When I had the heart attack, I exercised every day, I didn’t have high blood pressure or cholesterol, there was no history [of heart conditions] in my family.” She and her husband had heard of health care sharing ministries and applied for membership in Medi-Share. It accepted Owens’ husband, but not her.

“We would love [for] health care sharing ministries to get big enough that pre-existing conditions are no longer an issue.”

Owens eventually got coverage through Colorado’s Rocky Mountain Health Plans, but the experience rankled. “I had the question for this program, ‘Christian how?’” she told me. “In part because they wouldn’t even listen to me; there was no discussion of my case. Which made it feel like another corporate experience, where I’m a number rather than a person.”

A spokesperson for Medi-Share told me that the ministry’s guidelines changed in 2013 (three years after Tara Owens applied), and “pre-existing conditions are no longer a barrier to membership.” But costs associated with pre-existing conditions still may not be shared.

Health care sharing ministries try to keep costs low for their clients, and, according to Solidarity founder Faddis, sharing the costs of pre-existing conditions would be prohibitive. “We would love [for] health care sharing ministries to get big enough that pre-existing conditions are no longer an issue,” he said. But “at this point in the game, that’s almost as lofty a goal as Elon Musk getting to Mars.” Which, Faddis acknowledges, could happen in the not-too-distant future — just not right now.

Ministry members often pay their medical bills out of pocket and wait for reimbursement; they are also encouraged to negotiate discounts with their providers. Bet Olson did this when she was with Samaritan: “I remember saying, ‘We don’t have insurance. Do you have a cash rate?’ Sometimes that would drop [the bill] by, like, two-thirds.” The website for Christian Healthcare Ministries recommends a similar strategy: “Insurance companies regularly negotiate prices and you can, too.” If a patient doesn’t get a discount of at least 40%, Christian Healthcare Ministries recommends working with its patient advocates to coach you.

There is little to no cost sharing for chronic conditions or preventive care. If you are diabetic, for example, you will most likely have to cover the cost of insulin on your own. (The price of insulin, which has to be refrigerated and lasts six months at most, continues to rise, and can be as high as $900 per month.) Visits to physical therapists or occupational therapists are usually capped (for instance, with Medi-Share you can share “up to 20 visits combined per referral”), and mental health is almost never shared.

Jones, the South Dakota pastor, was reluctant to join Samaritan at first. “I’m more of a traditional person,” he said — Jones worked at Blue Cross Blue Shield and Farmers Insurance before he was a pastor — but has been happy with the experience so far. In the last few years, he’s even acted as an ambassador, encouraging others to join if they are struggling to pay insurance premiums. But, Jones said, his family doesn’t always make preventive care — which isn’t covered — a priority. “I’ve had trouble convincing my wife to make the expense” of regular gynecological checkups, he said. “I don’t think she’s really seen a specialist in a few years now.”

And then there’s the question of adoption. Under federal law, insurance companies must treat an adoptive child as a “natural” child from the time he or she is placed with the adoptive parents, and cannot deny coverage because of pre-existing conditions. Health care sharing ministries, however, make their own rules.

Erik Olson gives his daughter, Tess, a high five.

Alyssa Schukar for BuzzFeed News

Erik Olson gives his daughter, Tess, a high five.

As Zain got older, Bet and Erik Olson decided to begin the process of adopting again. In November 2012, almost two years after they went to Ethiopia to meet Zain, they were matched with their daughter, Tess, a vibrant young girl with boundless energy. They met her in April 2013, she turned 2 in May, and they brought her home in June. This time, they knew there would be some challenges: Tess had received conflicting test results in Ethiopia, indicating the possibility of a blood disorder.

Bet and Erik called Samaritan. “We knew what the answer was going to be,” Bet said, “but we just wanted to challenge it again.” As they expected, Samaritan said that it wouldn’t share any needs related to Tess’s bloodwork. Bet and Erik decided to appeal. They wrote an email to the leadership of Samaritan Ministries, asking the organization to reconsider its stance.

“With all of its faults, our government still shows glimmers of compassion,” Bet and Erik wrote. “A law was put into place that made sure adopted children were treated by health care companies without discrimination. A health care company cannot deny coverage to an adopted child that it would have otherwise provided for a biological child.” Later, they wrote, “I find it interesting that you do not want to fall under this law — which I feel is one that protects human rights — but then when it comes to ObamaCare, you want to be considered an exclusion.”

The Olsons also asked Samaritan to consider that to be anti-abortion means to be pro-adoption. “As we become more like Christ, we care more about what he cares about,” they wrote. “I feel he gives us a mandate to care for orphans and widows. It is not an option in the Kingdom of God, but rather a command.”

“With all of its faults, our government still shows glimmers of compassion.”

The command that Erik was referring to is peppered throughout the Bible, most pointedly in James 1:27: “Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world.” Practicing Christians are twice as likely to adopt compared with their secular counterparts. There are no statistics for how many evangelical Christians in the US adopt each year, but since the mid-2000s adoption has been the subject of evangelical conferencesministries, and initiatives designed to “defend the cause of the fatherless,” as a verse from Isaiah says. In fact, the recent “evangelical orphan boom” has been criticized for prioritizing parents’ desires over children’s well-being. Bet and Erik are aware of these criticisms and have worked to understand them. “I have been made more aware of my white privilege,” Bet said. “I want to use that awareness to educate people.”

The number of international adoptions in the United States is declining overall (from 19,601 in 2007 to just 5,370 in 2016) as other countries increase regulations, but the Christian interest in adoption is going strong. And while each family is different, it seems likely that the Olsons are far from the only parents in the US who might find that the medical care their adopted children need isn’t considered essential by their Christian health care sharing ministry.

Tess, with her special needs, would require some care that Zain had not, and Bet and Erik felt it was incumbent on them to encourage Samaritan to raise its standards. “Her name is Tesfa,” Bet said. “That’s the Amharic word for ‘hope.’ There’s no hope in saying, ‘But not special needs.’ That’s where most hope is needed.”

The Olsons were told that their letter would be passed along “to higher leadership” at Samaritan. After that response, they waited, but didn’t hear back from anyone else. “It was crickets,” said Bet. “They never did give us an answer.” (Samaritan declined requests to comment for this article.)

Former President Barack Obama signs the Affordable Care Act on March 23, 2010.

Andrew Harrer / Bloomberg / Getty Images

Former President Barack Obama signs the Affordable Care Act on March 23, 2010.

Health care sharing ministries remained in business after the implementation of the Affordable Care Act only because of extensive lobbying by two groups that work on their behalf: the Alliance of Health Care Sharing Ministries and the National Coalition of Health Care Sharing Ministries. These organizations spend hundreds of thousands of dollars annually, seeking to “return health care to a private, patient-centered model,” as the Alliance’s website puts it.

The authors of the Affordable Care Act weren’t keen to make an exception for these ministries, but they knew that if they didn’t, they would be putting the bill at risk. “It would have been none of our choices,” said John McDonough, a professor of the practice of public health at Harvard and former adviser to Sen. Ted Kennedy, who worked on the development of the ACA. “But with all the disruption and opposition to the legislation, we were also concerned about the public response and impact on wavering Democratic senators if this became a public controversy, which seemed more than possible.” So the ministries were written into the ACA, with their members exempt from having to pay the tax penalties associated with the individual mandate.

Aware of their unique position in the health care landscape, these ministries continue to think about how to protect themselves from meddling regulations, and that involves a robust public relations effort. Deborah Hamilton, who heads Hamilton Strategies, the public relations firm that represents Samaritan Ministries, declined to arrange an interview after asking me via email whether this would be a “positive” article, and then told me that she did not think BuzzFeed News would be a “strategic media outlet” for Samaritan.

I did speak with Jon Watts, a former member services advocate at Samaritan Ministries who is now a student pastor at Crosspoint Community Church in Eureka, Illinois. He loved his time working for Samaritan, which he describes as “a phenomenal place to work” with people who came from “a wide variety of evangelical backgrounds.” For Watts, Samaritan was “a place to be challenged to grow in your faith around other people who are also pursuing Jesus with you,” where he could talk about theology on his lunch break. Watts would occasionally mediate difficult situations, like instructing a member about what to do if a check bounced or what to do if someone was late in sending in a share (usually, wait on another member’s check to come in).

What the AHCA would mean for sharing ministries remains uncertain — and it might not be good.

With the ongoing GOP effort to repeal and replacethe Affordable Care Act, these ministries are once again concerned for their futures. In March, before the Republican American Health Care Act passed the House, Liberty HealthShare encouraged members to contact their representatives and ask for protections for health care sharing ministries: “[W]e are asking for the continued freedom to make health care decisions based on our needs and values,” part of the provided script read. Sharing ministries might seem like an appealingly stable alternative to traditional insurance coverage, as legislation is up in the air, but what the AHCA or other changes to health care policy would mean for them remains uncertain — and it might not be good.

“The American Health Care Act basically eliminates the individual mandate, the very requirement that likely made it much easier for health sharing ministries to pitch their cheaper but skimpier and discriminatory plans to consumers,” Lucia, the Georgetown professor, said. The membership growth that these ministries have seen in recent years could be stalled if the Republican health plan goes forward, according to Lucia, “because under the AHCA consumers won’t have to be covered at all, and the market will likely be flooded with plans that are similar to those being marketed by health care sharing ministries.”

There’s some irony in all of this. Most social conservatives and many Christian organizations are united against the Affordable Care Act: Richard Land, while president of the Southern Baptist Convention’s Ethics and Religious Liberty Commission, said that Obamacare was written by “ideologues” who represent “the greatest threat to religious freedom in America.” But the ACA has allowed Christian health care sharing ministries to flourish, and it could be that the Trump-backed AHCA is the thing that will cause them to falter.

Still, ministry leaders have confidence in their continued survival. Samaritan Ministries spokesman Anthony Hopp said in a recent interview with Christianity Today, “Health care sharing ministries existed before the ACA, God willing, they thrived during the ACA, and they will survive after.”

As nonprofits, these ministries aren’t holding on to vast reserves of cash, meaning they have less financial and political clout to throw around compared to big insurance companies — and leaving much less cushion between members and the ministry’s bottom line, should anything go wrong. Which does happen.

Some ministries have had solvency issues because of clear-cut financial mismanagement. Christian Brotherhood Newsletter, a health care sharing ministry based in Ohio, found itself at the center of a scandal in 2001 when its founder Bruce Hawthorn was found to have stolen over $700,000 from CBN’s coffers to pay for cars, real estate, an airplane, and the credit card payments of an exotic dancer. Members sued, saying that Hawthorn’s alleged theft resulted in payment delays of up to 18 months and millions of dollars — as much as $34 million — in unpaid needs. Hawthorn and others were eventually required to repay $15 million in money taken from the funds where members had sent in their payments.

