WHEN Theresa
Bixby, 63, learned that she had breast cancer four years ago, she reacted as
many Americans do. “One of my first thoughts was, ‘will they pay?’ ” she
said. But she wasn’t talking about a conventional insurance plan. She lost hers
when she left her full-time position for part-time work at her church in
Greenville, S.C. She was worried about the program that she had joined six
months earlier: Christian Healthcare Ministries.
Christian
Healthcare Ministries is not an insurance company. It is a nonprofit “health
care sharing ministry” based in Barberton, Ohio. The cost of membership is far
lower than the rates of traditional insurance policies — $45 a month for the
cheapest plan — but the ministry makes no guarantees of payment. Members send their monthly
“gift” to an escrow account, which disburses payments for eligible medical
bills, excluding costs like routine physicals, continuing treatment for
pre-existing conditions or procedures that members have voted to exclude, like
care for pregnancies outside wedlock.
Each time Ms.
Bixby visited her hospital for tests or chemotherapy, she explained that she
was a self-pay patient and a member of a cost-sharing ministry. Sometimes the
receptionist nodded; sometimes she got a blank stare. The hospital never denied
her treatment, but “I was getting a two-inch stack of bills every month, and
threats that they would take me to collections,” she told me.
Christian
Healthcare Ministries assigned her case to a “member advocate,” who negotiated
discounts on her fees. These counted toward Ms. Bixby’s $5,000 deductible, so
she paid out of pocket only for office visits. In the end, the ministry persuaded the hospital to lop $220,900 off a
bill of $301,540 and reimbursed or paid directly the remaining $80,640.
Despite stories
like this, organizations such as Christian Healthcare Ministries claim a modest
membership. The four main cost-sharing ministries in the United States have
about 340,000 members. Regulators in several states have raised concerns that
these ministries offer the illusion of insurance while sidestepping the
Affordable Care Act’s baseline standards of coverage and skirting requirements
that apply to conventional insurance companies, like minimum cash reserves.
Nonetheless, membership in the ministries has been growing, particularly since
the act granted them an exemption as one of the only ways to avoid the law’s
mandate to buy insurance without paying a fine.
But the debate
over consumer protections may disguise a more interesting question: Could this
model scale up? These ministries seem to achieve a remarkable level of member
satisfaction, even if they sometimes must portion out reimbursements when the
bills outstrip monthly contributions.
The ministries’
appeal lies partly in their low fees, but also in their ideological boundaries.
“This isn’t something that’s for everyone,” said Tony Meggs, the C.E.O. of the
Florida-based Christian Care Ministry, which runs a health care sharing program
called Medi-Share.
Christian
cost-sharing ministries have been around for about 30 years. They claim that
their true origins lie in the Book of Acts, the biblical account of how the
first Christians “had everything in common” and “gave to anyone as he had
need.” The ministries “show the world something that works, and works well, and
is a reflection of the commandments of Christ,” Mr. Meggs said.
The resemblance
to apostolic Christianity is debatable: After all, Jesus’ healing ministry
didn’t take pre-existing conditions into account, and the early church offered
aid to nonbelievers. The real precursors are the mutual aid societies of the
19th and early 20th centuries. In their heyday, organizations like the Odd
Fellows and the Loyal Order of Moose pooled fees to provide insurance for huge
numbers of working-class Americans. It is no accident that in our new Gilded
Age, the model that prevailed during the first Gilded Age is enjoying a second
life.
These aid
societies did more than provide relief from doctors’ bills, lost wages or
funeral expenses. They also divided the “deserving” poor from miscreants who
suffered through their own fault. Their bylaws stressed “thrift, leadership
skills, self-government, self-control and good moral character,” the historian
David Beito has written. Lodges required members to hold an “honorable” job,
banned women of “immoral or questionable behavior,” and limited the use of
alcohol and drugs.
