Judd Grossman may be an outlier, but he is far from the only person in Teton County, let alone the United States, to find himself staring at exorbitant health insurance costs.
Until 2018 he and his wife, Mary, were enrolled in an Affordable Care Act-approved plan, purchased on the marketplace set up by the landmark health care legislation. Their insurance was expensive — $1,800 a month — but the peace of mind was worth the financial hit.
Then they received their renewal information for 2019. Their joint premium was set to jump to $2,800 a month, with an $8,000 deductible and $13,000 in maximum out-of-pocket costs. All told, they would be on the hook for $33,600 in premiums alone, and $46,600 in total costs before the insurance company began to cover all their costs.
They knew they needed to find another option.
“Insurance is supposed to protect your life savings from disaster,” Grossman said, “not drain it.”
A friend suggested a cost-sharing ministry, an organization that doesn’t provide health insurance but helps members with health costs in a similar way. Cost-sharing ministries take a payment from members each month, put that money in a fund and disburse it based on bills members submit.
On its face, the system is similar to how insurance companies function, but the parallels are skin deep. The ministries proliferated after the Affordable Care Act was passed, in part because they are exempt from some of the legislation’s key patient protections.
Some require members to be Christians, going as far as making them send in an annual form signed by their pastor. Others, like Liberty HealthShare, which the Grossmans use, ask for a pledge to uphold Christian values like helping the poor and needy, something Grossman said he had no problem with, even though he is Jewish.
Data from the Alliance for Healthcare Sharing Ministries, an industry group, shows that roughly 160,000 people were enrolled in the ministries in 2014. The little-known, little- used option was popular in Amish and Mennonite communities, which lumped money together to cover medical costs.
The Affordable Care Act included an exemption for ministries on religious grounds, in part because it required insurance to cover procedures and medications, like birth control and other family planning, antithetical to some faiths. The exemption allowed the ministries to cover what they wanted, meaning they could reject controversial procedures like abortions and refuse to cover pre-existing conditions.
As Affordable Care Act-compliant plans became more and more expensive, people like the Grossmans began turning to the ministries because they offered much lower monthly premiums, with about 1 million enrolled, according to the ministry alliance.
The Grossmans now pay about $500 a month into Liberty HealthShare.
“It was nerve wracking to sign up for,” Grossman said, “but the deductible is five or 10 times more reasonable.”
Working without a contract
The Grossmans are a rarity in Teton County. St. John’s Health, which recently changed its name from St. John’s Medical Center, has few patients who are members of the ministries.
“It’s not the norm,” Revenue Cycle Director James Hohl said. “We don’t have many.”
Hohl’s job at the hospital is to work with payers to cover patients’ costs. Working with cost-sharing ministries is different than the hospital’s relationship with insurance companies, which have federal oversight and a spate of regulations that govern how they operate.
St. John’s negotiates prices with insurance companies, so when a patient goes in for something like gallbladder surgery all parties should understand what price the insurance company and patient will pay. Since cost-sharing ministries don’t work with the hospital in the same way, they can decide not to cover some, or all, of the cost of a procedure.
When that happens, the hospital goes to the patient, in part because its contracts with insurance companies mean it can’t offer lower prices to members of cost-sharing ministries.
“We’re obligated to collect what’s due,” Hohl said. “We have lots of agreements with payers; we can’t undercut those folks.”
Not only can cost-sharing ministries make life difficult for hospitals, they can leave patients holding the bill. The website of Samaritan Ministries, one of the country’s larger such organizations, says, “A health care sharing ministry does not assume any transfer of medical risk from its members or make any guarantee of payment for any expenses.”
The News&Guide requested comment from both Liberty and Christian Health Ministries, another large cost-sharing program. Liberty did not respond, and Christian Health Ministries declined an interview, saying it would answer questions by email if it could. Answers to a set of emailed questions were not returned by press time.
St. John’s CEO Paul Beaupre said one flaw in the ministry system that can lead to patients being stuck with the bill is a lack of preauthorization. Insurance companies are required to tell hospitals if they will cover a procedure and what the financial breakdown will be. That happens before a patient goes under the knife.
Cost-sharing ministries don’t always tell hospitals what they’ll pay first, Beaupre said, or they tell patients to undergo a procedure then don’t cover the full costs. To him, that “degree of lack of transparency” is the ministries’ main problem.
When a hospital can’t collect on a bill from an insurance company or cost-sharing ministry, it turns to the patient. If those bills are for smaller services, like physical therapy or a specialist visit, patients can often cover the charge.
For larger procedures or long-term care, patients are often not financially equipped to pay out of pocket. After all, patients pay into monthly plans, even when they aren’t going to the doctor, because they have the trust larger costs will be covered.
Trying to deal with it
Hohl said he and his staff try everything they can to avoid charging patients, but when cost-sharing ministries don’t pick up the whole bill, they don’t have much choice.
“What’s hardest on me and the staff is that it’s putting the patient and us in the middle and at odds,” he said. “That patient just wants to feel better.”
If the ministries have similar problems to those the health insurance market had before passage of the Affordable Care Act, the question is: Why have more than 800,000 people signed up for them in the past six years?
“For someone who absolutely cannot afford the premiums on traditional programs,” Beaupre said, “this does offer a certain amount of security and a safety net.”
Beaupre and Hohl both said St. John’s works with all payers, including the cost-sharing ministries, despite the drawbacks. Because some patients feel the organizations may be their only option, the hospital doesn’t turn them away.
However, Beaupre wants anyone who signs up for the ministries to understand how they work. Knowing they don’t always cover pre-existing conditions or that the potential exists for them to deny part of a bill goes a long way toward avoiding a surprise bill.
The Grossmans, for their part, are well aware Liberty isn’t legally obligated to cover them the same way insurance would. Grossman said the up-front cost reduction is worth the risk, though he knows that could change quickly.
“If something catastrophic happens and they won’t pay,” he said, “it was a bad idea.”
He said that the ministry has been easy to work with so far in his claims, but he insisted the lower cost was not the only bonus. In addition to shoveling money at insurance companies in the past, he felt the relationship was adversarial. With Liberty, he feels differently.
“There’s more of a feeling that we’re in this together,” he said. “The whole vibe is ‘let’s work together.’ The concept makes me happy to be a part of it.”