Scandals like this are rare, but some state regulators consider the basic premise of health care sharing ministries misleading, and have tried (and mostly failed) to exercise oversight. In 2007, the state of Oklahoma issued a cease-and-desist order against Medi-Share, claiming that it was indistinguishable from traditional insurance: “If it looks like a rose and smells like a rose, then it’s a rose,” said Kim Holland, then Oklahoma’s insurance commissioner. The state passed a bill in 2008 that allowed Medi-Share to resume operations, but a number of Medi-Share members faced trouble nonetheless.

Karen Niles, a homemaker from Blackwell, Oklahoma, saw her brain tumor returnduring this period of time and was told by Medi-Share that it wouldn’t be able to share in any of her expenses. (The ministry had previously shared about $450,000 worth of needs related to Niles’ condition.) Niles and her husband, Robert, claimed that Medi-Share couldn’t pay because it didn’t have enough money; Medi-Share maintained that it couldn’t share her expenses because the ministry was told it couldn’t operate in Oklahoma. The Oklahoma Insurance Department said there was nothing stoppingMedi-Share from facilitating payments in the state. The Nileses and Medi-Share underwent a binding arbitration process, which ruled in favor of Medi-Share. Karen Niles died in 2011.

Every state in the US has a department that regulates insurance, but state policies on health care sharing ministries vary widely, if they exist at all. Insurance commissioners in Washington and Kentucky, as well as in Oklahoma, have all tried at different times to stop certain ministries from operating within their state borders, on the grounds that they are actually insurance companies and should be regulated as such. But in each case, the ministries were given exemptions by state legislatures that saw the issue as one of religious freedom.

In recent years, health care sharing ministries have worked with the conservative legislative forum the American Legislative Exchange Council to prevent the same back-and-forth from playing out in other states. ALEC offers legislators a model exemption bill that argues that “the regulatory requirements of insurance, if imposed on HCSMs, would destroy the voluntary, ministerial nature of the organizations.” As of the last amendment, in 2011, 11 states had safe-harbor exemptions for health care sharing ministries. As of last year, 30 do.

At the heart of the debate is the question of how health care sharing ministries differ from traditional insurance, and, ultimately, what the consequences of those differences are. Health care sharing ministries are legally required to disclose the fact that they are not insurance. Which is fine, but to hear them tell it, theirs is still the superior product. In its prospective members packet, Samaritan Ministries includes a glowing letter of recommendation from one couple: “We became aware of Samaritan Ministries in 2001 or 2002, but continued to play the juggling game with the insurance industry due to our lack of faith/trust in God’s provision through Samaritan.”

The letter goes on: “I would recommend this over EVERY ‘insurance’ product out there. Traditional ‘insurance’ has no assurances. In fact, everything is written in such a way that there is no assurance at the bottom line. We just wish that we had trusted in His provisions sooner.”

Just a few pages later in the membership application, though, is this proviso:

Samaritan Ministries and its members assume no responsibility for your medical bills. Whether you receive any share money to help you with your medical needs will depend on the voluntary giving of your fellow members as an expression of Christian love, but no matter how much money you receive, you always remain solely responsible for payment of your own medical bills.

The Affordable Care Act was written in part to ban certain discriminatory practices that led to people being denied insurance coverage. But health care sharing ministries have retained the right to discriminate, either by not sharing certain costs or by requiring more of certain members they deem unfit. For example, health care sharing ministries uniformly refuse to share costs related to self-inflicted injuries or suicide attempts — an issue that has also plagued traditional insurance companies, despite a health care privacy law requiring them to do so. Nor will they share needs related to fertility treatments, contraception, or, in some cases, injuries related to acts of war.

Several ministry plans have special tracks for overweight members, requiring them to meet regularly with coaches, as with Medi-Share’s Health Partner program: “If a Member experiences significant weight gain, he or she will be required to participate as a Health Partner.” The Medi-Share guidelines for Health Partners adds that “by reversing and/or preventing certain diseases, people are able to live healthier and fuller lives, ultimately being able to do more work for the Kingdom of God.”

Even if health care sharing ministries are very good for (most of) their members, ultimately they make it more difficult for traditional insurance plans under the ACA to flourish. “When you have a system like the ACA marketplace that covers everyone with robust coverage, regardless of their gender, age, or health status, what you don’t want is any seepage from that pool of risk,” said Lucia, the professor. “When healthy people leave the marketplace for cheap and skimpy coverage, it drives up premiums for everyone left behind.” (The current AHCA bill, which would allow healthy people to leave their community pools of coverage for less expensive plans, would essentially write a version of that seepage into law.)

They may divert resources from the most vulnerable, and undermine the common good for the well-being of the devout few.

Most ministries have lifetime caps on the amount of money they’ll share per illness. For example, at Christian Healthcare Ministries, there is a $125,000 lifetime limit per diagnosis. (If you enroll in the Brother’s Keeper “catastrophic bills program,” you can pay more into the program each quarter and share costs over that amount, although there is no guarantee that all your costs will be shared.) A cancer diagnosis or complications with the delivery of a child can result in bills well over that standard lifetime limit, leaving members on the hook and in search of an insurance program that will help them out. And since insurance companies can no longer discriminate against sick people, they must accept whatever patients come back to them from these ministries — now with more serious and more expensive conditions.

This question of seepage is also, in a way, a question about the fundamental nature of health care sharing ministries. These ministries want Christians to “bear one another’s burdens,” but in practice they may divert resources from the most vulnerable, and undermine the common good for the well-being of the devout few.

Insurance is far from perfect — unwieldy, expensive, and often byzantine in its structure. Disputes are common and there is no guarantee of fairness. Yet the contract involved with insurance exists to protect consumers. In signing up for health care sharing ministries, those consumers are legally agreeing to be financially responsible for all of their own medical bills, while hoping that their community of Christians won’t leave them in a desperate situation. A popular saying in evangelical churches is that everyone — even atheists — has faith. It’s what we put our faith in that differs.

Left, protestors in New York, Jan. 2017. Right, protestors demonstrate at a health care rally in Philadelphia, Feb. 2017.

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Left, protestors in New York, Jan. 2017. Right, protestors demonstrate at a health care rally in Philadelphia, Feb. 2017.

Insurance companies deal in a strange collision of the ethics of capitalism, compassion, and cronyism, in a manner that often makes it difficult for the sickest people to get the money they need for care. Customers who take out more money than they put in — to pay for surgery, chemo, radiation, or hospice care, perhaps — are a drain on their system. So as insurance companies allocate resources, they are also making statements about which patients, and which conditions, are worth coverage, and which aren’t — in effect enacting a system of values.

Health care sharing ministries also enact values, and they exist in large part because one or two Christian individuals were moved to put their faith into action in new ways. Most ministries cite the same Bible verses as foundational to their existence: Acts 2 and Galatians 6. Acts 2 describes the life of the early church, just after Jesus’s death and resurrection: “All the believers were together and had everything in common. They sold property and possessions to give to anyone who had need.” And in Galatians, the Apostle Paul encouraged Christians to “carry each other’s burdens, and in this way you will fulfill the law of Christ.”

Jesus, after all, never asked about pre-existing conditions.

The Christian faith has a long history of caring for the health of the most vulnerable, following Jesus’s example of healing many of the outcasts of his day — the blind, the lame, lepers — as well as children. For some, like the Daughters of Charity of Saint Vincent de Paul, the mandate to care for “the least of these” meant they offered health care for orphaned children in New York during crises of public health. The Catholic Church is currently one of the largest, if not thelargest, private providers of health care in the US, with nearly 650 hospitals across the country. But truly universal health care is often lost in translation, with each sect offering care to those it deems worthy due to practical considerations, and by its own subjective standards. Are we holding sharing ministries to the standards of a Christian organization, or are we holding them to the standards of other health insurers? And when they incorporate parts of both, how should this new space be regulated? What does it mean to be a “Christian” organization, anyway?

Faddis, the Solidarity HealthShare cofounder, told me that some Catholic bishops encouraged him to expand Solidarity’s sharing into mental health treatment, which it will begin to do this year, offering to share up to seven therapy sessions. “We’re all trying to be as generous as we can,” Faddis said of his sharing ministry colleagues. “We want to say, ‘Bring everyone.’ But in being practical and good stewards, we have to consider” financial limits.

Radical inclusivity is a noble and biblical ideal for Christian organizations to work toward. But, as Molly Worthen pointed out in her 2015 New York Times op-ed about health sharing ministries, they don’t resemble Jesus’s healing ministry so much as they do the mutual aid societies that flourished during (and since) the Gilded Age. Jesus, after all, never asked about pre-existing conditions.

No organization that claims to be Christian can ever fulfill everyone’s idea of what that should look like. If the conversations I’ve had over the last four months are any indication, sharing ministries’ constituents are generally very pleased with the care they receive. That may be enough. However, there are Christian values that can seem at odds with one another. When they collide, the results can be messy, denying care for people who have violated some tenet of Christianity — real or perceived.

All five of the big ministries require their members to sign a statement of faith; some, like Samaritan and Medi-Share, require that members agree to reserve sex for lifelong marriage between a man and a woman. They won’t share treatment costs for STDs unless it can be proven that they were acquired “innocently,” i.e., through a blood transfusion or sex within marriage.

These prohibitions may lead young adults to commit one sin (lying) to cover up another, just to stay on their parents’ plan. That was the case for Sarah (not her real name), a pastor’s daughter in a small town in Kansas. Sarah, who just graduated from high school and will head to college in the fall, got a letter from Medi-Share around the time of her 18th birthday that asked her to agree to the ministry’s “lifestyle agreement” in order to remain included in her parents’ plan.

“I’m grateful to have Medi-Share, but I want birth control so I don’t end up a teen mom.”

One of the three primary “biblical standards” Medi-Share requires for eligibility is “No sex outside of traditional Christian marriage” — but Sarah has been having sex with her boyfriend for the last few months. Sarah didn’t feel like she could talk to her mother about it, so her older sister took her to get birth control — an implant in her arm — in another city. “I’m still a Christian,” Sarah said. “I’m grateful to have Medi-Share, but I want birth control so I don’t end up a teen mom.”

If she did, she and her boyfriend would be on their own; many evangelical sharing ministries, including Medi-Share, won’t share in maternity costs for unwed mothers. (Solidarity and Liberty HealthShares both share costs for unwed mothers.)

“There are times even in the Christian community that unwed women become pregnant,” read the Christian Healthcare Ministries guidelines. “Christian Healthcare Ministries members have agreed not to share medical bills for pregnancies of unwed mothers. Instead, Christian Healthcare Ministries recognizes that in such circumstances the assistance needed goes far beyond financial aid. Therefore, we encourage you to seek help from a compassionate, Christian pregnancy center if you find yourself in this situation…You are in our prayers.”

