Mind the Coverage Gap (A Look at Healthcare Sharing Ministries)

From AU's Senior Litigation Counsel Greg Lipper's guest post on Bill of Health.

The Wall Street Journal published a story earlier this week about an increase in the number of Americans enrolling in healthcare sharing ministries: faith-based alternatives to standard health insurance. According to the Journal, the number of participants in these ministries has grown from under 200,000, before the Affordable Care Act was enacted, to approximately 500,000 today. Under 26 U.S.C. § 5000A(d)(2)(B), participants in these ministries are exempt from the Act’s individual mandate, which requires most Americans to either obtain qualifying health insurance coverage or pay a tax.

As the Journal article makes clear, however, participants in healthcare ministries lack many of the protections otherwise provided to patients by the Affordable Care Act. For example,

  • Ministries often don’t cover preexisting conditions;
  • Ministries often don’t cover preventive care; and
  • Ministries often don’t cover contraception, maternity care, or mental-health care.

If and when coverage disputes arise, moreover, “[m]inistries generally don’t allow members to sue and require disagreements to be settled by arbitration and mediation.”

The Journal’s article reminded me of a profile published last year by the New York Times and Texas Tribune about the healthcare ministries run by an organization called Samaritan Ministries. I found it especially striking that Samaritan’s program—which in 2013 had approximately 14,000 members in Texas alone—barely resembles actual insurance:

Samaritan members send medical bills to the ministry, which in turn directs other members to mail their monthly payments to the person in need. If there is not enough money available in a given month, members receive a percentage of their request and hope to be reimbursed later when there is more money to go around.

Even that non-guarantee of coverage is subject, for most members, to a lifetime cap of $250,000 per medical condition. Plus Samaritan doesn’t offer coverage for preexisting conditions.

Then there are restrictions on participants’ personal lives. Samaritan requires members “to abide by a lifestyle that includes frequent church attendance, little drug or alcohol use, and no premarital or gay sex.” Indeed, “if a ministry member contracts a sexually transmitted disease, he or she has to foot the bill.”

In short, many health ministries offer neither the comprehensive coverage nor the financial security that the Act’s minimum-coverage requirements seek to ensure. And their personal-conduct requirements are likely to deprive patients, especially women, of reproductive healthcare.

This is bad for the people enrolled in these plans: cutting back on preventive care can turn small medical problems into bigger ones, preexisting conditions and mental illnesses may go untreated entirely, catastrophic illnesses may lead to financial ruin, and those unable to follow through on abstinence pledges lose out on reproductive care and more. Children of people who enroll their families in these programs lack any say in the matter. And spotty coverage undermines public health more generally: lack of preventive care can cause diseases to intensify and proliferate, untreated STDs can spread more easily, untreated mental illness can impose a variety of massive costs, and unpaid medical bills often get passed on to other patients and providers.

The Affordable Care Act is supposed to ensure that everyone has access to a minimum bundle of care, that patients have incentives to seek preventive care, that preexisting conditions no longer disqualify people from getting coverage, that coverage for mental illness is on par with coverage for physical illness, that women’s health and reproductive care aren’t shortchanged, and that catastrophic illnesses don’t wipe out patients’ savings. Healthcare ministries risk undermining each of those goals.

(h/t Religion Clause)