Today,
Medi-Share requires members to “live by biblical standards:” no tobacco or
illegal drugs and no sex “outside of traditional Christian marriage.” Samaritan Ministries, with headquarters in Peoria, Ill.,
requires a pastor’s approval of medical expenses (and refuses to cover
treatment for S.T.D.s unless “contracted innocently”). Liberty HealthShare, based in Independence, Ohio, is the
only Affordable Care Act-exempt ministry open to people of many faiths. It asks
them to affirm that “it is my spiritual duty to God
and my ethical duty to others to maintain a healthy lifestyle.”
Members say
these rules are marks of the kind of community that government programs
undermine. “This is a solution for those of us who see the A.C.A. as a
problem,” said Daniel Alders, 28, a Samaritan member who lives in Nacogdoches,
Tex., and has turned to the ministry to pay for the births of his two children.
Samaritan members send their monthly share directly to another member with
medical expenses. “When we receive money, nine times out of 10 there’s a note
attached saying they’re praying for us and the health of the baby,” he told me.
“A community is
an organically grown organism, so it can’t succeed if it’s pushed and enforced
from the top level down,” he said. “You have to have a moral foundation, a
reason to trust those whose needs you’re sharing.”
In a recent
interview with NPR, President Obama acknowledged that many white working-class voters
felt no such trust in the government. “They think: ‘I’m being left out. Nobody
seems to be thinking about how tough it is for me right now,’ ” he said.
He’s not the
first liberal to hope that publicly funded
health insurance could win that trust. More than a
century ago, the Progressive reformer Jane Addams admired the
parades of mutual aid societies in Chicago’s Italian quarter, where members
marched “with a brave showing of banners, celebrating their achievement in
having surrounded themselves by at least a thin wall of protection against
disaster.” She longed “to pour into the government of their adopted country all
this affection and zeal, this real patriotism. A system of State insurance
would be a very simple device and secure a large return.”
In fact, mutual aid societies fought compulsory insurance
legislation that Progressive activists proposed in the World War I era, fearing
that such laws would endanger Americans’ “spirit of self-reliance.” The
legislation failed, but the societies’ days were numbered, too. The financial
burdens of their aging membership sometimes became crushing. And they were no
match for the growing political power of commercial insurance companies and organized
medicine, or the I.R.S.’s ruling in 1943 to grant tax breaks to employers who
paid for workers’ insurance.
In a way, Addams still got her wish. Persuaded by a new
vision of solidarity, many of those Italian immigrants joined the New Deal
coalition. In 1941, Franklin Delano Roosevelt advocated for the right to
“security for those who need it,” including “adequate medical care.” Roosevelt
wanted to surpass the model of the voluntary aid society by turning the social
contract into a covenant that bound people who otherwise had little in common,
that granted a basic level of economic security to people excluded by the
market or mutual aid.
For a small, self-selected group of Americans,
cost-sharing ministries make our broken health care system bearable. There is
much to admire in their nonprofit structure and their tireless advocacy for
members. The problem is that too often their proponents take them as proof that
it’s “in the DNA of Americans to assist and help one another” and success comes
“when the marketplace is given the opportunity to produce solutions on its
own,” as Dale Bellis, Liberty HealthShare’s executive director, put it.
The truth is that Americans never enjoyed a golden age
when local communities came together to solve social problems. In colonial
times, villages “warned
out” the aged, disabled and unmarried pregnant women, deporting
their neediest residents to other towns.
The great insight of the New Deal reformers was that
fetishizing a romantic idea of community is as perilous as making a false idol
of the free market. Cost-sharing ministries nurture one kind of community, but
only by opting out of the broader obligations of society. To make the
Affordable Care Act stick, and to make it work, means convincing more Americans
that they are not just their brother’s keeper.
Molly Worthen is an assistant
professor of history at the University of North Carolina, Chapel
Hill, and the author, most recently, of “Apostles of Reason: The Crisis of
Authority in American Evangelicalism.”
A version of this op-ed appears in print on February 1,
2015, on page SR10 of the New York edition with the headline: Onward, Christian
Health Care?. Order Reprints| Today's
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http://www.nytimes.com/2015/02/01/opinion/sunday/onward-christian-health-care.html?_r=1
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