In seven years, Bethany Joy Kim has cycled through Obamacare, a Christian health care sharing ministry, state insurance, employer-based insurance, and back to Obamacare.

Kim’s biggest concern, amid her various insurance experiences, has been cost. She was living in Arizona in 2014 when she purchased insurance through the marketplace established by the Affordable Care Act (ACA). But her premiums increased and she couldn’t find doctors who would accept her plan, so eventually she canceled it.

When Kim and her husband moved to Wisconsin in late 2017, she was expecting. She qualified for BadgerCare, the state’s insurance program for pregnant women and children. Not long after, the family got insurance through her husband’s new employer. Even with about $600 taken out of her husband’s paycheck each month to pay for premiums (the employer paid the other half), Kim was surprised that they still spent thousands of dollars annually out of pocket in the form of copays and uncovered percentages.

“When I look at the amount I pay in for the library system or the fire department, that seems reasonable. When I look at what I pay for health care, it doesn’t make sense to me anymore,” Kim said. She is hardly alone: The average premium for family insurance coverage last year was $20,000, a 54 percent increase from a decade earlier.

In between Obamacare and state insurance, when Kim was without insurance, she joined Medi-Share, one of several major nationwide Christian health care sharing ministries (HCSMs). Since 2010, when HCSMs and their members were exempted from various ACA requirements, these ministries have seen a dramatic increase in enrollment and now count over 1.5 million members.

HCSMs bill themselves as an antidote to the costly and complex insurance system. Members agree to a statement of shared beliefs and contribute set monthly amounts in the range of $300 to $800 per household that go toward other members’ health care expenses. These ministries keep member contributions to a fraction of the price of insurance premiums because they usually don’t share costs related to preventative care or preexisting conditions. Members also follow lifestyle guidelines, such as avoiding illegal drugs and tobacco use, enabling HCSMs to screen out higher-risk populations.

The health-sharing ministry alleviated Kim’s main concern about affordability. But for the theologian and leader in the Society of Vineyard Scholars, it triggered a new problem: the feeling that she was participating in a system that used religious exemption to discriminate.

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HCSMs are exempted from ACA minimum coverage requirements because they are faith-based nonprofits that aren’t exactly insurance. They generally don’t cover out-of-wedlock pregnancies, contraception, or abortion, and they are not bound by ACA rules to cover mental health. “They are keeping costs low at the expense of the vulnerable,” Kim said. Those same people, she feels, are the ones Christians are explicitly called to care for.

In fact, a lot of traditional health insurers also discriminate, if by different criteria. The Trump administration has exempted employers from requirements to cover birth control if they have moral or religious objections (churches were always exempt). Recent years have seen a rapid rise in workplace wellness programs and medical screenings, where healthy employees receive coupons and steeply discounted premiums. And economists have long argued that employer-based plans, where roughly half of Americans receive health coverage, are an important tool for insurance companies because they screen out the highest-risk individuals—those unable to hold full-time jobs or pass drug tests, for example—and are able to entice healthy, young workers to pay premiums to cover the costs of less-healthy workers.

So while health coverage groups pass over bad health bets in varying ways, the net result is the same: a health care system with many ways to get in but crowds of sick people still stuck outside.

It could soon shut out even more: This November, the Supreme Court begins hearing arguments against the constitutionality of the ACA and is expected to rule next year. A decision against the law could potentially be the final blow in a long series of political and legal challenges meant to kill the Obama-era health care expansion, leaving millions suddenly uninsured and at risk of having coverage denied because of preexisting conditions.

Never has the fragility of the US medical system been more apparent than this year, when the coronavirus pandemic overwhelmed many hospitals and highlighted disparities in access to health care among communities of color. The COVID-19 death rate among African Americans has been twice as high as among whites, prompting many in the mainstream to ask for the first time why black people tend to be sicker than white people.

Lack of health coverage plays a significant role. In 2018, uninsured rates for nonelderly Hispanics and blacks were 19 percent and 11.5 percent, respectively, compared to 7.5 percent for whites. And those numbers don’t reflect the impacts of the pandemic, which has led millions of Americans to lose their health coverage.

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Kim became one of them when the Wisconsin college where her husband taught shut down in June. The couple went back to the ACA marketplace and found an affordable insurance plan that’s working for their family—for now.