Medi-Share has the same policy, with the stated exception that it will publish costs related to such a pregnancy if it is the result of a rape, but only if the rape is “reported to a law enforcement authority.” There are, of course, many reasons women choose not to report rape to law enforcement, including that they often feel revictimized in the process. But the choice not to do so would mean that they would have to shoulder the entire cost of their prenatal care and delivery, which in most hospitals generally runs into tens of thousands of dollars.

I asked a representative of Christian Healthcare Ministries how they would respond to a difficult situation in which, say, a member was raped and needed assistance with maternity expenses. “For things outside the control of our members, we will look at it individually and with an attitude of mercy,” said Lauren Gajdek, Christian Healthcare Ministries’ communications director. “CHM would support someone who was raped and pregnant. We are a ministry. The criminal would be held accountable to the extent of the law and CHM would coordinate with the family and all applicable resources to assist the victim.”

But the messiness of any system that determines worthiness on a case-by-case basis becomes apparent fairly quickly, and makes for some strange rules for women in vulnerable positions. Samaritan Ministries refuses to share costs related to ectopic pregnancies, which occur when the fertilized egg attaches itself somewhere outside of the uterus, usually in the fallopian tubes. Ectopic pregnancies can almost never go full term, and women who have them often require emergency surgery to remove the embryo in order to save their own lives, which can cost upwards of $15,000. Yet in its guidelines, Samaritan Ministries clarifies that “considerations of the health or life of the mother does not change that the removal of a living unborn child from the mother may be a termination of life.”

Bet and Erik Olson walk home with their children.

Alyssa Schukar for BuzzFeed News

Bet and Erik Olson walk home with their children.

While I spoke with the Olsons in their kitchen in Illinois, Tess was upstairs playing with her brother. But she knew our time was almost up, and I had promised to play a game with her before I left. She ran into the living room and, having a hard time deciding on a game, made up her mind to dance instead. Her mom played a clean version of “Uptown Funk” (Sample lyric: “Fill my cup, put some water in it”) as Tess did the splits, jumped, and shook her hips.

Even though Samaritan wouldn’t cover the medical tests Zain and Tess needed when they were adopted, everything turned out okay for the Olson family. Erik had just started a new job when they brought Tess home, as vice president of Dignity Coconuts, a community formation organization that works primarily in the Philippines. Through Dignity, the Olsons were all able to get health care coverage, including coverage for a regular medication that Tess takes. They are a healthy, energetic family of four, with homework to do and errands to run and hockey games to go to.

As long as potential changes to US health care policy — and the fate of the health insurance laws and marketplaces we do have — remain unsettled, the only thing that’s clear is that no one’s future is certain. Christian health care sharing ministries will continue to lobby for their special position, and consumers will continue to look for the best way to save money while taking care of their families. Faith, in every sense of the word, will be required for everyone involved — faith that the government will keep loopholes open; faith that fellow Christians will send their checks every month; faith that God will provide. And the Olsons, despite leaving Samaritan, still have faith.

“Erik and I both have a heart to say we really believe in what Samaritan does, and think there are a lot of good things,” Bet said. “I just want them to rethink and really think about why they’re doing it that way.” ●

Oliver Munday for BuzzFeed News

How Over A Million Christians Have Opted Out Of Health Insurance

For a growing number of Christians in the US, faith-based health care sharing ministries seem like the perfect alternative to an expensive, volatile insurance marketplace. But there may be serious drawbacks for some members — and for everyone else.

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Bet Olson was 16 years old when she realized she wanted to adopt a child someday. Bet, who was raised in a Christian family outside Chicago, was attending a youth group service at Willow Creek Community Church, a megachurch in South Barrington, Illinois. A young man started to talk about adoption. “He talked about how the story that God has for his people is to adopt them as his own,” Bet recalls. “That this is God’s character, to bring love and redemption. He talked about how he was adopted and what a difference that made in his life. I soaked up every word.”

Nearly 20 years later, Bet and her husband, Erik, live in a small green house on a quiet road in Elgin, Illinois. When I visited, it was early March, that time of year in the Midwest when you can wake up to a 70-degree day or to snow. This day was somewhere in between — overcast and in the low 40s. The Olsons’ children, Zain, 7, and Tesfa, 6 — Tess for short — had just gotten home from school and were playing in the sunroom at the front of the house. Tess was talking about her kindergarten class, where she had just been named Kid of the Week. “That means everyone’s going to say good things about me!” she said.

Bet and Erik adopted Zain and Tess from Ethiopia. “People kept telling me I would change my mind” about adoption, Bet said. “And I just said no. I felt so strongly that this was my calling.”

Bet and Erik began the process of international adoption in 2008, after three years of marriage. Following a home study and over a year of waiting, they were matched with Zain in August 2010. “For the longest time we had two pictures, and we would just look at those two pictures and we just fell in love with this kid,” Erik said. They flew to Ethiopia in November 2010 to meet Zain, and then waited six weeks in Addis Ababa for all the visa paperwork to go through in the US before they were allowed to bring him home, when he was 7 months old. They came back just before Christmas as a family.

Being adopted was akin to a pre-existing condition.

But there were complications ahead. Because the Olsons were members of a Christian health care sharing ministry, rather than a traditional insurance plan, some of Zain’s health care costs wouldn’t be covered the way a biological child’s would. Being adopted was akin to a pre-existing condition.

Since 2007, Bet and Erik had been members of Samaritan Ministries, one of a number of Christian health care sharing ministries in the US that take the place of traditional health insurance by pooling and redistributing members’ money each month. They joined when they were both working for a Christian nonprofit founded by Bet’s dad, where they had to personally raise funds from donors to cover their own salaries. Raising more than that to pay for insurance through the organization as well would have been a burden, so they started to look for creative solutions.

Some of their friends from church recommended Samaritan, which is based in Peoria; Bet and Erik looked into it, liked what they saw, and joined. “I love the idea of sharing each other’s burdens and helping each other out,” Erik said. And up to a point, Samaritan worked for the Olsons. Each month they wrote checks to the name Samaritan sent them. Sometimes they prayed for the recipient; sometimes they forgot. Outside of an incident where Erik broke his toe, Bet and Erik never submitted a need for themselves. But when their children had needs, things were different.

Before Bet and Erik could bring Zain home, in 2010, they had to show proof of insurance coverage. They got a letter from Samaritan attesting to their membership, and planned to add Zain to their Samaritan coverage once they were back in Illinois. According to its guidelines, Samaritan, like other health care sharing ministries, does not share in costs for “any physical condition which the adopted child has prior to the adopted parent being legally responsible for the child’s expenses.” Essentially, all conditions an adopted child has prior to adoption are considered pre-existing. Had the Olsons adopted a child with Down syndrome, or a neurological disorder, they would have incurred all the costs related to living with that condition.

Luckily, Zain was healthy. But Bet and Erik took him to the doctor for a general checkup when they arrived home, and as a precaution the pediatrician ordered a panel of blood tests recommended for international adoptees by the University of Minnesota. The tests cost around $6,000, a sizeable portion of their annual income, and Erik and Bet set about submitting their need to Samaritan. “God blessed our family by giving us a beautiful boy from Ethiopia!” they wrote on their need processing form to Samaritan. “We had to have some medical testing done. All recommended international adoption medical testing came back normal and healthy. Praise God!”

Samaritan declined to share their need.

“We went to Samaritan Ministries with the need and they said, ‘This is pre-existing,’” Bet said. “We said, ‘What? What do you mean by pre-existing?’” What Samaritan meant is still unclear, because the ministry became fairly unresponsive to the couple in early 2011, when all of this was happening. The only communication the leadership provided was to explain that they would not share this cost, but that Bet and Erik could list it as a “special prayer need” in the monthly newsletter, where members could pray for them and send money if they chose to do so (six or seven people did, Bet said, all less than $50 apiece). Bet and Erik scrambled to get coverage for Zain under Medicaid in Illinois, ending up in an income-based tier where coverage would cost them $70 per month. They were able to negotiate Zain’s bloodwork costs down to about $3,000, and worked out a payment plan with the hospital.

Even through this disruption, the Olsons stayed with Samaritan, both because the price was right (around $350 per month for the two of them) and because they still believed in its mission. Samaritan was “so biblical,” Bet said, “an amazing way to show what the kingdom of God could look like.” But, she said, “it was missing this huge piece.”

For Christians looking for a way to opt out of an expensive health insurance market that they see as profit-driven, intruding on their personal freedom, and indifferent (at best) to issues of abortion and the sanctity of life, health care sharing ministries may seem like the perfect, providential solution. These ministries now legally satisfy the individual mandate of the 2010 Affordable Care Act, and have expanded rapidly since its passage. But there are serious drawbacks lurking below the surface. These ministries’ policies replicate some of the most significant problems with insurance that the ACA was intended to address in the first place, and come with their own unique risks for consumers.

Legally, ministries are not insurance providers, so there are no laws regulating who they must accept as members or which costs they cover — just a social contract between their members. Pre-existing conditions can disqualify someone from membership, while lifetime reimbursement caps and religious restrictions might mean that some members’ medical needs aren’t, in fact, reimbursed. These ministries are, to many, a straightforward blessing: a cheaper alternative to insurance and an extra assurance that their money is not going toward abortions. Many of the members I’ve spoken with are very happy with the care they receive and have found these ministries to be a source of security and community. But for others, like the Olsons, the relationship is not so simple. That’s because the stated Christian mission of these ministries doesn’t always match the reality of what they offer in the face of real, painful need.

Bet and Erik Olson sit down for a snack with their children, Zain and Tess, at their home in Elgin, Illinois.

Alyssa Schukar for BuzzFeed News

Bet and Erik Olson sit down for a snack with their children, Zain and Tess, at their home in Elgin, Illinois.

The health care sharing ministry landscape is dominated by five major players with the largest memberships and highest revenue, spread across the country and across Christian denominations. Samaritan Ministries (in Illinois), Christian Healthcare Ministries (in Ohio), and Medi-Share (in Florida) are the three large evangelical operations. (Dozens of similar ministries exist across the country, mostly smaller and more localized.) Ohio’s Liberty HealthShare is Mennonite, a denomination traditionally committed to pacifism and dialogue. Solidarity HealthShare, founded in 2015, is Catholic, and partnered with another Mennonite aid group in Ohio to be grandfathered into the ACA exemption for sharing ministries, which required that they exist before 1999. All ministries require members to sign statements of faith. Liberty’s is the broadest, and could theoretically be signed by people of varying religious backgrounds, but the others are fairly stringent. Many require regular church attendance, and Samaritan Ministries requires the signature of a pastor or church leader attesting that prospective members meet all requirements.

Each ministry operates slightly differently, but the basic premise remains the same: Every month, members pay a certain amount (their “share”) into the ministry. When a need arises — say you break your leg, or get diagnosed with lung cancer, or have a baby — you submit your bills to the ministry’s office and you receive payments for the total amount you owe, usually in the form of checks or direct deposits from various members. Some ministries hold the funds in an online escrow account; others have members mail their checks directly to the other members. Shares out are published by the ministries each month, so you can see that your $405 is going to, say, Irene in Idaho who recently had a hip replacement.

