The Affordable Care Act requires nearly every American to have health insurance or pay a penalty, beginning Jan. 1. The so-called "individual mandate" has been controversial ever since the law was passed.
But for people who fall into a few select categories, the mandate doesn't apply. Like Native Americans who get health coverage through the Indian Health Service, or people who are incarcerated.
Another exception is for members of "health care sharing ministries," a way for individuals with a "common set of ethical or religious beliefs" to share medical bills.
Sharing Health Burdens
The sharing ministries are not insurance: there's no guarantee that a given bill will be covered. Instead, it's like a co-op, where members decide what procedures to cover, and then all pitch in to cover the cost as group.
"It's a group of people, in this case Christians, who band together and agree that they want to share one another's burdens," says Andrea Miller, medical director for the largest Christian health-insurance alternative, Medi-Share.
She says members put aside a certain amount of money every month, which then goes to other Christians who need help paying their medical bills. Medi-Share's monthly fees vary, but its website advertises that family options "average less than $300 a month."
There are a few requirements to fulfill before participating, Miller says. The first is that you have to be Christian. "Second, you need to agree to living a Christian lifestyle, including no smoking, including not abusing alcohol or drugs," she says.
To constitute as a health care sharing ministry — and therefore be exempt from the Affordable Care Act requirements — the nonprofit has to have been in existence since 1999 (Medi-Share has existed since '93). The ministries also have an independent accounting firm conduct a publicly available annual audit.
Footing The Bill
Tens of thousands of Americans belong to Christian health sharing ministries, including Fred Bennett of Chattanooga, Tenn.
Bennett and his wife, Beth, have belonged to a health care sharing ministry for 19 years. They've always been healthy, but in the last few years, as they've entered their 60s, they started to have medical trouble.
"In '04, my wife was rushed to the hospital with E.coli in her kidneys and, actually, it spread to all of her body," he says.
She recovered, but the hospital bill was staggering. After six days in the hospital, most of which was spent in intensive care, the cost came to about $70,000.
And that bill was just the beginning for the Bennetts.
"She hasn't had many claims, but unfortunately, I had a stretch of five or six years there that things were pretty rough," Bennett says, including multiple surgeries and a heart attack.
The medical bills reached tens of thousands of dollars, but for each incident, the Bennetts paid only their $250 deductible. The rest was paid by fellow Christians through Medi-Share.
Of course, the same would have been true if they had normal health insurance. But Bennett says he prefers the health sharing ministry because the ministry doesn't pay for procedures he thinks are immoral, like abortions.
"The part I liked about it was that I wouldn't have to be having some of my premiums spent to take care of someone who wasn't taking of themself, physically or spiritually, either one," he says.
What's Not Covered
While the federal health law includes an exemption for health sharing ministries, some states have sued to try to keep them out. The concern is that consumers shopping for insurance will be confused about what ministries really guarantee in the way of coverage.
"We do not share in every medical need that a person has," Miller of Medi-Share says. "Some of the things we don't share in are related to lifestyle issues, such as an abortion. But others of them are related to things that the members have agreed that they would rather pay for themselves."
For example, she says, members tend to pay for their own preventative care (with the exception of very young children). There are also some restrictions on pre-existing conditions.
At Medi-Share, Miller works with a steering committee of health share members who discuss what kind of care is covered by the guidelines. "Any significant change in the guidelines is something that has to be passed by all the members," she says.
In August, CNBC reported that members whose claims are rejected have the right to file an appeal. In the current fiscal year, 76 percent of the bills submitted to Medi-Share were considered eligible, and all of those were covered, Medi-Share told CNBC.
Bennett of Tennessee points out that because all the members decide what to share the cost of, health ministries often cover things insurance rarely does, like adoption fees and funeral costs. Plus, he says, his health sharing ministry gives him a service he could never get from an insurance company.
"The night before my surgery, the lady who'd helped me locate the right providers and everything called me back and said, 'Would it be OK if I prayed with you for your surgery tomorrow?'"
Three days later, she called back to ask how the surgery went.
ARUN RATH, HOST:
No matter what happens in Congress, the Obamacare deadlines are still in effect. On Tuesday, public exchanges will open for business. But already, several companies are making changes to the way they provide health care to their employees.
Retailer Trader Joe's will give their employees 500 bucks to shop for insurance on the public exchanges. Meanwhile, pharmacy chain Walgreens will shift some of its employees to a private exchange that offers a lot more options than they currently have. Michael Polzin is a spokesman for the company.
MICHAEL POLZIN: By going to this corporate exchange where they can have up to 25 different choices of health care plans, it's going to give them a lot more options to get the coverage that really suits them.
RATH: I asked NPR health policy correspondent Julie Rovner to explain the difference between the public and the private options.
JULIE ROVNER, BYLINE: A private exchange is really just a way for an employer to contract its health insurance functions to a third party. The employer is still paying its share of the coverage; although in some cases, it may provide a specific amount of money that the employee can then use to shop for a plan, so it can be a win-win. But they're really, really, really new, so there's not a lot of evidence so far to judge.