The irony of America’s anxiety over medical coverage is this: Modern health insurance was a charitable evangelical invention, sold and managed by humble not-for-profit groups, designed especially to be affordable for low-income and vulnerable Americans. But in the span of two generations, astounding growth in the insurance industry and equally astounding advances in medical technology left most Americans staring at a starkly different picture: seemingly heartless insurance corporations paying hospital systems to provide care that they increasingly can’t afford.

For Christians to find a better way forward, we may need to rediscover our roots.

Justin Ford Kimball had not even worked a year in health care when he invented medical insurance in 1929.

A former teacher and school administrator, the square-jawed vice president of Baylor Hospital in Dallas was watching the stock market crash and was thinking about money. His hospital was half empty and sitting on piles of unpaid bills, and “the people who owed them had no money,” Kimball later wrote. Many of those debtors were teachers.

Kimball had developed one of the first sick-time programs for teachers as a school superintendent. He felt that “teachers tended to worry too much—and none more so than over illness, with consequent loss of pay.”

Find a way to reduce that worry, Kimball figured, and he could fill more hospital beds.

His solution was the earliest version of modern health insurance. The hospital sold it to Dallas schoolteachers for 50 cents a month and, in exchange, covered most of the cost of one three-week hospital stay per year.

The plan was instantly popular. Three in four Dallas teachers signed up, followed by local newspaper and radio employees. Within a few years, as the Great Depression wreaked its havoc, hospitals around the country established similar nonprofit programs to keep people, regardless of health, from being crushed by medical bills. Thus began the Blue Cross and Blue Shield family of insurance companies.

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Kimball was watching out for his employer’s bottom line, but he and the Texas Baptists who oversaw the hospital were also following in the footsteps of the early church. When the plague struck third-century Rome, Christians organized themselves to care for the sick and the dying as both the government and their pagan neighbors looked on in dismay. As historian Gary Ferngren documents, these public displays of righteousness persisted despite growing persecution of the church—and they laid the groundwork for modern Western medicine. In less than a century, once Christians enjoyed the favor of Constantine’s rule, church-run infirmaries and hospitals emerged as formal parts of Roman society.

In contrast, the philanthropic era of American health insurance was fleeting. Health reporter Elisabeth Rosenthal writes that during World War II, in the face of labor shortages and a wage freeze, US employers sought to attract workers by offering insurance as an incentive. The IRS, and later Congress, decided that those benefits didn’t have to be taxed—a subsidy that now translates to the third-largest federal health care expenditure ($250 billion in 2017, according to the Congressional Budget Office), behind Medicare and Medicaid.

The rapid expansion of health benefits that followed, together with scientific advancement in medicine and rising costs, drew for-profit companies into the insurance industry. Businesses began offering an array of options and, to bolster profits, began charging customers different rates based on age and other risk factors.

What we call insurance today barely resembles the low-cost hospitalization coverage that Kimball developed for his Dallas teachers. Insurance premiums now devour nearly a third of the average American household’s income. And in May, only a couple of months into the COVID-19 pandemic, an estimated 29 percent of working-age adults in Texas were uninsured, the highest rate in the US.

In the latter half of the 20th century, complaining about our broken health care system became an American pastime. So did fighting over ways to fix it.

The acrimony reached new heights in 1994, when the nation divided sharply over President Bill Clinton’s health care reform plan. Pat Robertson’s Christian Coalition spent a record $1.4 million to lobby against it. Other evangelicals supported pared-down versions of the proposal, which ultimately failed.

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A little more than a decade ago, as many as two-thirds of Americans—even politically conservative evangelicals—believed the government should do something to improve health care access for the poor. In 2009, Charles Colson wrote in CT that “our present system, still the best in the world, needs to expand coverage to the uninsured.”

The United States is the only country where health insurance is tied to employment, and experts across the political spectrum agree it creates problems. It leaves many who are self-employed, who work part-time, or whose employers provide insurance with few, if any, options for affordable, comprehensive coverage.

But solutions have been elusive. When President Obama signed the ACA into law in 2010, the legislation sought to dramatically expand coverage by providing tax credits to pay for health plans not provided through employers and by expanding Medicaid to cover anyone whose income fell below 139 percent of the federal poverty level.

