Onward, Christian Health Care?
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.
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