Most health care sharing ministries were born out of tragedy and frustration with the health care system in the US. Chris Faddis, the cofounder of Solidarity HealthShare, found himself at the end of his rope when his first wife was diagnosed with late-stage colon cancer in 2011. “She was so far into her diagnosis that there was not much that traditional chemo by itself would offer,” he told me. “So we found ourselves in a situation where we had to raise money.”

His connections in the church world helped them raise over $125,000, but the experience left him wondering what less connected people could rely on. “At the end of that I felt like I was supposed to be helping other people find a sustainable way that we can do health care, where people are taking care of each other,” he said. A number of the people I spoke with in reporting this story had turned to online fundraising to cover expenses that traditional insurance wouldn’t take care of, but crowdsourcing health care is the opposite of a sustainable solution. It makes sense, after an experience like Faddis’s, to want to create an entirely new system — although it is worth noting that had his wife been diagnosed and then tried to join Solidarity, her disease would have been considered a pre-existing condition, and she would have been unable to share any of her cancer-related costs.

“Financially, it was the best route for us to go. It seems to me, in some ways, like a really well-kept secret.”

These ministries are attractive to consumers for a number of reasons, but the biggest draw is likely their affordability. The individual health care marketplace can be hard to navigate, and it’s often difficult to get a clear idea of what coverage will cost, although tools like the Kaiser Family Foundation’s Health Insurance Marketplace Calculator seek to make that easier. There, we can see that a young family of five making a combined annual income of $80,000 in Cleveland would pay $608 per month in premiums; the same family making $120,000 in San Francisco would pay $1,450 per month.

Monthly costs for health care sharing ministries vary, but are relatively low: A two-person family pays $440 per month with Samaritan Ministries and a family of three or more pays $495. A Gold membership in Christian Healthcare Ministries costs $450 a month for a family, one dollar more than a family pays for a Complete membershipwith Liberty HealthShare. So, for some families, these ministries represent enormous savings — or seem to. They don’t cover everything traditional insurance would; the cost of prescriptions and preventive care is rarely shared, and lifetime caps mean that sharing won’t go beyond a certain amount per illness, usually between $125,000 and $250,000, unless a member joins a “catastrophic savings” program. Still, the low monthly cost is enormously attractive for most members.

For Becky Boggs, a retired administrative assistant who lives in Lincoln, Illinois, that made all the difference. “Huge savings for us, huge,” she told me. “I wasn’t working and my husband was working at a church and he wasn’t making a ton of money. Financially, it was the best route for us to go. It seems to me, in some ways, like a really well-kept secret.”

These ministries are generally much smaller than the biggest insurance corporations, and operate as nonprofits. Many of the members I spoke with appreciated the fact that their hard-earned money isn’t going to line the pockets of an ultra-wealthy CEO. Samaritan’s CEO, Ted Pittenger, took home just over $184,000 in 2014, the last year for which the ministry’s information is available. Dale Bellis, the executive director of Liberty HealthShare, earned a salary of $110,829 in 2015. Compared with insurance CEOs, that’s a drop in the bucket — in 2015, the CEOs of Aetna and Cigna both earned$17.3 million.

Boggs likes that her monthly Samaritan payment goes directly to the person in need. “My check never goes to Peoria,” she said.

Another big draw for ministries is that they don’t cover abortion or birth control, so members with ethical objections can be certain their money isn’t funding procedures or medication they don’t support. “Are you working and praying for abortion to end while your health insurance company is using your premiums to pay for abortion and abortifacient drugs?” asks one Samaritan Ministries brochure. “Your company’s policies may not mention abortion. They might say ‘women’s services’ or ‘reproductive treatments’ or ‘birth control.’ The result is the same, no matter what they call it.” All five of the major health care sharing ministries — Samaritan, Medi-Share, Christian Healthcare Ministries, Solidarity HealthShare, and Liberty HealthShare — make explicit statements in their promotional material about not sharing in needs related to abortion.

Ultimately, ministry members seem to find value in the human connection of sharing their health care needs with fellow Christians, often in stark contrast to the impersonal nature of traditional insurance. Boggs had to have some testing done for a heart issue, and after submitting her need, she and her husband received notes in the mail along with their checks. “There was a whole family, six kids or so, and the parents had let the kids make a little card. They all drew little pictures on it and signed it. We also get these notes from people that say, ‘Hey, we’re happy to be able to share in your medical need for the month.’”

Brandon Jones, a 38-year-old pastor from rural Herreid, South Dakota, agrees. Jones supplements his income with some online teaching. He and his wife and three children are members of Samaritan Ministries. (They also take in foster children, who are all covered through Medicaid.) It was the personal touch, along with the affordability, that attracted him to Samaritan. “I send checks out each month to people across the nation, hear a little bit about their story, pray for them,” Jones said. “And when we have a need, that’s reciprocated.”

An anti-abortion activist prays outside a Planned Parenthood clinic on February 22, 2016 in Austin, Texas.

Christian Science Monitor / Getty Images

An anti-abortion activist prays outside a Planned Parenthood clinic on February 22, 2016 in Austin, Texas.

Because health care sharing ministries aren’t legally insurance companies, they don’t technically offer “coverage,” instead shifting monies from one member to another to “share” costs. But lobbying efforts earned them protected status under the Affordable Care Act, allowing their members to remain exempt from the individual insurance mandate the ACA established — provided that the ministries existed prior to 1999, underwent annual financial audits, and retained members even after they developed medical conditions. And membership of health care sharing ministries has seen explosive growth since the passage of the ACA in 2010.

Joel Noble, Samaritan Ministries’ director of public policy and the vice president of the Alliance of Health Care Sharing Ministries, told me that its three member ministries (Samaritan Ministries, Medi-Share, and Christian Healthcare Ministries) have a total membership of just under 900,000 individuals, up from about 565,000 in February 2016. Liberty HealthShare has 145,000 members; in 2016, it grew by more than 200%. Medi-Share, the Florida-based ministry, has grown from 35,000 members in 2010 to more than 290,000 members in April 2017.

Samaritan Ministries saw its revenue increase exponentially, from $6.6 million in 2013 to over $34 million in 2015. Liberty HealthShare has seen even greater growth — its revenue was $1.9 million in 2014, shot up to $10.9 million in 2015 and, according to the ministry, exceeded $36 million in the the final 2016 audit.

That’s likely due to a combination of factors: Affordability (compared to plans available on ACA exchanges) has been a big draw for new members, as well as the appeal of belonging to a community that shares similar values. The ACA requires insurers to fully cover some forms of birth control, for example; Christian sharing ministries have no such obligation. Some people simply didn’t like feeling compelled by the government to purchase insurance. In a post about the ACA, one evangelical blogger wrote, “When we do not have the real freedom to choose if or how we want to spend our earnings and care for our own person and family, we are in bondage.” To people who feel similarly, health care sharing ministries present themselves as not only a feasible option, but a desirable alternative.

But there are significant differences between what insurance companies and sharing ministries are legally required to offer consumers. “In general, these arrangements are not regulated as insurance, and they appear to embrace many of the discriminatory practices that health insurers used to employ against sick people and that the Affordable Care Act tried to eliminate,” said Kevin Lucia, a policy analyst and professor at Georgetown’s Center on Health Insurance Reforms. “It appears to me that the health sharing ministries are designed in a way to discriminate against sick people. They typically don’t always cover pre-existing conditions and often have gaps in critical services, such as coverage for mental health services.”

A pre-existing condition was a problem for Tara Owens. A spiritual director in Colorado, Owens suffered a heart attack in April 2010. The next month, her husband lost his job and they were soon left without insurance. “I was not a high-risk patient,” she said. “When I had the heart attack, I exercised every day, I didn’t have high blood pressure or cholesterol, there was no history [of heart conditions] in my family.” She and her husband had heard of health care sharing ministries and applied for membership in Medi-Share. It accepted Owens’ husband, but not her.

“We would love [for] health care sharing ministries to get big enough that pre-existing conditions are no longer an issue.”

Owens eventually got coverage through Colorado’s Rocky Mountain Health Plans, but the experience rankled. “I had the question for this program, ‘Christian how?’” she told me. “In part because they wouldn’t even listen to me; there was no discussion of my case. Which made it feel like another corporate experience, where I’m a number rather than a person.”

A spokesperson for Medi-Share told me that the ministry’s guidelines changed in 2013 (three years after Tara Owens applied), and “pre-existing conditions are no longer a barrier to membership.” But costs associated with pre-existing conditions still may not be shared.

Health care sharing ministries try to keep costs low for their clients, and, according to Solidarity founder Faddis, sharing the costs of pre-existing conditions would be prohibitive. “We would love [for] health care sharing ministries to get big enough that pre-existing conditions are no longer an issue,” he said. But “at this point in the game, that’s almost as lofty a goal as Elon Musk getting to Mars.” Which, Faddis acknowledges, could happen in the not-too-distant future — just not right now.

Ministry members often pay their medical bills out of pocket and wait for reimbursement; they are also encouraged to negotiate discounts with their providers. Bet Olson did this when she was with Samaritan: “I remember saying, ‘We don’t have insurance. Do you have a cash rate?’ Sometimes that would drop [the bill] by, like, two-thirds.” The website for Christian Healthcare Ministries recommends a similar strategy: “Insurance companies regularly negotiate prices and you can, too.” If a patient doesn’t get a discount of at least 40%, Christian Healthcare Ministries recommends working with its patient advocates to coach you.

There is little to no cost sharing for chronic conditions or preventive care. If you are diabetic, for example, you will most likely have to cover the cost of insulin on your own. (The price of insulin, which has to be refrigerated and lasts six months at most, continues to rise, and can be as high as $900 per month.) Visits to physical therapists or occupational therapists are usually capped (for instance, with Medi-Share you can share “up to 20 visits combined per referral”), and mental health is almost never shared.

Jones, the South Dakota pastor, was reluctant to join Samaritan at first. “I’m more of a traditional person,” he said — Jones worked at Blue Cross Blue Shield and Farmers Insurance before he was a pastor — but has been happy with the experience so far. In the last few years, he’s even acted as an ambassador, encouraging others to join if they are struggling to pay insurance premiums. But, Jones said, his family doesn’t always make preventive care — which isn’t covered — a priority. “I’ve had trouble convincing my wife to make the expense” of regular gynecological checkups, he said. “I don’t think she’s really seen a specialist in a few years now.”

And then there’s the question of adoption. Under federal law, insurance companies must treat an adoptive child as a “natural” child from the time he or she is placed with the adoptive parents, and cannot deny coverage because of pre-existing conditions. Health care sharing ministries, however, make their own rules.

Erik Olson gives his daughter, Tess, a high five.

Alyssa Schukar for BuzzFeed News

Erik Olson gives his daughter, Tess, a high five.