RATH: Other companies like Trader Joe's, they have said that they will ask their part-time employees to shop for insurance on those public exchanges established by the Affordable Care Act. What options are they going to have available?
ROVNER: Trader Joe's is doing something particularly interesting. They're giving those part-time workers a $500 stipend to help them shop. But in general, there doesn't seem to be a flood of companies dropping coverage, although the ones that are are getting a lot of attention.
RATH: Well, what's to stop companies from just dropping all their insurance for their employees and saying, no, go to the public exchanges instead?
ROVNER: Really, insurance has always been a voluntary benefit from employers, and most large employers have continued to offer it and most surveys say they're going to continue to do that in the future, if only to compete with other employers who offer it to get the best workers.
Now, starting in 2015, employers with more than 50 workers could be subject to penalties of two to $3,000 for every worker who goes to the exchange and gets one of those federal subsidies. Some people have calculated that it would still be cheaper for employers to pay those fines than to offer health insurance.
RATH: The public exchanges are going to go live on October 1st - that's just in a few days. What's going to happen on the rollout date?
ROVNER: Well, that's when people who don't have insurance and people who buy their own insurance can start shopping for coverage that starts January 1st. Every state will have an exchange, and people can go there, plug in some basic information. They can see what plans are available, how much they cost. And once things are working, they'll be able to find out what help, if any, they might be eligible to get paying for that insurance.
RATH: NPR health policy correspondent Julie Rovner. Thanks, Julie.
ROVNER: Thank you.
RATH: Now, remember, the Affordable Care Act requires nearly every American to buy health insurance or pay a penalty beginning January 1st. But if you fall into a few select categories, the penalty doesn't apply to you, for example, if you're a Native American and you get your health coverage through the Indian Health Care Service or if you're in prison, or another group you may not have heard of, the 100,000 or so Americans who belong to something called a health care sharing ministry. This is not insurance. It's sort of like a co-op where members all pitch in to cover the cost of medical bills.
FRED BENNETT: My name is Fred Bennett. We live in Chattanooga, Tennessee.
RATH: Fred and his wife, Beth, belong to a health care sharing ministry, and they have for 19 years. They've always been healthy, but they're a little older now and they're starting to have some medical trouble.
BENNETT: In '04, my wife was rushed to the hospital with E. coli in her kidneys.
RATH: Beth recovered, but the hospital bill was a staggering $70,000. And that bill was just the beginning for the Bennetts.
BENNETT: Well, I hate to tell you they know me on a first name basis almost. In '05, I had some cancer surgery... around six or $7,000... '06, I had some necessary surgeries... '07, same thing... I had a heart attack at home. She hasn't had many claims. But unfortunately, I had a stretch of five or six years there that things were pretty rough.
RATH: The medical bills were tens of thousands of dollars. But for each incident, the Bennetts paid only their $250 deductible. The rest was paid by fellow Christians. Of course, the same would have been true if they had regular health insurance, but Fred says he prefers the health sharing ministry because it's more in line with his beliefs.
BENNETT: The part I liked about it was that I wouldn't have to be having some of my premiums spent to take care of somebody who wasn't taking care of themself, physically or spiritually, either one.
RATH: Andrea Miller is the medical director for the largest Christian health insurance alternative called Medi-Share. I asked her to explain how the program works.
ANDREA MILLER: What it is is it's a group of people, in this case Christians, who band together and agree that they want to share one another's burdens. And the way they do that is that they each put a certain amount of money aside every month and then they actually send that money to another Christian who is in need of it that month in order to help them pay their medical bills.
RATH: Now, Medi-Share and other Christian health care programs are getting attention because of the rollout of the Affordable Care Act, also known as Obamacare. Can you explain how Medi-Share fits into this new health care landscape?
MILLER: Both Democrats and Republicans came together when they passed the Affordable Care Act and agreed that Christians who'd been sharing in this way for years would be allowed to continue to do so, that they would not be required to stop what they were doing and to purchase insurance.
RATH: Can you explain how the alternative works? This is obviously - it's not for everyone. To be eligible, do you have to be a Christian, to start off?
MILLER: Yes, you're right. It isn't for everyone. In order to be eligible, first of all, you do need to be a Christian. Second, you need to agree to living a Christian lifestyle, including no smoking, including not abusing alcohol or drugs. At that point, if you want to join, you agree that you are willing to put money in your own account that's available to be used for other people. And then we let you know what other people need that money.
RATH: And are there bills that are not covered, you know, procedures that might be considered un-Christian or not in line with your morality?
MILLER: We do not share in every medical need that a person has. Some of the things we don't share in are related to lifestyle issues, such as an abortion. But others of them are related to things that the members have agreed that they would rather pay for themselves.
RATH: Andrea Miller is the medical director at the Christian health insurance alternative Medi-Share.
And unlike regular insurance, members of Medi-Share all get a say in what's covered. But because it's not insurance, there's no guarantee that their fellow members will decide to cover any given bill. It's just one of the many options Americans will be using as Obamacare goes into effect. Transcript provided by NPR, Copyright NPR.