It met strong opposition, particularly among evangelicals. In one 2019 study, only 23.8 percent of white evangelicals approved of the ACA, compared to 84.8 percent of black Protestants, 66.2 percent of Hispanic Catholics, and 46 percent of white mainline Protestants. The reasons were many. Much of the resistance stemmed from concerns that the ACA would force people of faith to pay for abortions and other morally objectionable procedures like euthanasia—the same concerns Christians had about Clinton reform efforts. Also at work were the oft-repeated charges that the ACA would lead to excessive government control and deprive individuals of the opportunity to choose their own physicians and treatment options—forever encapsulated by Sarah Palin’s viral mantra about Obama’s “death panels.”

But there was also a perception, according to Ohio University sociologist Berkeley Franz, that the ACA amounted to a government handout, allowing people to receive health care without necessarily holding jobs.

There was an emphasis “on people deserving health insurance,” said Franz, who interviewed members of evangelical churches to study their views on health care reform. “They wanted to make sure it was linked in some way to hard work.”

The question of who deserves care is ubiquitous throughout health insurance debates. Should those with higher health risks pay more into the system—or even be excluded? Conservative scholar Merrill Matthews Jr. argued as much in a 1994 CT op-ed criticizing the Clinton plan. Those who make poor choices should pay more, he wrote, otherwise, “Christians who treat their bodies as temples of the Holy Spirit would, in effect, be subsidizing the inevitable cost of that risky behavior.”

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Or, conversely, should those with better health and more resources pay less? If you have enough disposable income to own an Apple Watch and boast enough flexibility in your schedule to exercise regularly, you can share your fitness data with life insurer John Hancock and health insurer Vitality Health in exchange for cheaper premiums.

This raises moral and ethical concerns, of course. But for an insurer, exclusion is imminently practical, a matter of risk management. Older people pay more for life insurance and poor drivers pay more for car insurance because they are far more likely to use it.

Often, the moral and the practical collide. Stephen Ko worked at the CDC and taught public health at Boston University before becoming a pastor. He recalls that his denomination, the Christian and Missionary Alliance, once offered a health-sharing plan to its pastors that didn’t cover preexisting conditions. After denominational leaders realized such practices left some elderly pastors out in the cold, they decided to cover these costs—and the program went bankrupt. “There was not enough money in the pot,” Ko said.

“For health insurance to work, you need a large enough pool of people with a variety of health profiles to share the risk, so that the majority who have good health are able to spend less to have more available for the minority who need it,” said Mark Strand, a public health professor at North Dakota State University and an elder at his church in Fargo. This is why HCSMs, which have relatively small pools, pick and choose the costs they share to keep contributions affordable and why the ACA included an individual insurance mandate (to make the pool bigger) when it required insurance companies to cover riskier customers with preexisting conditions. (That mandate has since been dismantled by the Trump administration.)

Strand puts health care in the category of a public good—something like education, roads, and water that everyone needs to flourish and that governments should ensure everyone can access. For evangelicals, who are rooted in a history of caring for others and in historical virtues such as the Protestant work ethic and personal holiness, Franz boiled the tension down to this: “Are we required to provide help to others who do not make responsible choices?”

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Freedom of choice has long been a paramount value for Americans when it comes to health care. Proposals to nationalize US health care in the 1930s were ultimately defeated by advocates who rallied around the “voluntary way” as the American way. And as the Communist specter rose in the 1940s, any program accused of forcing options on Americans became political anathema.

In today’s health insurance market, “People are encouraged to think of themselves as health care consumers,” said Goucher College anthropologist Carolyn Schwarz. “They’re shopping for health care.” Even Obamacare was pitched by proponents not as government-managed health insurance but as a feat of consumer-driven choice.

HCSMs make a similar appeal, projecting themselves as voluntary communities of one-on-one acts of compassion. At the Alliance of Healthcare Sharing Ministries, which coordinates between major HCSMs, spokeswoman Katy Talento stressed that HCSMs are “a totally different, transformational paradigm shift” from insurance. Instead of relying on “cold bureaucracies” beholden to government regulations, Talento said, HCSM members trust one another to come through for their health care needs. (Members are still kicked out of the programs for failure to pay their monthly contribution.)

But choice in health care doesn’t function in quite the same way as in other markets. Patients rely on doctors to know what treatments they need. The price of a mammogram or a knee surgery varies wildly from hospital to hospital, and consumers often have no way of knowing up front how much of that price they would actually owe. You can’t exactly shop for an ER visit the way you shop for an oil change.

