Caring for the Poor and Vulnerable: A Virtue Analysis of Mandated Health Insurance Compared with Healthcare Sharing Ministries

Abstract

In the present time, what has been called the “medical–industrial insurance complex” in the United States needs reform. As health insurance in the United States remains inaccessible to millions of people, and as prices continue to rise, questions arise about the most moral ways to ensure delivery of health care especially to the most vulnerable populations. In this essay, I offer a virtue analysis of the moral implications of health insurance mandated by the US Government in contrast to an increasingly popular alternative to insurance, namely, healthcare sharing ministries. In part 1, I list some of the moral problems entangled with US Government-mandated health insurance, including injustice, disrespect for patient autonomy, limitations on patient freedom, exploitation of patients for profit, undermining of conscience rights, cooperation with evil, and scandal. In part 2, I discuss the issue of risk and then list some potential moral advantages to healthcare ministries, including respect for patient autonomy, conscience, and the religious freedom to witness to the Catholic faith in charity and solidarity.

Summary:

Mandated health insurance the United States presents some moral challenges for conscientious Catholics, whereas healthcare sharing ministries appear to ameliorate some of these issues. Ultimately, the individual should have freedom to choose either insurance or healthcare sharing, given the different benefits and risks entailed by both.

Jesus Christ is the supreme “Good Samaritan” who cares for the bodies and souls of wounded persons (Lk 10:25–37). His example and strength guide and uphold the Church to be always in the front line in providing charitable help, especially to the weak and needy (John Paul II 1995, 27). The figure of the Good Samaritan in the Gospel of Luke speaks not only of the need for compassion and compassion toward the suffering; it also shows the need a “gift of self” manifested in an outpouring of concrete help (John Paul II 1995, 28). Physicians and nurses, when working for evangelical motives, are “Good Samaritans” in our midst. Some institutions also “from generation to generation have performed ‘Good Samaritan’ service” (John Paul II 1994, 29). With these examples in mind, Catholics have founded or reformed healthcare services on institutional levels, including in the development of hospitals, nursing homes, charity clinics, faith-based office practices, and insurance groups (Benestad 2017, 18–19). The aim has been to imitate Christ the Good Samaritan and ensure that as many as possible may have access to quality health care in all stages of life.

In the present time, the alliance of health care, industry, and regulation that has been called the American medical–industrial complex in the United States is often called to reform (Ehrenreich 1970; Maloney 1998; Jupiter and Burke 2013). Adding the term “insurance” to this mix emphasizes that these entities are often, perhaps inextricably, intertwined: hence, the “medical–industrial insurance complex.” As health insurance in the United States remains inaccessible to millions of people, and as prices continue to rise, questions arise about the most moral ways to ensure delivery of health care especially to the most vulnerable populations. This essay offers a virtue analysis of the moral implications of health insurance mandated by the US Government in contrast to an increasingly popular alternative to insurance, namely, healthcare sharing ministries, which are not considered insurance, focusing only on the situation in the United States. The principles are universal, but the particularities of situations may be significantly different in other jurisdictions such as the National Health Service in England or obligatory health insurance in Italy since 1943. Also, it should be noted that particular critiques may be subject to change upon better information.

Injustices in US Government–Mandated Health Insurance

In recent years, the US federal government has worked to ensure that more Americans have access to basic health insurance through the passage of the Affordable Care Act (ACA). The ACA mandates that all individuals must have health insurance, although as of 2019, the fine for lack of compliance is set at zero. There are exceptions: members of healthcare sharing ministries are exempt from the individual insurance mandate. However, US law stipulates that if a business has more than fifty employees, it must provide health insurance. The present healthcare system, including the insurance mandate for individuals and businesses, poses serious conscience problems from a Catholic perspective.

Excessive profit-seeking appears to create systemic injustice. Bipartisan studies show that medical and insurance providers are presently anything but transparent about treatment options, costs, and prices. Rosenthal (2017) in her book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, has documented ten “economic rules of the dysfunctional medical market,” with research corroborated by other works. The unspoken rules of the system manifest a lack of transparency and suggest pervasive dishonesty and inconsistency. Not all of these problems are attributable to the insurance system as such, but most are part of the entangled “medical–industrial insurance complex” as it presently exists.

Violations of Patient and Doctor Autonomy?

