U.S. Air Force photo by Senior Airman Jonathan Hehnly.

February 4, 2018; Politico

When President Obama signed the Affordable Care Act into law, it seemed that the nation was well on the path toward making a minimum level of health care available to all Americans. But now the pendulum is swinging back to a time when medical insurance came in many shapes and forms, with little standardization or guarantee of continuing coverage.

The efforts to undermine the core principles of the ACA—required insurance and a standard level of care—have increased coverage costs, pushing many to look for more affordable options. According to Politico, this has resulted in skyrocketing enrollment in health care ministries (HCMs), “particularly in states in which the individual insurance market has been beset by spiraling premiums and dwindling competition.”

As more people look for cheaper alternatives to health insurance, they are stumbling on ministry plans to escape Obamacare’s requirements and state oversight, but still satisfy the law’s individual mandate which, despite its repeal in the recent tax overhaul, remains in effect until 2019.

Traditionally, HCMs bring together individuals within a shared religious framework who agree to cooperatively share responsibility for medical costs. Each HCM member agrees to contribute a set monthly amount, to pay up to an annual maximum amount for their health needs, and to accept the plan’s behavioral expectations. Together, the members of the HCM agree to pay any costs a member has above their annual cap.

As described in an earlier look by NPQ, nonprofit HCMs draw their inspiration from “biblically rooted principles of community” and shared responsibility for the needs of others.” Since HCMs are not insurance policies, there’s no guarantee that the whole of a bill will be paid. As one ministry member told the New York Times, “There’s a little bit of fear going into it. What if people don’t pay their share and what if the money doesn’t come in? But that’s where the faith-based part comes in—I’m really going to rely on God.”

The uncertain future of the ACA, which has roiled the traditional insurance market, has proved to be beneficial to health care ministries, which now serve an estimated 1.1 million, up from 150,000 participants when the ACA became the law of the land. This growth, however, brings with it new challenges for HCM leadership.

As with many lower-cost alternatives, health care experts worry that HCMs are growing by attracting younger and healthier individuals, leaving older, sicker, and more expensive individuals for someone else to worry about. Kevin Lucia, a research professor at Georgetown University’s Center on Health Insurance Reforms, told Politico that “if healthy people gravitate toward these other arrangements, like health care sharing ministries, it can lead to higher premiums and less plan options for the people left behind. It can have detrimental effects on the risk pool.”

Because these are not insurance policies and fall outside the oversight of state insurance regulators, there is no oversight of how each plan manages its assets, nor any requirements for there being sufficient reserves on hand to cover projected costs. Each HCM member is taking a leap of faith that their ministry will be able to meet their needs when the bills come due. And, if they cannot or will not meet the medical needs of their members, that burden will fall to others.

The very forces that have fueled the growth of HCMs also pose a challenge to each plan’s organizers: Should they become more aggressive in the marketplace by deemphasizing their religious nature and downplaying the faith-based expectations that have been their hallmark? Some have begun to allow brokers to sell their plans and no longer require a pastor to certify the credentials of each new member.

At their best, HCMs let those with a shared belief band together to deal with the rising costs of modern health care. As long as their communities remain cohesive, they have a strong reason to exist and should be allowed to continue alongside any national health plan. But, when the allure of growth causes them to minimize this common element and become just another insurance option, there is reason to worry about continuing to allow them to operate outside the regulated health insurance system. Can they resist economic temptation? As long as the political winds continue to push away from the ACA’s shared vision, we will have a chance to find out.—Martin Levine