One of the best-known Amish traditions is that when a member’s barn burns down, the rest of the community comes together to build a new one.

As many as a million Christian Americans are inspired by that biblical principle of mutual aid to help pay for one another’s medical bills. Participants in so-called health care share ministries, which are generally cheaper than regular insurance, make monthly contributions to help pay the health care bills of other members. In return, they receive help when they need it.

Health care share ministries have grown steadily since the Affordable Care Act became law in 2010. But many health care experts warn that members risk being crushed by unforeseen medical bills, and that the growing popularity of the ministries could end up burdening people who don’t participate.

“It is lousy coverage,” said JoAnn Volk, a research professor at Georgetown University’s Center on Health Insurance Reforms and co-author of an August 2018 brief on health care sharing ministries from the Commonwealth Fund, a private health policy foundation.

In areas where the ministries are especially popular, Volk said, they might siphon enough healthy people out of the local insurance market to increase premiums.

The ministries are not considered health insurance because, unlike insurance, members are not guaranteed that their claims will be paid. Neither the ministries nor their members assume the financial liability of other members. Participants are not precluded from also having health insurance policies, but the ministries say it’s unlikely that many do.

What gets covered as a “shareable” expense is usually far less comprehensive than what is required by law for health insurance. For example, share ministries often do not cover preventive health care, medicines for chronic conditions, mental health care or treatments arising from “non-biblical lifestyles,” such as maternity care for out-of-wedlock pregnancies or substance abuse. They do not pay for abortions.

Nevertheless, many members praise the share ministries for their fellowship and as a cheap alternative to paying premiums for commercial health insurance.

Cliff McManis, pastor of Grace Bible Fellowship in Sunnyvale, California, said the option has worked perfectly for his family.

When his family health insurance premiums climbed to about $1,600 a month five years ago, he decided to sign up with Samaritan Ministries, one of the largest sharing ministries in the country.

McManis, married with four children, says his monthly sharing payments have never exceeded about $450 a month, and he’s been content with the coverage, which has included payments for his son’s surgery for a broken nose and his wife’s recent surgery to remove a tumor in her belly.

“We’re a hundred percent satisfied,” he said.

Although he said he joined the ministry out of financial considerations, the religious aspects were “a surprise major bonus.”

Checks to cover his wife’s surgery have arrived from strangers across the country, most of them accompanied by prayers for her recovery.

“Those prayers are probably the biggest encouragement we received,” he said, “and we value that.”

First Appeared in 1981

The first formal health care sharing organization didn’t make an appearance until 1981. That’s when the nonprofit Christian Healthcare Ministries in Ohio was formed. It purportedly remains one of the largest share ministries, although it doesn’t disclose membership numbers.

At least 104 health care sharing ministries now operate in the United States, according to the Alliance of Health Care Sharing Ministries. Only seven open membership to all comers rather than those from certain denominations or churches. All are Christian. There is no evidence of Jews or Muslims having similar organizations in the United States.

Several of the larger ministries claim to operate in all 50 states, but the alliance says half of the U.S. membership is concentrated in 10 states: California, Colorado, Florida, Georgia, Illinois, Indiana, North Carolina, Ohio, Pennsylvania and Texas.

The ministries say membership grew steadily after the passage of the ACA, which required that all Americans enroll in health insurance plans that provided a comprehensive set of benefits detailed in the law.

The ACA specifically exempted people belonging to health care sharing ministries whose members, the law said, “share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed.”

Members of the health care sharing ministries were not subject to the penalties levied on those failing to be in an ACA-compliant health plan.

Congress eliminated that mandate, effective next year.

The ministries grew from under 200,000 members before the ACA to about a million today, the Commonwealth Fund report says, but those numbers are based on self-reporting.

There is little confirmed data about either the membership levels of the largely unregulated organizations or the amount of money they disburse and for which services.

Christian Healthcare Ministries says on its website that its “members have shared over $3.5 billion in each other’s healthcare costs” over 35 years.

