ACA exemption of health care sharing ministries: Ethical concerns

Among the many things that Congress and President Obama have to account for in the Patient Protection and Affordable Care Act (ACA) is a little known feature called by one physician, the “Miracle on Page 327,” the “miracle” being the exemption of the more than 160,000 members of three Christian health care sharing ministries from the ACA requirement that nearly all U.S. residents carry minimum essential insurance coverage. These health care sharing ministries (HCSMs) are private tax-exempt, Christian organizations that coordinate the sharing of some of their members' medical expenses through insurance-like plans (absent health financing regulatory oversight). Persons wanting to join HCSMs must apply for membership and meet theological, behavioral, and in some cases health status criteria. Justification for the ACA exemption of HCSM members from the individual “mandate” and from the shared responsibility payment is not found in the legislation. Generally little is understood about the nature and operations of HCSMs as well as about their medical, moral, and financial effects. This paper begins with an examination of key characteristics of HCSMs and their ACA exemption, followed by an ethical analysis that finds several ethically concerning dimensions of HCSMs and the exemption. Given ACA's commitment to “universal” participation and affordable financing, I argue that the ACA exemption of HCSMs is unjust due to 1) the inequitable responsibility and risk it places on non-HCSM members (the broader US public) and 2) multiple exclusionary features of HCSM membership and coverage. For example, HCSMs typically do not “share” (or cover) medical expenses for preventive care, mental health services, and for many pre-existing conditions. To conclude, I explore the parallel notions of social solidarity and individualism that exist in tension within HCSMs and within the ACA.