According to Catholic bioethics, justice requires that the autonomy of patients who are of sound mind should be respected. This autonomy is more than a principle of self-direction, a subjective right unmoored from objective evaluations as is sometimes thought (Beauchamp and Childress 2009, 103). Rightly understood, personal autonomy is founded on each individual’s freedom and responsibility for making good moral choices in accord with a judgment regarding the truth of what affects his life (John Paul II 1993, 40–41, 61). Only when an adult is incapacitated, whether temporarily or chronically, may another assist his or her autonomy and make proxy decisions. By contrast, the very system of mandated insurance restricts a patient’s freedom to choose to have medical insurance or not, without legal penalty, and the ACA gives individuals and employers little option of what benefits and services the health insurance policies they are purchasing actually cover (McKalip 2016, 437–38). This is worrisome because Catholic moral thinkers argue that “the autonomy of persons in decision-making depends in part on the options open to them and that the worse the options, the lower the autonomy” (Finn 2010, 150). Doctors, too, are often coerced: financial penalties established by central committees constrain them to provide services they might not otherwise recommend (McKalip 2016, 438).

Mandated health insurance presents an additional threat to patient and doctor autonomy insofar as it is a step toward mandated health care, which tends toward socialism, and because medicine in these conditions can be coercive. Coercion is an attempt to bypass, override, or force choice by emotional, financial, or other pressures to accept (or render) a treatment or service that a patient of physician would otherwise not accept (or render). Coercive medical practices from government institutions are well-documented, including:

1. preventative treatments, such as contraceptives and sterilizations, which are sometimes strongly recommended by healthcare providers or even forced on vulnerable populations (J. Lawrence 2000; Stern 2005; Largent 2007; R. Lawrence et al. 2011; Patel 2017);

2. any nonemergency treatment to which a patient or caretaker conscientiously objects, such as euthanasia (Smith 2003; Manninen 2006; Cohen-Almagor 2015; Vermeer 2017; Catholic University of Valencia 2017a, 2017b; Bellaigue 2019); and

3. unnecessary and expensive treatments, medications, or services.

Presently, health care seems to be ever more driven by a profit-above-all mentality. The profit-above-all motive appears to be at the root of many other injustices.

Healthcare Costs and Charges

Businesses may legitimately aim at making a profit: a just recompense for labor or investment is reasonable and rightly beneficial (see Dt 24:15; Lk 10:7; 1 Tim 5:18). Aquinas (1955) indicates that a just exchange of goods and services is at the mutual advantage of the buyer and seller (ST II-II, q. 77, a. 1). It follows that the legitimate pursuit of profit always seeks to maintain and protect the inviolable dignity of persons (Pontifical Council for Justice and Peace [PCJP] 2004, 341). When human dignity and the common good no longer factor into an exchange, and when profit serves as the primary or exclusive goal of one’s work, the result is often the exploitation of others (Antoninus 1740, tit. 1, c. 16, § 2, col. 250C-E; Benedict XVI 2009, 21, 38; Francis 2013, 56). Thus, businesses and individuals may not seek profit by any means, especially not by dishonest practices, by fostering baser human passions such as excessive fear, or by taking advantage of a vulnerable person (Leo XIII 1891, 20; Pius XI 1931, 132).

In order for an exchange of goods or services to be just, the exchange must be preceded by a truthful exchange of relevant information about the good in question. Indeed, a just price is mutually agreed upon through free bargaining (John Paul II 1991, 32). Prior to the days in which health insurance was the norm, people paid for medical needs in a way similar to the way they would purchase other necessary items such as food or clothing (Grisez 1997, 417). Even in the present day, the duties of a healthcare provider are analogous to those of a seller in many respects. The justice of an exchange demands that a buyer believes that the price he or she intends to pay is worth the goods or services he or she will receive; likewise, the seller or service provider believes that the money he or she will receive is an acceptable recompose for the goods or services he or she offers. Both buying and selling (or providing services) are therefore founded on a judgment regarding the good/service and the price in question. But “judgment cannot be pronounced except for something that is manifest, for a person judges those things he knows” (Aquinas 1955, ST II-II, q. 77, a. 3, ad 1). Consequently, transparency is necessary for justice.

In order to establish a just price of a good or service, utility, scarcity, and desirability should be taken into account (Antoninus 1740, tit. 1, c. 16, § 3, col. 255-56). Utility regards the real qualities of the thing that can excellently and effectively respond to some need, as when a modern surgical procedure actually removes cancer in contrast to some less effective technique. Scarcity points to the well-known phenomenon that supply is inversely proportional to demand; the higher price of a scarce item mitigates against hoarding and helps foster just distribution according to need. Desirability is a subjective measure that can increase or decrease depending on what makes a person consider something as more or less valuable and attractive. To estimate the utility, scarcity, and desirability of a good or service, a person must have accurate and relevant information about the thing being evaluated. Thus, the virtue of truth and the subvirtues of honesty and transparency are essential on the part of the seller or provider to ensure just pricing. On the side of the provider, scarcity and difficulty of deliverability of health care necessitate that “prices must vary from place to place to reflect the differing underlying costs of providing care in radically divergent settings” (Babcock 2019, 92). On the side of the recipient of care, if an individual exaggerates the severity of his or her condition or seeks medical care for primarily emotional reasons, knowing that insurance will cover services, he or she is seeking health care nonrationally and may even be committing fraud (Grisez 1997, 416).