Thirty states passed so-called safe harbor laws for the ministries, stating that they are not insurance companies and are therefore exempt from insurance regulations. But the remaining states do not regulate them either.

“We tell people that if they have a problem, we can’t help you and the courts can’t help you,” said Martin Swanson, administrator for health policy at the Nebraska Department of Insurance.

Last month, his department, after receiving questions from consumers, issued an alert specifying that sharing ministries are not insurance and cannot be compelled to pay any member’s medical bills.

“Whether anyone chooses to assist you with your medical bills as a participant of this organization will be totally voluntary, and neither the organization nor any participant can be compelled by law to contribute toward your medical bills,” the alert says. “Regardless of whether you receive payment for medical expenses or whether this organization continues to operate, you are always personally responsible for the payment of your own medical bills.”

Because the ministries are exempt from insurance regulations, the only recourse members have is to file complaints with state attorneys general. But in their survey of states, authors of the Commonwealth Fund report say even the authority of the attorneys general is limited.

An official from an unidentified state told the authors that in investigating a case of unpaid claims, the state realized it couldn’t compel the ministry to act without clear evidence of fraud.

(Attorneys general offices in Texas, California and Florida did not respond to requests for information on consumer complaints about sharing ministries operating in their states.)

The large ministries all have internal appeals processes, but members have no recourse to go to court to challenge denials.

Some of the ministries explicitly state in their promotional materials that they are not insurance, and in interviews, officials with some of the organizations acknowledged that health care sharing doesn’t make sense for everyone.

Shared Values

The ministries require members to agree to a set of shared values. Solidarity HealthShare, a Catholic-oriented health care sharing ministry with 6,000 members, for example, states “Our core beliefs are rooted in Sacred Scripture and the Sacred Tradition of the Catholic Church.”

Most require members to adhere to “virtuous lifestyles,” which, for Samaritan Ministries, another of the big ministries with 258,000 members, means not drinking to excess, avoiding tobacco, not using illegal drugs, attending church at least three out of four weeks, and abstaining from sex outside of marriage or with someone of the same gender.

All the ministries say they are rooted in biblical calls to serve fellow humans. “It’s there in Romans 12,” said Anthony Hopp, a vice president with Samaritan: “Be devoted to one another in love.”

He described health care sharing as “almost like crowdsourcing for health care, people of faith coming together to share medical bills directly, person to person, household to household directly.”

Some of the ministries automatically deduct membership fees from members’ accounts and then disburse the money to needy members. Others instruct members to send checks directly to the other members, which they then verify.

Payments may go directly to providers or toward reimbursement of members. (The payments are not tax-deductible.) All ask members to pray for one another and to send personal, prayerful messages.

“We know our contribution is going directly to certain people,” said Kellie Soper of Tempe, Arizona, a tutor whose family has been in a health care sharing ministry since 2016. “Whereas with insurance, it’s just going to some company’s profit.”

In addition to the “virtuous lifestyle” restrictions, the ministries place other limits on what constitutes a shareable medical expense. Some do not take people with pre-existing conditions unless they have been symptom-free for a period.

Some, such as Christian Healthcare, Christian Care Ministry’s Medi-Share and Samaritan, do not cover routine preventive care, such as physicals, mammograms and colonoscopies. Christian Healthcare and Medi-Share do not cover mental health. Several cover prescriptions but only for a limited time span.

Members can generally see any provider they wish. Because they are technically uninsured, they are often able to receive discounts.

Richard Gundling, senior vice president of the Healthcare Financial Management Association, an association of financial managers of health care organizations, said that most providers are comfortable working with the ministries.

And for members of a certain bent, the ministries are a way to meld religious belief with medical necessity.

“It’s not for everybody,” said Bradley Hahn, CEO of Solidarity HealthShare, “but it may be for those who want to be faithful to their religion and be supported by others in their faith community.”

Stateline is an initiative of The Pew Charitable Trusts.

Stateline stories are published daily at pewtrusts.org/stateline.