As Zain got older, Bet and Erik Olson decided to begin the process of adopting again. In November 2012, almost two years after they went to Ethiopia to meet Zain, they were matched with their daughter, Tess, a vibrant young girl with boundless energy. They met her in April 2013, she turned 2 in May, and they brought her home in June. This time, they knew there would be some challenges: Tess had received conflicting test results in Ethiopia, indicating the possibility of a blood disorder.

Bet and Erik called Samaritan. “We knew what the answer was going to be,” Bet said, “but we just wanted to challenge it again.” As they expected, Samaritan said that it wouldn’t share any needs related to Tess’s bloodwork. Bet and Erik decided to appeal. They wrote an email to the leadership of Samaritan Ministries, asking the organization to reconsider its stance.

“With all of its faults, our government still shows glimmers of compassion,” Bet and Erik wrote. “A law was put into place that made sure adopted children were treated by health care companies without discrimination. A health care company cannot deny coverage to an adopted child that it would have otherwise provided for a biological child.” Later, they wrote, “I find it interesting that you do not want to fall under this law — which I feel is one that protects human rights — but then when it comes to ObamaCare, you want to be considered an exclusion.”

The Olsons also asked Samaritan to consider that to be anti-abortion means to be pro-adoption. “As we become more like Christ, we care more about what he cares about,” they wrote. “I feel he gives us a mandate to care for orphans and widows. It is not an option in the Kingdom of God, but rather a command.”

“With all of its faults, our government still shows glimmers of compassion.”

The command that Erik was referring to is peppered throughout the Bible, most pointedly in James 1:27: “Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world.” Practicing Christians are twice as likely to adopt compared with their secular counterparts. There are no statistics for how many evangelical Christians in the US adopt each year, but since the mid-2000s adoption has been the subject of evangelical conferences, ministries, and initiatives designed to “defend the cause of the fatherless,” as a verse from Isaiah says. In fact, the recent “evangelical orphan boom” has been criticized for prioritizing parents’ desires over children’s well-being. Bet and Erik are aware of these criticisms and have worked to understand them. “I have been made more aware of my white privilege,” Bet said. “I want to use that awareness to educate people.”

The number of international adoptions in the United States is declining overall (from 19,601 in 2007 to just 5,370 in 2016) as other countries increase regulations, but the Christian interest in adoption is going strong. And while each family is different, it seems likely that the Olsons are far from the only parents in the US who might find that the medical care their adopted children need isn’t considered essential by their Christian health care sharing ministry.

Tess, with her special needs, would require some care that Zain had not, and Bet and Erik felt it was incumbent on them to encourage Samaritan to raise its standards. “Her name is Tesfa,” Bet said. “That’s the Amharic word for ‘hope.’ There’s no hope in saying, ‘But not special needs.’ That’s where most hope is needed.”

The Olsons were told that their letter would be passed along “to higher leadership” at Samaritan. After that response, they waited, but didn’t hear back from anyone else. “It was crickets,” said Bet. “They never did give us an answer.” (Samaritan declined requests to comment for this article.)

Former President Barack Obama signs the Affordable Care Act on March 23, 2010.

Andrew Harrer / Bloomberg / Getty Images

Former President Barack Obama signs the Affordable Care Act on March 23, 2010.

Health care sharing ministries remained in business after the implementation of the Affordable Care Act only because of extensive lobbying by two groups that work on their behalf: the Alliance of Health Care Sharing Ministries and the National Coalition of Health Care Sharing Ministries. These organizations spend hundreds of thousands of dollars annually, seeking to “return health care to a private, patient-centered model,” as the Alliance’s website puts it.

The authors of the Affordable Care Act weren’t keen to make an exception for these ministries, but they knew that if they didn’t, they would be putting the bill at risk. “It would have been none of our choices,” said John McDonough, a professor of the practice of public health at Harvard and former adviser to Sen. Ted Kennedy, who worked on the development of the ACA. “But with all the disruption and opposition to the legislation, we were also concerned about the public response and impact on wavering Democratic senators if this became a public controversy, which seemed more than possible.” So the ministries were written into the ACA, with their members exempt from having to pay the tax penalties associated with the individual mandate.

Aware of their unique position in the health care landscape, these ministries continue to think about how to protect themselves from meddling regulations, and that involves a robust public relations effort. Deborah Hamilton, who heads Hamilton Strategies, the public relations firm that represents Samaritan Ministries, declined to arrange an interview after asking me via email whether this would be a “positive” article, and then told me that she did not think BuzzFeed News would be a “strategic media outlet” for Samaritan.

I did speak with Jon Watts, a former member services advocate at Samaritan Ministries who is now a student pastor at Crosspoint Community Church in Eureka, Illinois. He loved his time working for Samaritan, which he describes as “a phenomenal place to work” with people who came from “a wide variety of evangelical backgrounds.” For Watts, Samaritan was “a place to be challenged to grow in your faith around other people who are also pursuing Jesus with you,” where he could talk about theology on his lunch break. Watts would occasionally mediate difficult situations, like instructing a member about what to do if a check bounced or what to do if someone was late in sending in a share (usually, wait on another member’s check to come in).

What the AHCA would mean for sharing ministries remains uncertain — and it might not be good.

With the ongoing GOP effort to repeal and replacethe Affordable Care Act, these ministries are once again concerned for their futures. In March, before the Republican American Health Care Act passed the House, Liberty HealthShare encouraged members to contact their representatives and ask for protections for health care sharing ministries: “[W]e are asking for the continued freedom to make health care decisions based on our needs and values,” part of the provided script read. Sharing ministries might seem like an appealingly stable alternative to traditional insurance coverage, as legislation is up in the air, but what the AHCA or other changes to health care policy would mean for them remains uncertain — and it might not be good.

“The American Health Care Act basically eliminates the individual mandate, the very requirement that likely made it much easier for health sharing ministries to pitch their cheaper but skimpier and discriminatory plans to consumers,” Lucia, the Georgetown professor, said. The membership growth that these ministries have seen in recent years could be stalled if the Republican health plan goes forward, according to Lucia, “because under the AHCA consumers won’t have to be covered at all, and the market will likely be flooded with plans that are similar to those being marketed by health care sharing ministries.”

There’s some irony in all of this. Most social conservatives and many Christian organizations are united against the Affordable Care Act: Richard Land, while president of the Southern Baptist Convention’s Ethics and Religious Liberty Commission, said that Obamacare was written by “ideologues” who represent “the greatest threat to religious freedom in America.” But the ACA has allowed Christian health care sharing ministries to flourish, and it could be that the Trump-backed AHCA is the thing that will cause them to falter.

Still, ministry leaders have confidence in their continued survival. Samaritan Ministries spokesman Anthony Hopp said in a recent interview with Christianity Today, “Health care sharing ministries existed before the ACA, God willing, they thrived during the ACA, and they will survive after.”

As nonprofits, these ministries aren’t holding on to vast reserves of cash, meaning they have less financial and political clout to throw around compared to big insurance companies — and leaving much less cushion between members and the ministry’s bottom line, should anything go wrong. Which does happen.

Some ministries have had solvency issues because of clear-cut financial mismanagement. Christian Brotherhood Newsletter, a health care sharing ministry based in Ohio, found itself at the center of a scandal in 2001 when its founder Bruce Hawthorn was found to have stolen over $700,000 from CBN’s coffers to pay for cars, real estate, an airplane, and the credit card payments of an exotic dancer. Members sued, saying that Hawthorn’s alleged theft resulted in payment delays of up to 18 months and millions of dollars — as much as $34 million — in unpaid needs. Hawthorn and others were eventually required to repay $15 million in money taken from the funds where members had sent in their payments.

Scandals like this are rare, but some state regulators consider the basic premise of health care sharing ministries misleading, and have tried (and mostly failed) to exercise oversight. In 2007, the state of Oklahoma issued a cease-and-desist order against Medi-Share, claiming that it was indistinguishable from traditional insurance: “If it looks like a rose and smells like a rose, then it’s a rose,” said Kim Holland, then Oklahoma’s insurance commissioner. The state passed a bill in 2008 that allowed Medi-Share to resume operations, but a number of Medi-Share members faced trouble nonetheless.

Karen Niles, a homemaker from Blackwell, Oklahoma, saw her brain tumor returnduring this period of time and was told by Medi-Share that it wouldn’t be able to share in any of her expenses. (The ministry had previously shared about $450,000 worth of needs related to Niles’ condition.) Niles and her husband, Robert, claimed that Medi-Share couldn’t pay because it didn’t have enough money; Medi-Share maintained that it couldn’t share her expenses because the ministry was told it couldn’t operate in Oklahoma. The Oklahoma Insurance Department said there was nothing stoppingMedi-Share from facilitating payments in the state. The Nileses and Medi-Share underwent a binding arbitration process, which ruled in favor of Medi-Share. Karen Niles died in 2011.

Every state in the US has a department that regulates insurance, but state policies on health care sharing ministries vary widely, if they exist at all. Insurance commissioners in Washington and Kentucky, as well as in Oklahoma, have all tried at different times to stop certain ministries from operating within their state borders, on the grounds that they are actually insurance companies and should be regulated as such. But in each case, the ministries were given exemptions by state legislatures that saw the issue as one of religious freedom.

In recent years, health care sharing ministries have worked with the conservative legislative forum the American Legislative Exchange Council to prevent the same back-and-forth from playing out in other states. ALEC offers legislators a model exemption bill that argues that “the regulatory requirements of insurance, if imposed on HCSMs, would destroy the voluntary, ministerial nature of the organizations.” As of the last amendment, in 2011, 11 states had safe-harbor exemptions for health care sharing ministries. As of last year, 30 do.

At the heart of the debate is the question of how health care sharing ministries differ from traditional insurance, and, ultimately, what the consequences of those differences are. Health care sharing ministries are legally required to disclose the fact that they are not insurance. Which is fine, but to hear them tell it, theirs is still the superior product. In its prospective members packet, Samaritan Ministries includes a glowing letter of recommendation from one couple: “We became aware of Samaritan Ministries in 2001 or 2002, but continued to play the juggling game with the insurance industry due to our lack of faith/trust in God’s provision through Samaritan.”

The letter goes on: “I would recommend this over EVERY ‘insurance’ product out there. Traditional ‘insurance’ has no assurances. In fact, everything is written in such a way that there is no assurance at the bottom line. We just wish that we had trusted in His provisions sooner.”

Just a few pages later in the membership application, though, is this proviso:

Samaritan Ministries and its members assume no responsibility for your medical bills. Whether you receive any share money to help you with your medical needs will depend on the voluntary giving of your fellow members as an expression of Christian love, but no matter how much money you receive, you always remain solely responsible for payment of your own medical bills.

