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‘A very good track record’

But the most interesting cases are the exemptions based on belief. There is a “religious conscience” clause for such groups as the Old Order Amish or Old Order Mennonites, who restrict or bar contact with modern society and also have never paid into Social Security or Medicare.

“They just don’t do insurance,” said Timothy S. Jost, a health care analyst at the Washington and Lee University School of Law. “Groups like that are exempt.”

To secure the exemption, the groups must certify to the IRS they are conscientiously opposed to public and private insurance and that their religious group provides a reasonable level of living for its members and has existed continuously since Dec. 31, 1950.

A second contingent, Christian-based health care sharing ministries such as Samaritan, are exempted because they pick up their own costs.

The Alliance of Health Care Sharing Ministries’ website says ministries have members in all 50 states and share $165 million per year for health care. To qualify for the exemption from Mr. Obama’s health care law, a member must belong to a ministry that has existed in some form since 1999.

If Congress had refused to shelter the Old Order Amish and Old Order Mennonites from the individual mandate, it would have created a high-profile standoff.

“They would have gone to prison over it,” said Donald B. Kraybill, a specialist on the Amish and senior fellow at the Young Center for Anabaptist and Pietist Studies at Elizabethtown College in Pennsylvania. “There was a great deal of concern but it was kind of a no-brainer.”

He said the roughly 280,000 Amish and 50,000 Mennonites in the U.S. emphasize a strong separation between church and state, so they don’t feel they should obtain public benefits they view as “handouts.”

Despite their lack of formal insurance, the Amish are model patients because they pay cash and will not sue doctors for malpractice, and the hospital does not have to deal with the paperwork associated with big insurers, said Mr. Kraybill, whose most recent book, “The Amish,” was published in April.

“They know these people will pay,” he said. “They have a very good track record.”

The Amish are not homogenous and have varying approaches to health care, but serious injuries or illnesses do result in medical bills. Some congregations will pool funds to share the burden of health costs before church leaders negotiate with hospitals “just like an insurance company would,” Mr. Kraybill said, while others will seek direct donations or hold benefit auctions.

‘Island of freedom’

Samaritan and other sharing ministries employ the same kind of concept — voluntarily sharing a burden with like-minded religious people.

Guided by Christian principles, members of the ministries promise to live a healthy lifestyle — no illegal drugs, alcohol only in moderation and no sex outside marriage. In doing so, they say, members reap the benefit of monthly payments that are far lower than insurance premiums and a community-driven system that replaces corporate red tape with prayer cards.

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