Is Your Medical Bill “Eligible for Sharing?” New research on Christian Health Care Sharing Ministries (HCSMs)

By Aobo Dong

As the future of Affordable Care Act (ACA) hangs in the balance amid political deadlock in Washington, more Americans are signing up for Christian health care sharing ministries (HCSMs) – a growing alternative to traditional health insurance. Instead of paying a monthly premium to insurance companies, most members of HCSMs write monthly checks directly to other members in need. If you are on the receiving end, chances are you may be surprised with a wave of letters, flowers, and prayer cards wishing you well. However, not all medical bills are “eligible for sharing.” Most HCSMs exclude pre-existing conditions, as well as any conditions or medical expenses caused by “unbiblical lifestyle” involving using drugs/alcohol or having sex outside of heterosexual marriage. Also, if you are an adopted child with disabilities or an undocumented immigrant, some ministries explicitly exclude you from participating at all.

For more detailed background on HCSMs, check out the website of the Alliance of Health Care Sharing Ministries (AHCSM), which encompasses three largest HCSMs today: Samaritan Ministries, Christian Healthcare Ministries, and Medi-Share – together constitute over 1 million members in counting. Former Academic Fellow Rachel E. Sachs at Petrie-Flom also presented a helpful overview and analysis of HCSMs in relation to the ACA Individual Mandate at the 2015 Conference. Her conference paper is available in the newly released book by Petrie-Flom: Law, Religion, and Health in the United States (2017).

As a new Student Fellow, I will be continuing the research on HCSMs during this academic year. My research will focus more on the legal and ethical implications of HCSM in the context of the current political deadlock under the Trump administration. Below are some of the questions I will most likely explore:

How will HCSMs function under Trump?

The President’s lack of will to fully enforce and improve the ACA may create interesting tensions with HCSMs. The fast growth of HCSMs can be attributed to the creation of ACA to a great extent. White evangelical Christians in America have a long tradition of distrust of governmental intervention in certain areas of life that they believe could be better handled through individual and private means. Health care is certainly one of their most pressing concerns. The pushbacks against the Individual Mandate that imposes a tax penalty on individuals without insurance compelled many Christians to seek alternative ways to avoid Obamacare, and HCSMs, which satisfy the religious exemption requirement under the Mandate, emerged as an appealing option. Indeed, HCSMs have existed long before ACA, yet the statutes of ACA limit the exemption only to HCSMs in continuous existence from December 31, 1999. Consequently, new HCSMs created in the 21st century would not be granted exemptions under current laws, essentially granting a handful of HCSMs an oligopoly over the industry. If the Individual Mandate is revoked under Trump, new HCSMs could be established, including potential “secular HCSMs” that are open to all regardless of religious affiliations.

How do HCSMs influence the traditional insurance marketplace?

Given the uncertainty facing the ACA, it is quite likely that even more Americans will consider replacing traditional insurance plans with HCSMs. There were past debates over whether HCSMs would disrupt the traditional insurance marketplace, since people joining these ministries tend to be overall healthier than the general population, leaving a higher proportion of less healthy people in the insurance pools. Such disruptions could contribute to the rising insurance premiums in certain marketplaces. Rachel Sachs argues that HCSMs embody a number of insurance theories including the Health Promotion model of insurance that encourages members to stay healthy in order to minimize preventable health costs. Although HCSMs rarely cover preventive services, they enforce strict eligibility requirements barring individuals with “unbiblical” lifestyles from joining. The equivocation between “biblical” and “healthy” lifestyle is arguably a central assumption that is essential for the financial sustainability of these ministries. Their relative success could become a talking point among lawmakers considering alternative approaches to healthcare, since such Health Promotion practices are not exclusive to religious communities. I do not see why secular mutual aid societies cannot implement similar cost-saving mechanisms.

Should HCSMs be subject to more regulations and legal/ethical scrutiny?

The drafters of religious exemption provisions under the Affordable Care Act probably did not envision a near future where HCSMs could gain a non-negligible and arguably significant share of the health care market. Many Americans are devoid of good options and are turning to HCSMs. It could be argued that more and more Americans in need of HCSMs do not come from the narrow Christian communities they traditionally serve. Prospective enrollees may not agree with certain religious views of white evangelicals, identify as heterosexual, or attend church regularly. Meanwhile, undocumented immigrants, who may be devout Christians by evangelical standards, are excluded as well. One could argue that such exclusions based on one’s nationality and resident status run contrary to certain central tenets of Christianity. If HCSMs are charitable ministries, not public entities enforcing the federal government’s immigration policies, why are they closing doors against fellow religious believers in need of life-saving health care?

In the next few months, I will continue to wrestle with these questions in my research. Watch out for future blog posts on HCSMs. Please feel free to contact me if you have relevant sources and ideas to share.

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