The Affordable Care Act was written in part to ban certain discriminatory practices that led to people being denied insurance coverage. But health care sharing ministries have retained the right to discriminate, either by not sharing certain costs or by requiring more of certain members they deem unfit. For example, health care sharing ministries uniformly refuse to share costs related to self-inflicted injuries or suicide attempts — an issue that has also plagued traditional insurance companies, despite a health care privacy law requiring them to do so. Nor will they share needs related to fertility treatments, contraception, or, in some cases, injuries related to acts of war.

Several ministry plans have special tracks for overweight members, requiring them to meet regularly with coaches, as with Medi-Share’s Health Partner program: “If a Member experiences significant weight gain, he or she will be required to participate as a Health Partner.” The Medi-Share guidelines for Health Partners adds that “by reversing and/or preventing certain diseases, people are able to live healthier and fuller lives, ultimately being able to do more work for the Kingdom of God.”

Even if health care sharing ministries are very good for (most of) their members, ultimately they make it more difficult for traditional insurance plans under the ACA to flourish. “When you have a system like the ACA marketplace that covers everyone with robust coverage, regardless of their gender, age, or health status, what you don’t want is any seepage from that pool of risk,” said Lucia, the professor. “When healthy people leave the marketplace for cheap and skimpy coverage, it drives up premiums for everyone left behind.” (The current AHCA bill, which would allow healthy people to leave their community pools of coverage for less expensive plans, would essentially write a version of that seepage into law.)

They may divert resources from the most vulnerable, and undermine the common good for the well-being of the devout few.

Most ministries have lifetime caps on the amount of money they’ll share per illness. For example, at Christian Healthcare Ministries, there is a $125,000 lifetime limit per diagnosis. (If you enroll in the Brother’s Keeper “catastrophic bills program,” you can pay more into the program each quarter and share costs over that amount, although there is no guarantee that all your costs will be shared.) A cancer diagnosis or complications with the delivery of a child can result in bills well over that standard lifetime limit, leaving members on the hook and in search of an insurance program that will help them out. And since insurance companies can no longer discriminate against sick people, they must accept whatever patients come back to them from these ministries — now with more serious and more expensive conditions.

This question of seepage is also, in a way, a question about the fundamental nature of health care sharing ministries. These ministries want Christians to “bear one another’s burdens,” but in practice they may divert resources from the most vulnerable, and undermine the common good for the well-being of the devout few.

Insurance is far from perfect — unwieldy, expensive, and often byzantine in its structure. Disputes are common and there is no guarantee of fairness. Yet the contract involved with insurance exists to protect consumers. In signing up for health care sharing ministries, those consumers are legally agreeing to be financially responsible for all of their own medical bills, while hoping that their community of Christians won’t leave them in a desperate situation. A popular saying in evangelical churches is that everyone — even atheists — has faith. It’s what we put our faith in that differs.

Left, protestors in New York, Jan. 2017. Right, protestors demonstrate at a health care rally in Philadelphia, Feb. 2017.

Getty Images

Left, protestors in New York, Jan. 2017. Right, protestors demonstrate at a health care rally in Philadelphia, Feb. 2017.

Insurance companies deal in a strange collision of the ethics of capitalism, compassion, and cronyism, in a manner that often makes it difficult for the sickest people to get the money they need for care. Customers who take out more money than they put in — to pay for surgery, chemo, radiation, or hospice care, perhaps — are a drain on their system. So as insurance companies allocate resources, they are also making statements about which patients, and which conditions, are worth coverage, and which aren’t — in effect enacting a system of values.

Health care sharing ministries also enact values, and they exist in large part because one or two Christian individuals were moved to put their faith into action in new ways. Most ministries cite the same Bible verses as foundational to their existence: Acts 2 and Galatians 6. Acts 2 describes the life of the early church, just after Jesus’s death and resurrection: “All the believers were together and had everything in common. They sold property and possessions to give to anyone who had need.” And in Galatians, the Apostle Paul encouraged Christians to “carry each other’s burdens, and in this way you will fulfill the law of Christ.”

Jesus, after all, never asked about pre-existing conditions.

The Christian faith has a long history of caring for the health of the most vulnerable, following Jesus’s example of healing many of the outcasts of his day — the blind, the lame, lepers — as well as children. For some, like the Daughters of Charity of Saint Vincent de Paul, the mandate to care for “the least of these” meant they offered health care for orphaned children in New York during crises of public health. The Catholic Church is currently one of the largest, if not thelargest, private providers of health care in the US, with nearly 650 hospitals across the country. But truly universal health care is often lost in translation, with each sect offering care to those it deems worthy due to practical considerations, and by its own subjective standards. Are we holding sharing ministries to the standards of a Christian organization, or are we holding them to the standards of other health insurers? And when they incorporate parts of both, how should this new space be regulated? What does it mean to be a “Christian” organization, anyway?

Faddis, the Solidarity HealthShare cofounder, told me that some Catholic bishops encouraged him to expand Solidarity’s sharing into mental health treatment, which it will begin to do this year, offering to share up to seven therapy sessions. “We’re all trying to be as generous as we can,” Faddis said of his sharing ministry colleagues. “We want to say, ‘Bring everyone.’ But in being practical and good stewards, we have to consider” financial limits.

Radical inclusivity is a noble and biblical ideal for Christian organizations to work toward. But, as Molly Worthen pointed out in her 2015 New York Times op-ed about health sharing ministries, they don’t resemble Jesus’s healing ministry so much as they do the mutual aid societies that flourished during (and since) the Gilded Age. Jesus, after all, never asked about pre-existing conditions.

No organization that claims to be Christian can ever fulfill everyone’s idea of what that should look like. If the conversations I’ve had over the last four months are any indication, sharing ministries’ constituents are generally very pleased with the care they receive. That may be enough. However, there are Christian values that can seem at odds with one another. When they collide, the results can be messy, denying care for people who have violated some tenet of Christianity — real or perceived.

All five of the big ministries require their members to sign a statement of faith; some, like Samaritan and Medi-Share, require that members agree to reserve sex for lifelong marriage between a man and a woman. They won’t share treatment costs for STDs unless it can be proven that they were acquired “innocently,” i.e., through a blood transfusion or sex within marriage.

These prohibitions may lead young adults to commit one sin (lying) to cover up another, just to stay on their parents’ plan. That was the case for Sarah (not her real name), a pastor’s daughter in a small town in Kansas. Sarah, who just graduated from high school and will head to college in the fall, got a letter from Medi-Share around the time of her 18th birthday that asked her to agree to the ministry’s “lifestyle agreement” in order to remain included in her parents’ plan.

“I’m grateful to have Medi-Share, but I want birth control so I don’t end up a teen mom.”

One of the three primary “biblical standards” Medi-Share requires for eligibility is “No sex outside of traditional Christian marriage” — but Sarah has been having sex with her boyfriend for the last few months. Sarah didn’t feel like she could talk to her mother about it, so her older sister took her to get birth control — an implant in her arm — in another city. “I’m still a Christian,” Sarah said. “I’m grateful to have Medi-Share, but I want birth control so I don’t end up a teen mom.”

If she did, she and her boyfriend would be on their own; many evangelical sharing ministries, including Medi-Share, won’t share in maternity costs for unwed mothers. (Solidarity and Liberty HealthShares both share costs for unwed mothers.)

“There are times even in the Christian community that unwed women become pregnant,” read the Christian Healthcare Ministries guidelines. “Christian Healthcare Ministries members have agreed not to share medical bills for pregnancies of unwed mothers. Instead, Christian Healthcare Ministries recognizes that in such circumstances the assistance needed goes far beyond financial aid. Therefore, we encourage you to seek help from a compassionate, Christian pregnancy center if you find yourself in this situation…You are in our prayers.”

Medi-Share has the same policy, with the stated exception that it will publish costs related to such a pregnancy if it is the result of a rape, but only if the rape is “reported to a law enforcement authority.” There are, of course, many reasons women choose not to report rape to law enforcement, including that they often feel revictimized in the process. But the choice not to do so would mean that they would have to shoulder the entire cost of their prenatal care and delivery, which in most hospitals generally runs into tens of thousands of dollars.

I asked a representative of Christian Healthcare Ministries how they would respond to a difficult situation in which, say, a member was raped and needed assistance with maternity expenses. “For things outside the control of our members, we will look at it individually and with an attitude of mercy,” said Lauren Gajdek, Christian Healthcare Ministries’ communications director. “CHM would support someone who was raped and pregnant. We are a ministry. The criminal would be held accountable to the extent of the law and CHM would coordinate with the family and all applicable resources to assist the victim.”

But the messiness of any system that determines worthiness on a case-by-case basis becomes apparent fairly quickly, and makes for some strange rules for women in vulnerable positions. Samaritan Ministries refuses to share costs related to ectopic pregnancies, which occur when the fertilized egg attaches itself somewhere outside of the uterus, usually in the fallopian tubes. Ectopic pregnancies can almost never go full term, and women who have them often require emergency surgery to remove the embryo in order to save their own lives, which can cost upwards of $15,000. Yet in its guidelines, Samaritan Ministries clarifies that “considerations of the health or life of the mother does not change that the removal of a living unborn child from the mother may be a termination of life.”

Bet and Erik Olson walk home with their children.

Alyssa Schukar for BuzzFeed News

Bet and Erik Olson walk home with their children.

While I spoke with the Olsons in their kitchen in Illinois, Tess was upstairs playing with her brother. But she knew our time was almost up, and I had promised to play a game with her before I left. She ran into the living room and, having a hard time deciding on a game, made up her mind to dance instead. Her mom played a clean version of “Uptown Funk” (Sample lyric: “Fill my cup, put some water in it”) as Tess did the splits, jumped, and shook her hips.

Even though Samaritan wouldn’t cover the medical tests Zain and Tess needed when they were adopted, everything turned out okay for the Olson family. Erik had just started a new job when they brought Tess home, as vice president of Dignity Coconuts, a community formation organization that works primarily in the Philippines. Through Dignity, the Olsons were all able to get health care coverage, including coverage for a regular medication that Tess takes. They are a healthy, energetic family of four, with homework to do and errands to run and hockey games to go to.

As long as potential changes to US health care policy — and the fate of the health insurance laws and marketplaces we do have — remain unsettled, the only thing that’s clear is that no one’s future is certain. Christian health care sharing ministries will continue to lobby for their special position, and consumers will continue to look for the best way to save money while taking care of their families. Faith, in every sense of the word, will be required for everyone involved — faith that the government will keep loopholes open; faith that fellow Christians will send their checks every month; faith that God will provide. And the Olsons, despite leaving Samaritan, still have faith.

“Erik and I both have a heart to say we really believe in what Samaritan does, and think there are a lot of good things,” Bet said. “I just want them to rethink and really think about why they’re doing it that way.” ●

The Moral-Hazard Myth

August 14, 2017

The Moral-Hazard Myth

The bad idea behind our failed health-care system.

