Typically, a hospital patient paying out of pocket for major surgery needs a long-term payment plan, so when Gary L. Edwards' friend paid off his $30,000 emergency hernia operation tab in about a month, it left hospital officials flabbergasted.
Mr. Edwards and his pal are members of Samaritan Ministries International, a "health care sharing ministry" in which Christian members pay for each other's health care needs through monthly shares.
"My doctors are very impressed by it," said Mr. Edwards, a 59-year-old from Falls Church who says Samaritan Ministries helped him pay for a biopsy and helped cover treatment for his wife, Susan, when she injured her back.
While most Americans next year will have to grapple with the intricacies of President Obama's health law and the "individual mandate" requiring residents to have health insurance, Mr. Edwards and more than 160,000 others who use health-sharing ministries will be exempt.
They're one of nine exemptions built into the health care law, covering everyone from illegal immigrants to prisoners; those who have religious conscience objections, such as the Amish; and health care sharing ministries members like Mr. Edwards.
Many of those exemptions were practical: Prisoners already get government-sponsored health care, for example.
But through long-standing pacts and persuasion on Capitol Hill, devout groups such as Samaritan Ministries and the Amish secured exemptions because they argued that they meet two of the founding principles behind Mr. Obama's law — that if you like your health plan, you should be able to keep it, and that broader access to health insurance will reduce the financial toll that results when uninsured Americans use the emergency room as their go-to clinic.
"We're not free-riders on the system," said James Lansberry, Samaritan's executive vice president.
Escaping the mandate
Political controversy has surrounded many aspects of "Obamacare" since its passage three years ago, but clamor over the individual mandate rang the loudest until the Supreme Court deemed it constitutional last June, saying it was a viable exercise of Congress' taxing authority.
Starting in early 2015, taxpayers will have to say on their returns for the previous year whether they were covered by insurance or, if not, whether they were exempt. For each nonexempt family member without coverage, "the taxpayer will owe a payment," according to guidance from the Internal Revenue Service.
The penalty starts at $95 for low-income taxpayers in 2014, rising to $659 in 2016. Higher-income taxpayers who reject coverage will pay more — 1 percent of their income in 2014, rising to 2.5 percent in 2016.
People who are not legal residents of the U.S. are exempt from the mandate, although undocumented immigrants are not eligible for government benefits under the law either.
American Indians, many of whom obtain care through the government's Indian Health Care system, also are exempt, although The Associated Press recently reported on concerns the law defines qualified Indians and their tribal affiliations too narrowly.
Other exemptions apply to those who do not earn enough to file a tax return, who will not be covered by Medicaid because their state chose not to expand the program under Mr. Obama's law, and those who cannot afford even the cheapest qualified health plan.
'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.
"It's nicer to get a call from someone saying they're praying for you than a computer slip in the mail from an insurance company that says your bill's been paid," Mr. Edwards said.
Unlike insurance, sharing ministries do not pool health risks or face state regulations mandating reserves of capital or surpluses. A local pastor must sign off on membership at Samaritan, and members say they like knowing their dollars will not subsidize practices to which they object, such as abortion.
When the health care law was being written, Mr. Lansberry of Samaritan said House lawmakers weren't inclined to grant the ministries an exemption, but the bill's authors in the Senate were willing to accommodate.
"When that passed," Mr. Lansberry said of the upper chamber's bill, "there was a little bit of a sigh of relief."
He said that despite general concerns about Mr. Obama's law as a government intrusion into health care, they do appreciate their self-described "island of freedom."
Samaritan's membership has grown steadily, but there hasn't been much uptick on the cusp of the individual mandate's impact in 2014, Mr. Lansberry said. While it could still happen, he thinks it's unlikely.
"This," he said, "would be the last thing on people's minds if they're trying to get around the mandate."
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