Schwarz, who has studied HCSMs, said that members often speak of joining an HCSM as their own choice, but major factors constrain those choices. Many lack access to employer-based insurance. Some are retired but don’t yet qualify for Medicare. Their income may be too high to qualify for Medicaid but not high enough to afford insurance premiums, even with ACA subsidies.

Likewise, employer-based insurance often feels like the only option rather than a real choice. Because the federal tax break allows many employers to offer coverage more cheaply to employees than the individual marketplace can, refusing insurance from your workplace is almost unthinkable.

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Then there are those without any choice: people who work part-time jobs that don’t offer health insurance and who still can’t afford marketplace insurance or even an HCSM. In states with restrictive Medicaid eligibility, such people likely end up uninsured.

In health care, then, “freedom of choice” may be more of a dream than a reality.

For Patrick Smith, an ethicist at Duke University, the connections we draw between personal choices and health outcomes pivot around how we understand sin. Sin, he said, has disrupted all aspects of God’s good creation, not just our personal relationship with God or our face-to-face relationships, but also the social order—“all of those things that are generated by human beings that may not be material in the sense of trees and chairs and airplanes but are no less real, which are our institutions—our various ways of doing life together in a larger society.”

Sin can disrupt institutions on a small scale, such as the case of an abusive parent instigating cycles of familial trauma and abuse. But also, Smith points out, it keeps governments and markets from functioning justly. Take historical discriminatory practices like redlining, which prevented African Americans from buying houses in certain neighborhoods, limited the growth of black wealth, and perpetuated housing segregation. These policies kept many from thriving and still contribute to poor health outcomes.

Black communities and other marginalized communities, which were pivotal in pushing reforms such as Medicare and Medicaid, have long recognized the role of government in protecting health. In 1966, Martin Luther King Jr. famously declared that “Of all the inequalities that exist, the injustice in health care is the most shocking and inhuman.” (Many US hospitals did not integrate until the Civil Rights Act of 1964 forced them to.)

As the COVID-19 crisis plays out, the limits of personal choice on health are on full display. “It’s as if the veil has been peeled back,” said Michelle Kirtley, a fellow at the Center for Public Justice, a Christian think tank. “We’ve realized that having people who do not have easy access to health care walking around spreading COVID-19 is not good.” With the widespread support for government relief packages that waive COVID-19 testing and treatment fees for the uninsured, people are admitting a lot, Kirtley said. “That there is a public, common good.”

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Even some cost-sharing ministries, such as Medi-Share, have waived fees for coronavirus-related doctor and ER visits in some circumstances—a concession, perhaps, that even the healthiest lifestyle can be derailed by forces beyond our control.

Image: Illustrations by Ileana Soon

Take even a cursory look at the political rhetoric surrounding health care reform, and it would be easy to conclude evangelicals don’t care about the medical plight of the poor.

But the field of medical missions tells a different story.

Like their early-church forebearers in Rome, modern Christians have been some of the first in and the last out in responding to medical needs. They have founded some of the world’s most important medical centers. They are a key driver of short-term medical mission trips, which provide an estimated $3.7 billion worth of volunteer health care in poor countries each year. And evangelical groups operate countless small hospitals and clinics around the globe, filling prescriptions and performing major surgeries for free.

“Traditionally, Christian missions have led the way in caring for the sick,” Henry Mosley, then a professor of international medicine at Johns Hopkins University, told CT back in 1986, when concern was rising that economic hardship was leading some ministries to pull back overseas. “Mission agencies can take the initiative to demonstrate compassion and caring for those who are neglected by their governments.”

That sense of crisis is harder to find among evangelicals when it comes to health care in the United States, however. That could be because it feels easier to solve other people’s problems than our own. The closer we are to a challenge, the more likely we are to get lost in the minutiae and approach it with what University of Wisconsin–Madison business professor Evan Polman calls a “cautious mindset.” And, Kirtley adds, acknowledging negligence in our own country would require reckoning with complex histories of inequity.

Christians have tended to focus their domestic health ministries on serving specific populations like pregnant women or the homeless. Of the US-focused nonprofits registered as medical ministries with the Evangelical Council for Financial Accountability, most are crisis pregnancy centers and rescue missions that offer health services as part of a broader outreach, causes that churches tend to already be interested in.

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More recently, churches have expanded their outreach into new realms. Congregations like Revolution Annapolis in Maryland have attacked health care expenses directly, collecting offerings to pay off millions of dollars of medical debts in their communities.