Tooth decay begins, typically, when debris becomes trapped between the teeth and along the ridges and in the grooves of the molars. The food rots. It becomes colonized with bacteria. The bacteria feeds off sugars in the mouth and forms an acid that begins to eat away at the enamel of the teeth. Slowly, the bacteria works its way through to the dentin, the inner structure, and from there the cavity begins to blossom three-dimensionally, spreading inward and sideways. When the decay reaches the pulp tissue, the blood vessels, and the nerves that serve the tooth, the pain starts—an insistent throbbing. The tooth turns brown. It begins to lose its hard structure, to the point where a dentist can reach into a cavity with a hand instrument and scoop out the decay. At the base of the tooth, the bacteria mineralizes into tartar, which begins to irritate the gums. They become puffy and bright red and start to recede, leaving more and more of the tooth’s root exposed. When the infection works its way down to the bone, the structure holding the tooth in begins to collapse altogether.

Several years ago, two Harvard researchers, Susan Starr Sered and Rushika Fernandopulle, set out to interview people without health-care coverage for a book they were writing, “Uninsured in America.” They talked to as many kinds of people as they could find, collecting stories of untreated depression and struggling single mothers and chronically injured laborers—and the most common complaint they heard was about teeth. Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had “a peculiar mannerism of keeping her mouth closed even when speaking.” It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. “They’ll break off after a while, and then you just grab a hold of them, and they work their way out,” she explained to Sered and Fernandopulle. “It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better.”

People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of “poor parenting, low educational achievement and slow or faulty intellectual development.” They are an outward marker of caste. “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.’ ”

The U. S. health-care system, according to “Uninsured in America,” has created a group of people who increasingly look different from others and suffer in ways that others do not. The leading cause of personal bankruptcy in the United States is unpaid medical bills. Half of the uninsured owe money to hospitals, and a third are being pursued by collection agencies. Children without health insurance are less likely to receive medical attention for serious injuries, for recurrent ear infections, or for asthma. Lung-cancer patients without insurance are less likely to receive surgery, chemotherapy, or radiation treatment. Heart-attack victims without health insurance are less likely to receive angioplasty. People with pneumonia who don’t have health insurance are less likely to receive X rays or consultations. The death rate in any given year for someone without health insurance is twenty-five per cent higher than for someone with insur-ance. Because the uninsured are sicker than the rest of us, they can’t get better jobs, and because they can’t get better jobs they can’t afford health insurance, and because they can’t afford health insurance they get even sicker. John, the manager of a bar in Idaho, tells Sered and Fernandopulle that as a result of various workplace injuries over the years he takes eight ibuprofen, waits two hours, then takes eight more—and tries to cadge as much prescription pain medication as he can from friends. “There are times when I should’ve gone to the doctor, but I couldn’t afford to go because I don’t have insurance,” he says. “Like when my back messed up, I should’ve gone. If I had insurance, I would’ve went, because I know I could get treatment, but when you can’t afford it you don’t go. Because the harder the hole you get into in terms of bills, then you’ll never get out. So you just say, ‘I can deal with the pain.’ ”

One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century—during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years—efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the extra spending comes to hundreds of billions of dollars a year. What does that extra spending buy us? Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average. Infant-mortality rates are in the nineteenth percentile of industrialized nations. Doctors here perform more high-end medical procedures, such as coronary angioplasties, than in other countries, but most of the wealthier Western countries have more CT scanners than the United States does, and Switzerland, Japan, Austria, and Finland all have more MRI machines per capita. Nor is our system more efficient. The United States spends more than a thousand dollars per capita per year—or close to four hundred billion dollars—on health-care-related paperwork and administration, whereas Canada, for example, spends only about three hundred dollars per capita. And, of course, every other country in the industrialized world insures all its citizens; despite those extra hundreds of billions of dollars we spend each year, we leave forty-five million people without any insurance. A country that displays an almost ruthless commitment to efficiency and performance in every aspect of its economy—a country that switched to Japanese cars the moment they were more reliable, and to Chinese T-shirts the moment they were five cents cheaper—has loyally stuck with a health-care system that leaves its citizenry pulling out their teeth with pliers.

America’s health-care mess is, in part, simply an accident of history. The fact that there have been six attempts at universal health coverage in the last century suggests that there has long been support for the idea. But politics has always got in the way. In both Europe and the United States, for example, the push for health insurance was led, in large part, by organized labor. But in Europe the unions worked through the political system, fighting for coverage for all citizens. From the start, health insurance in Europe was public and universal, and that created powerful political support for any attempt to expand benefits. In the United States, by contrast, the unions worked through the collective-bargaining system and, as a result, could win health benefits only for their own members. Health insurance here has always been private and selective, and every attempt to expand benefits has resulted in a paralyzing political battle over who would be added to insurance rolls and who ought to pay for those additions.

Policy is driven by more than politics, however. It is equally driven by ideas, and in the past few decades a particular idea has taken hold among prominent American economists which has also been a powerful impediment to the expansion of health insurance. The idea is known as “moral hazard.” Health economists in other Western nations do not share this obsession. Nor do most Americans. But moral hazard has profoundly shaped the way think tanks formulate policy and the way experts argue and the way health insurers structure their plans and the way legislation and regulations have been written. The health-care mess isn’t merely the unintentional result of political dysfunction, in other words. It is also the deliberate consequence of the way in which American policymakers have come to think about insurance.

“Moral hazard” is the term economists use to describe the fact that insurance can change the behavior of the person being insured. If your office gives you and your co-workers all the free Pepsi you want—if your employer, in effect, offers universal Pepsi insurance—you’ll drink more Pepsi than you would have otherwise. If you have a no-deductible fire-insurance policy, you may be a little less diligent in clearing the brush away from your house. The savings-and-loan crisis of the nineteen-eighties was created, in large part, by the fact that the federal government insured savings deposits of up to a hundred thousand dollars, and so the newly deregulated S. & L.s made far riskier investments than they would have otherwise. Insurance can have the paradoxical effect of producing risky and wasteful behavior. Economists spend a great deal of time thinking about such moral hazard for good reason. Insurance is an attempt to make human life safer and more secure. But, if those efforts can backfire and produce riskier behavior, providing insurance becomes a much more complicated and problematic endeavor.

In 1968, the economist Mark Pauly argued that moral hazard played an enormous role in medicine, and, as John Nyman writes in his book “The Theory of the Demand for Health Insurance,” Pauly’s paper has become the “single most influential article in the health economics literature.” Nyman, an economist at the University of Minnesota, says that the fear of moral hazard lies behind the thicket of co-payments and deductibles and utilization reviews which characterizes the American health-insurance system. Fear of moral hazard, Nyman writes, also explains “the general lack of enthusiasm by U.S. health economists for the expansion of health insurance coverage (for example, national health insurance or expanded Medicare benefits) in the U.S.”

What Nyman is saying is that when your insurance company requires that you make a twenty-dollar co-payment for a visit to the doctor, or when your plan includes an annual five-hundred-dollar or thousand-dollar deductible, it’s not simply an attempt to get you to pick up a larger share of your health costs. It is an attempt to make your use of the health-care system more efficient. Making you responsible for a share of the costs, the argument runs, will reduce moral hazard: you’ll no longer grab one of those free Pepsis when you aren’t really thirsty. That’s also why Nyman says that the notion of moral hazard is behind the “lack of enthusiasm” for expansion of health insurance. If you think of insurance as producing wasteful consumption of medical services, then the fact that there are forty-five million Americans without health insurance is no longer an immediate cause for alarm. After all, it’s not as if the uninsured never go to the doctor. They spend, on average, $934 a year on medical care. A moral-hazard theorist would say that they go to the doctor when they really have to. Those of us with private insurance, by contrast, consume $2,347 worth of health care a year. If a lot of that extra $1,413 is waste, then maybe the uninsured person is the truly efficient consumer of health care.

The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick. “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?”

For that matter, when you have to pay for your own health care, does your consumption really become more efficient? In the late nineteen-seventies, the rand Corporation did an extensive study on the question, randomly assigning families to health plans with co-payment levels at zero per cent, twenty-five per cent, fifty per cent, or ninety-five per cent, up to six thousand dollars. As you might expect, the more that people were asked to chip in for their health care the less care they used. The problem was that they cut back equally on both frivolous care and useful care. Poor people in the high-deductible group with hypertension, for instance, didn’t do nearly as good a job of controlling their blood pressure as those in other groups, resulting in a ten-per-cent increase in the likelihood of death. As a recent Commonwealth Fund study concluded, cost sharing is “a blunt instrument.” Of course it is: how should the average consumer be expected to know beforehand what care is frivolous and what care is useful? I just went to the dermatologist to get moles checked for skin cancer. If I had had to pay a hundred per cent, or even fifty per cent, of the cost of the visit, I might not have gone. Would that have been a wise decision? I have no idea. But if one of those moles really is cancerous, that simple, inexpensive visit could save the health-care system tens of thousands of dollars (not to mention saving me a great deal of heartbreak). The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money.

Sered and Fernandopulle tell the story of Steve, a factory worker from northern Idaho, with a “grotesquelooking left hand—what looks like a bone sticks out the side.” When he was younger, he broke his hand. “The doctor wanted to operate on it,” he recalls. “And because I didn’t have insurance, well, I was like ‘I ain’t gonna have it operated on.’ The doctor said, ‘Well, I can wrap it for you with an Ace bandage.’ I said, ‘Ahh, let’s do that, then.’ ” Steve uses less health care than he would if he had insurance, but that’s not because he has defeated the scourge of moral hazard. It’s because instead of getting a broken bone fixed he put a bandage on it.

At the center of the Bush Administration’s plan to address the health-insurance mess are Health Savings Accounts, and Health Savings Accounts are exactly what you would come up with if you were concerned, above all else, with minimizing moral hazard. The logic behind them was laid out in the 2004 Economic Report of the President. Americans, the report argues, have too much health insurance: typical plans cover things that they shouldn’t, creating the problem of overconsumption. Several paragraphs are then devoted to explaining the theory of moral hazard. The report turns to the subject of the uninsured, concluding that they fall into several groups. Some are foreigners who may be covered by their countries of origin. Some are people who could be covered by Medicaid but aren’t or aren’t admitting that they are. Finally, a large number “remain uninsured as a matter of choice.” The report continues, “Researchers believe that as many as one-quarter of those without health insurance had coverage available through an employer but declined the coverage. . . . Still others may remain uninsured because they are young and healthy and do not see the need for insurance.” In other words, those with health insurance are overinsured and their behavior is distorted by moral hazard. Those without health insurance use their own money to make decisions about insurance based on an assessment of their needs. The insured are wasteful. The uninsured are prudent. So what’s the solution? Make the insured a little bit more like the uninsured.

Under the Health Savings Accounts system, consumers are asked to pay for routine health care with their own money—several thousand dollars of which can be put into a tax-free account. To handle their catastrophic expenses, they then purchase a basic health-insurance package with, say, a thousand-dollar annual deductible. As President Bush explained recently, “Health Savings Accounts all aim at empowering people to make decisions for themselves, owning their own health-care plan, and at the same time bringing some demand control into the cost of health care.”

