Since the signing of the Affordable Care Act, participation in medical sharing ministries has more than doubled—increasing from 200,000 to 530,000 participants between 2010 and 2016. [1] These ministries share healthcare costs among members with common ethical beliefs, enabling people to abide by the Act’s individual mandate—that everyone must have a certain minimum of health care coverage—without purchasing insurance that covers unethical procedures, such as abortion. Although the mandate was repealed in 2019, thousands of Christians have continued to reject health insurance and embrace these ministries instead. The switch has been encouraged by the latter's lower premiums, which are made possible by cutting CEO salaries and unethical medical practices from the total cost of coverage. But the savings aren’t all these programs have going for them. They may have begun as an alternative to insurance, but the growth of these Christian ministries raises a more radical question: whether insurance is a good thing at all.
To know a thing, it is helpful to know where it came from—and insurance, like many modern institutions, came about in the midst of the Reformation. The first clear example of contractual risk-management can be found in the Protestant “Hamburg Fire Contracts” of 1591. This insurance contract did not protect houses, horses, or health—but breweries. At the time, it was not uncommon for the fire used in the malting process to get out of hand and burn down the facilities. The contract stated that the 100 brewery heirs in Hamburg, Germany mutually agreed to pay 10 Reich Thalers to any victim of fire damage among them. Payments were contingent on the severity of damage and were to only be paid if the building was completely rebuilt within a year. [2]
A similar pact was formed by a group of Christian Mennonites in 1623, called the “Tiegenhöfer Fire Regulations.” These Mennonites were adamant that the organization was congenial to the scriptures and an example of fraternal aid. [3] According to The Mennonite Encyclopedia, “The principle of sharing losses is an old one among Christians. Mennonites from their earliest history have practiced it as an integral part of brotherhood life. Sharing is, however, not thought of in terms of systematic and selective risk-bearing modern insurance.” [4] Their agreements differ greatly from modern insurance systems: benefits payments are small, the agreements are entirely mutual, there are no payments to administrative officials, and membership is typically limited to church members. [5] Many Mennonite groups are in strict opposition to modern forms of life insurance—going so far to excommunicate members who bought it—as “it reflects trust in man rather than in God.” [6]
Obviously, modern insurance companies have left this model far behind. Whereas these Hamburgians and Mennonites knew one another and signed up to help one another in case of disaster, modern insurance companies operate as a for-profit business. Their list of clients is astronomically large: each of the three largest health networks enroll over 40 million members. [7] Obviously, these 40 million people do not pay one another directly or know where their money is going. This does not breed the “brotherhood” that the Mennonites sought to cultivate. Why does this matter?
Even though the fire contacts required gifts to the devastated parties out of binding contract, the fellow members knew exactly where their Reich Thalers were going and what good they were doing. Modern insurance companies require prepaid premiums on a monthly basis, which are then used to pay off enrolled members claims. There is no knowledge of the person to whom the payments are allocated. This encourages a shift in the motivation with which we give our money. The individual Mennonite was acting self-interestedly, but not selfishly, in his insurance model: he hoped to help himself in and through helping the community in which he was embedded. It was not an act of almsgiving, in which a gift is given to them. It was an act of solidarity, in which the gift to us—to me and them, united in our common need. But modern insurance is a gift given to me, for my own sake. I do not know or care who receives my premium, rather, paying the premium is my means of limiting the cost of my own future catastrophes. It is true that this premium is only effective in serving me insofar as it serves others, but this service of others is not a part of my motivation. If, by some different system, the same money mitigated my health care costs without ever helping others, I would just as willingly pay it. Fear, and not solidarity, is the reason for my “gift.”
The clients of insurance companies find a certain financial stability in a sea of unknown people: a larger pool of participants equates to less overall risk. But it also leads to more overall costs. First, because of their size, modern insurance companies have higher administrative costs. Second, because they are for-profit companies, a successful insurance company isn't one that simply provides relief for victims, as in the case of the Hamburg Fire Contracts: success means making a profit. Most insurance companies abide by an 80/20 rule: 80% of premiums must be paid toward claims while the rest goes to other business operations and profit. [8] By buying insurance, one is only partially paying for the well-being of others in the network. He is also supporting the corporation's profitability (especially in the salaries and bonuses of their CEOs) and its investments in the stock market. To offer a substantive example, in 2020, United Health earned $201.4 billion in premium revenue and spent $2.8 and $4.2 billion on market investments and share buybacks, respectively. [9] While investing in stocks and engaging in financial engineering may seem like a clear departure from the purposes of an insurance organization, most claim that this activity increases overall profits and hypothetically reduces premiums. It may indeed increase profits. Whether it reduces premiums is doubtful: they only continue to rise. [10]
Because insurance companies aim to make profits, and subordinate serving people as a means to that end, they are radically exposed to cost-inflation on the part of medical companies–which are also profit-driven. Hospitals are not billing consumers with limited funds, but an insurance company, invested in the stock market and turning a large profit: There is no clear limit to how much one might demand for a drug or a procedure. The avarice of one inspires the avarice of the other.