And many US cities have churches increasingly taking a bigger-picture approach, like the United Methodist Church for All People in Columbus, Ohio. The congregation, which collaborates with sociologist Franz in her community-based health work, hosts a free medical clinic, partners with a nearby children’s hospital to remediate low-income housing of mold and lead, and runs a community garden–based food pantry and low-cost bike shop.

The church has “leveraged all kinds of different partners, from local groups to federal grants, to change the community in positive, structural ways,” Franz said—ways that “seek the welfare of the city” as a whole, in the spirit of Jeremiah 29:7 (ESV), and impact health. Access to health care, according to Franz, accounts for only 10 percent of health outcomes. The other 90 percent is factors like access to safe housing, nutritious foods, playgrounds, and other ways to exercise.

Still, these efforts can feel like drops in the bucket. Important as they are, they cannot on their own help the millions of Americans falling through cracks in our piecemeal health care system.

For some evangelicals, political advocacy and voting to expand health care coverage at the federal level are, no doubt, part of the solution. But for many, that option will probably always represent an untenable moral compromise. They may prefer to advocate at the state level—some states are beginning to offer ACA marketplace plans that don’t cover abortion, for instance, and have created avenues for employer-provided health plans to opt out of paying for controversial procedures (some states are moving in the opposite direction, requiring all plans to cover abortion).

Others may want to join physician Morgan Wills by investing in something more on the front lines: getting Christians passionate about health care again.

A Vanderbilt-trained doctor, Wills says his life was “ruined” during his time volunteering at a mission hospital in West Africa. That eventually led him to become the CEO of Siloam Health, a health care ministry in Nashville that markets itself as sharing the love of Christ with the “uninsured, underserved, and culturally marginalized” and that prides itself on “ruining” the health students who serve there “for medical careers as usual.”

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Siloam was founded 32 years ago by Nashville’s Belmont Church and has grown into a primary care clinic that treats more than 3,000 patients a year in more than 50 languages while also training more than 50 students a year from various Tennessee universities.

Wills’s clinic is funded by churches, grants, corporate partners, and individual donors—who, Siloam says, can cover the cost of treating a patient for just $12 a month. Patients are screened for eligibility and pay as they are able, on average less than $20.

Serving immigrants and refugees—another area that many churches are already passionate about—is a key selling point of Siloam. Ask why places like Siloam are needed, and Wills might tell a story like this: One Saturday, an immigrant from Southeast Asia was shot. Instead of risking a crippling bill from a trip to the emergency room, the man waited two days so he could walk into Wills’s clinic Monday morning.

Charitable medical clinics are nothing new; there are hundreds across the country. They are typically small and cash strapped, with budgets averaging less than half a million dollars—in other words, they aren’t equipped for the big-ticket specialized procedures that contribute so much to the costliness of American health care.

But they are a vital resource for the rising number of uninsured Americans, especially as COVID-19 hits minority communities the hardest. And because they’re not driven by billing, they’re “motivated to see the image of God in each patient in a way that a government agency or a for-profit health care institution just isn’t designed and wired to do,” said Kirtley, who serves on the board of Samaritan Health Center, a free clinic in Durham, North Carolina.

Wills believes clinics like his are an essential part of the solution, but he is also not shy about speaking out for broader health care reform. “We believe in enabling the private, faith-based sector to do its work,” he made clear in an op-ed for the Nashville Tennessean addressed to legislators and Christians after the state’s governor attempted unsuccessfully to expand Medicare in 2015. “But at least the governor put his faith into action on behalf of those in need,” Wills wrote. “What—for heaven’s sake—will YOU do?”

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Ministries like these take dedication and, in Siloam’s case, decades to build. But they are possible, a way forward through our health care brokenness that is entirely within the church’s means to build and sustain. Siloam’s annual budget, at around $4 million, is smaller than that of many churches.

If every city had a Siloam or a Samaritan, our health care crisis would by no means be over. Christians in third-century Rome, after all, did not end the plague by caring for the dying. But in ministering to sick bodies that their fellow citizens dared not touch, they modeled a different way, one driven not by risk management but by risky compassion. Within a hundred years, the church and its quirky ideas of neighbor love had spread across the empire.

Liuan Huska is a writer living in the Chicago area. Her new book on chronic illness, Hurting Yet Whole, publishes in December with InterVarsity Press.

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