The country described in the President’s report is a very different place from the country described in “Uninsured in America.” Sered and Fernandopulle look at the billions we spend on medical care and wonder why Americans have so little insurance. The President’s report considers the same situation and worries that we have too much. Sered and Fernandopulle see the lack of insurance as a problem of poverty; a third of the uninsured, after all, have incomes below the federal poverty line. In the section on the uninsured in the President’s report, the word “poverty” is never used. In the Administration’s view, people are offered insurance but “decline the coverage” as “a matter of choice.” The uninsured in Sered and Fernandopulle’s book decline coverage, but only because they can’t afford it. Gina, for instance, works for a beauty salon that offers her a bare-bones health-insurance plan with a thousand-dollar deductible for two hundred dollars a month. What’s her total income? Nine hundred dollars a month. She could “choose” to accept health insurance, but only if she chose to stop buying food or paying the rent.

The biggest difference between the two accounts, though, has to do with how each views the function of insurance. Gina, Steve, and Loretta are ill, and need insurance to cover the costs of getting better. In their eyes, insurance is meant to help equalize financial risk between the healthy and the sick. In the insurance business, this model of coverage is known as “social insurance,” and historically it was the way health coverage was conceived. If you were sixty and had heart disease and diabetes, you didn’t pay substantially more for coverage than a perfectly healthy twenty-five-year-old. Under social insurance, the twenty-five-year-old agrees to pay thousands of dollars in premiums even though he didn’t go to the doctor at all in the previous year, because he wants to make sure that someone else will subsidize his health care if he ever comes down with heart disease or diabetes. Canada and Germany and Japan and all the other industrialized nations with universal health care follow the social-insurance model. Medicare, too, is based on the social-insurance model, and, when Americans with Medicare report themselves to be happier with virtually every aspect of their insurance coverage than people with private insurance (as they do, repeatedly and overwhelmingly), they are referring to the social aspect of their insurance. They aren’t getting better care. But they are getting something just as valuable: the security of being insulated against the financial shock of serious illness.

There is another way to organize insurance, however, and that is to make it actuarial. Car insurance, for instance, is actuarial. How much you pay is in large part a function of your individual situation and history: someone who drives a sports car and has received twenty speeding tickets in the past two years pays a much higher annual premium than a soccer mom with a minivan. In recent years, the private insurance industry in the United States has been moving toward the actuarial model, with profound consequences. The triumph of the actuarial model over the social-insurance model is the reason that companies unlucky enough to employ older, high-cost employees—like United Airlines—have run into such financial difficulty. It’s the reason that automakers are increasingly moving their operations to Canada. It’s the reason that small businesses that have one or two employees with serious illnesses suddenly face unmanageably high health-insurance premiums, and it’s the reason that, in many states, people suffering from a potentially high-cost medical condition can’t get anyone to insure them at all.

Health Savings Accounts represent the final, irrevocable step in the actuarial direction. If you are preoccupied with moral hazard, then you want people to pay for care with their own money, and, when you do that, the sick inevitably end up paying more than the healthy. And when you make people choose an insurance plan that fits their individual needs, those with significant medical problems will choose expensive health plans that cover lots of things, while those with few health problems will choose cheaper, bare-bones plans. The more expensive the comprehensive plans become, and the less expensive the bare-bones plans become, the more the very sick will cluster together at one end of the insurance spectrum, and the more the well will cluster together at the low-cost end. The days when the healthy twenty-five-year-old subsidizes the sixty-year-old with heart disease or diabetes are coming to an end. “The main effect of putting more of it on the consumer is to reduce the social redistributive element of insurance,” the Stanford economist Victor Fuchs says. Health Savings Accounts are not a variant of universal health care. In their governing assumptions, they are the antithesis of universal health care.

The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes? In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem. ♦

  • Malcolm Gladwell has been a staff writer for the The New Yorker since 1996.

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Why Republicans Fail In Health Care

August 14, 2017

Why Republicans Fail In Health Care

07/28/2017 02:51 pm ET | Updated Jul 30, 2017

Sisyphus was a lot like Trump. In Greek mythology Sisyphus, King of Ephyra, had an overabundance of hubris. He thought he was smarter than everyone, even Zeus. Consequently, he was punished for eternity by having to repeatedly push a boulder up a hill only to have it roll back down again. According to Camus’ interpretation, Sisyphus eventually accepted the absurdity of his fate, thereby achieving a certain happiness. Trump assuredly does not fit into Camus’ explanation. But on healthcare, Trump and his congressional allies align well with the interpretation of the Roman philosopher and poet Lucretius, who said that Sisyphus “is the man who thirsts to run for the rods and cruel axes of public office, and who always returns beaten and dejected.”

Lucretius wrote of the emptiness of the pursuit of power for its own sake. That is essentially what the Republicans have been up to with healthcare. Their Sisyphean push of ACA repeal reflects not just run-of-the-mill political divisions but an utter lack of substance. Trump, McConnell and Ryan ultimately didn’t care what was in their various bills but just wanted a “victory.”

They didn’t care because any notions they advanced of “Republican approaches” to health care would not solve real problems. They can’t because of a deep philosophical flaw in the thinking of Republicans. That’s why controlling he White House, the House of Representatives, and the Senate wasn’t enough. It’s why the various explanations offered for the GOP’s failure don’t really address the point. The failure to repeal and/or replace isn’t just because of a division in the Republican Party between its libertarian/ultraconservative wing and the so-called moderate wing. Nor is it simply because of the lack of presidential leadership, even though Trump has shown, appallingly, his ignorance of the content of his party’s proposed legislation, of the ACA itself, and of the fundamentals of how insurance markets are supposed to work.

The reality is that even if we had a knowledgeable, rational president, and a more unified GOP senate caucus, it is doubtful they could produce a solution that actually addresses deficiencies in health care. The real reason for Republicans’ paralysis on health care is that the party simply will not accept that the only way to produce an efficient and equitable health care system is through more, not less government involvement. There is a reason why among the world’s 25 richest nations, only the US doesn’t have some form of universal health care. The other countries that have universal health care all accept the notion that ensuring equitable access to health care depends on heavy government intervention, and that the “free market,” for all its virtues, is not equipped to guarantee access for rich and poor.

The concept of “moral hazard” underlies much of Republican thinking about health care, especially among those Republicans who advocate the least amount of government involvement in health care. Moral hazard is the idea that people take more risks when they are insured against the consequences of their behavior. In the health care arena, theoretically that induces excessive and inefficient consumption of medical services. However, as Malcolm Gladwell wrote in a seminal 2005 New Yorker article,

The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists… this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick. “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says.

The focus on moral hazard suggests that the changes we make in our behavior when we have insurance are nearly always wasteful. Yet, when it comes to health care, many of the things we do only because we have insurance—like getting our moles checked, or getting our teeth cleaned regularly, or getting a mammogram or engaging in other routine preventive care—are anything but wasteful and inefficient. In fact, they are behaviors that could end up saving the health-care system a good deal of money.

Republicans have promoted health savings accounts as a way to reduce moral hazard. The problem is that poor people – and many in the “middle class” – don’t have enough income to benefit from tax-protected HSAs. Moreover, HSAs can be quite complicated when it comes to accounting and paperwork. Even if HSAs were somehow simplified, there is little evidence that substituting tax credits for direct government health care subsidies is effective in reducing wasteful health care spending or in improving the health of citizens. As Gladwell said, health care is not like the regular consumer marketplace. While informed and engaged patients generally experience better health outcomes, it’s nearly impossible for patients to be fully equipped to make wise decisions in choosing medical services, drugs and doctors simply based on the idea that they are spending their own money rather than money provided by the government or a good insurance plan.

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Is there a reasonably workable Republican approach to health care coverage? Yes, it’s called Obamacare, a.k.a. the ACA. As Democrats occasionally remind Republicans, the concept of mandated individual coverage coupled with government subsidies was hatched at the conservative Heritage Foundation in 1989. A foundational principle of Obamacare is to preserve the private insurance marketplace. As Northwestern professor Craig Garthwaite said in a recent Washington Post op-ed, “Obamacare is broadly an extension of traditional Republican beliefs.”

Obamacare’s flaws flow in large part from the gymnastics it performs to protect private insurers, and its failure to sufficiently regulate the private marketplace. Take Switzerland, for example. It’s fair to say that the Swiss are enthusiastic capitalists. They chose not to establish a government-run health system like in the UK. Switzerland, like the U.S., decided to preserve the private insurance marketplace. But in order to make its system widely accessible and affordable, the Swiss version of Obamacare much more tightly regulates insurers and providers. Insurance companies must provide basic insurance plans to all citizens. These basic plans are standardized and cover most needs. Deductibles and co-pays are capped and are much lower than in the US. Premiums are low because insurers are not allowed to make a profit on the compulsory basic insurance. They are permitted to profit only on supplemental plans that cover, for example, private hospital rooms and certain services. In other words, the Swiss have accepted the need for much more government involvement than do the Republicans.

I remember attending a health care conference in Austin, and being warned by a consultant that Obamacare was a big step toward “being like the Europeans. You don’t want that do you?” I asked the consultant if he had ever been treated in Europe. No, he hadn’t. I told him that I have – in Britain, Germany and Switzerland. I told him my experiences were positive and asked him why he was so fearful of European systems. He uttered some banalities about quality of care and alleged waiting times (by the way, waiting times in the US are soaring). I told him that I had lived in the UK for four years and that, while the UK’s National Health Service (NHS) has its problems, I had no doubt the vast majority of Britons would pick their system over the hazardous uncertainties of U.S. health care. In fact, I’m quite sure that the results of a 2016 Gallup poll could not be replicated in Britain. The poll showed that six in ten Americans worry about unexpected medical costs.

Republicans must abandon their anti-government dogma and go big in the opposite direction. The U.S. needs to adopt universal health care (UHC). Whether that would involve a single payer system or something else, it will require more government involvement. To quote from a 2016 report by the Organisation for Economic Cooperation and Development:

…There are some core organisational principles of UHC that all countries share in common. In UHC systems, health coverage is mandatory regardless of age, gender, income, health status, employment and occupation. Risk is pooled across the broader population… Funding of UHC implies cross-subsidisation from the healthy to the sick and from richer to poorer populations. These principles mean that individuals should not face financial hardship because of the costs of health care. That is, an individual’s access to care should be based on need and not on ability-to-pay.

Achieving effective and equitable UHC has a strong potential to improve and extend people’s lives, reduce inequality and potentially lead to economic growth. There is a positive association between UHC and health outcomes. Failing to do may lead to deteriorating population health outcomes.

That’s the reality – not dogmatic and false assertions about the magic of the “free” health care marketplace.

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