Between covering unethical procedures, making market investments in who knows what, raising costs, and reaping unreasonable profits, modern insurance seems like a bad deal for Christians. But there is something more worrisome than their use of our fear to turn a profit: as mentioned, the insurance model makes it difficult to attain certain social virtues, like charity, goodwill, honesty, and affability.
Pope Saint John Paul II warned us of this in Centesimus annus: “A society is alienated if its forms of social organization, production and consumption make it more difficult to offer this gift of self and to establish solidarity between people.” [11] Relying on insurance companies instead of one another habituates us to ask incredulously, as did Cain, “Am I my brother’s keeper?”
So are medical sharing networks a better option? For the most part, yes. In order to mitigate the financial burdens of health care in a manner that helps us become charitable rather than fearful, our money ought to be allocated directly toward a fellow member in need. Health sharing plans achieve this more effectively because of their non-profit status and minimal overhead costs. Most of them promote some form of community, requiring personal statements of faith before joining. Medi-Share, one of the more popular options, goes so far as to reserve the right to check with members’ ministers, ensuring they regularly attend church. While still abstracted from one’s immediate physical community, these programs provide enrollees with the solace of participating in a community of faith. Members know that their contributions are not going to pay someone else’s fees for abortions, transition surgery, or for an executive bonus. While not a definitive attainment of a good, these ministries are a definite help in avoiding ill.
However, most plans are set up to require monthly contributions, mirroring traditional insurance premiums. Members still don't know exactly who they are giving to.
Samaritan Ministries, a protestant health-share program, recognizes this danger. Instead of collecting premiums, Samaritan monthly notifies its members of a medical need of someone in the network; the members then send a pre-set monthly amount directly to the recipient—often with a note of encouragement and a promise to pray for him. Within a society so reliant on abstract mechanisms of interaction, Samaritan offers a relatively good opportunity to engage in friendship. It’s an even better step forward, offering members the chance to practice charity, instead of fear.
The typical objection to calls for departure from modern financial schemes is that such acts are imprudent. Many claim that we must participate in them in order to care for ourselves and our families. And indeed, people buy health and life insurance because they care about their families or business insurance because they care for their employees. But it is not sufficient to serve some others (our families) through a system that is deleterious to “other others” (our society) and which habituates us to using people for our own ends, rather than knowing, loving, or caring for them. Saint Thomas criticizes a notion of prudence that focuses on the individual at the expense of the common good: “the individual good is impossible without the common good of the family, state, or kingdom.” [12] Individual and even familial-oriented prudence must be well-ordered within a prudence directed towards the larger common good. With medical sharing plans, we have the chance to love, not just ourselves and our families, but those other selves and other families with whom we are bound in mutual need.
Kimberly Leonard, “Christians Find Their Own Way to Replace Obamacare” U.S. News February 23, 2016.
William L. Evenden, Deutsche Feuerversicherungs-Schilder German Fire Marks. (Germany: VVW Karlsruhe, 1989), 2-3.
Myles A. Tracy, “Insurance and Theology: The Background and the Issues,” The Journal of Risk and Insurance, 33.1 (1966): 85-93.
The Mennonite Encyclopedia, Vol. III, pp. 42-43, Scottdale, Pennsylvania: Mennonite Publishing House, 1957.
Ibid., 343-344.
Ibid.
Robinson Townsend, “The Largest Health Insurance Companies of 2022,” Value Penguin February 11, 2022.
The Affordable Care Act requires health insurers to submit data on the proportion of premium revenue spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). Depending on size, the law requires insurers to achieve at least an 80% or 85% MLR. If the insurer fails to meet this threshold, it must provide a rebate to its customers. Centers for Medicare and Medicaid Services. https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio
https://www.unitedhealthgroup.com/content/dam/UHG/PDF/investors/2020/UNH-Form-10-K.pdf.
A share buyback is when a company uses its cash to purchase its own shares, artificially increasing demand for the stock. This directly increases the share price without doing anything to improve the business or market demand for the stock.
Sarah O’Brien, “Average family premiums for employer-based health insurance have jumped 47% in the last decade, outpacing wage growth and inflation” CNBC November 11, 2021.
Centesimus annus §40.
STh II-II q47 a10 ad2.