If a person taking out a policy of health insurance purposely concealed facts that would be relevant to the price of the policy, such as a preexisting condition of cancer, he or she commits fraud, for the obligation of transparency falls on both buyer and seller. Insurance companies rightly denounce such concealment. Insurers or healthcare providers could perpetrate fraud if they depicted a good or service as more useful, more rare, or more desirable than it is, in order to drive up sales or the price (Antoninus 1740, tit. 1, c. 16, § 4, col. 258). Some reports suggest that up to 60 percent of durable medical equipment spending is entangled in fraud (Silver and Hyman 2018, 234).

Overtreatment is a legitimate concern in medical care. Reasons are complex. On the side of the patient, guaranteed health care, and to a lesser extent mandated insurance, may encourage the “nonrational use of healthcare” (Grisez 1997, 417), in which patients indiscriminately seek health care in the absence of cost triggers that would ordinarily prompt more thoughtfulness (McKalip 2016, 436). On the side of the healthcare provider, interests include avoiding malpractice and negligence claims, as well as seeking additional profit, sometimes as a result of shrinking reimbursement. At the recommendation of physicians or healthcare providers, many patients receive—and pay for—unneeded services, and the industry does not foster careful budgeting of resources: between 34 percent and 47 percent of medical spending is estimated to be unnecessary (Rosenthal 2017, 192–204; Silver and Hyman 2018, 150; Makary 2019, 143). Health Affairs published a study arguing that chargemaster prices for health care are an average of 3.4 times the actual cost of patient care; and in fifty hospitals, the prices were ten times the cost (Bai and Anderson 2015). Unfortunately, to balance out underpayments for services whose prices are kept artificially low by government price controls, healthcare providers charge higher prices in noncontrolled segments of their offerings (Babcock 2019, 91). Sadly, the uninsured typically pay the most (Anderson 2007), a situation that threatens to impoverish religious communities such as the Amish (Makary 2019, 22–23). In addition to the cost-shifting described above, predatory practices designed to eliminate competition are directly contrary to the Catholic solicitude and mercy for the poor, a reminder that from a Catholic perspective, mercy should be exercised not only by individuals and government but by businesses as well (John Paul II 1988, 42–43; PCJP 2004, 182–84).

Uninformed Consent?

In nonemergency situations, patients typically sign a contract to pay in due time; after signing, they undergo a treatment. A contract by its nature is an agreement between two parties who knowingly, freely, and legitimately oblige themselves in some way (Liguori 1953, lib. 3, tr. 5, c. 3, dub. 1, no. 707). Contracts are important for the well-functioning of society because they are powerful tools that help bring predictability to economic relationships (Finn 2010, 143). For contracts to achieve their end, a mutually agreed exchange between parties, truth-telling is essential. Before any service is rendered in nonemergency situations, the provider must explain what goods or services will foreseeably be rendered, giving relevant information regarding what may affect their utility and scarcity as well as the price that the recipient will be expected to pay and what alternatives exist. Important in any exchange, transparency and honesty are vital for health care. These virtues can help a patient evaluate how a proposed treatment or medical device might burden him or her, or his or her loved ones, financially and in other ways. Without accurate, complete, and understandable information about the potential total cost of a medical good or service, a person will be unable to evaluate accurately the relative burden entailed by a treatment. That is, the patient will not be able to weigh accurately the potential benefits of the service with the potential cost (Babcock 2019, 91).

Catholic bioethics holds as a principle that the high price of some medical treatments or services may constitute an undue burden on a potential patient or his or her family members. Even if they are life-saving, unsustainably expensive treatments may be reasonably rejected on the grounds that they pose very grave financial burdens (Austriaco 2011, 142; Sgreccia 2012, 685; Eijk et al. 2014, 572). A clear and honest exchange of information before medical services are rendered can therefore help eliminate unnecessary and unwanted spending by enabling a patient to make an act of informed consent to treatments as well as their proposed price or to reject them. Instead of feeling disempowered and helpless because of a lack of transparency, patients would then experience greater autonomy and responsibility for their health. Blase (2019) shows that transparency can lead to four benefits:

1. better informed customers and patients,

2. better informed employers who can help workers shop for value,

3. improved ability to monitor insurer effectiveness and eliminate counterproductive middlemen, and

4. increased pressure on high-cost providers to offer more reasonable prices.

As in other service industries, patients are billed only after the service is rendered, that is, when the treatment is complete. It is undoubtedly difficult to predict accurately potential costs and treatments because a patient’s needs cannot fully be known until they are “in the actual moment of care,” at which point the primary concern is not cost but the patient’s health (Babcock 2019, 92). However, even when healthcare providers do discuss the price of a known procedure, such as a surgery, many do not disclose the full potential price (or range of prices) of all the services and goods related to a complete treatment. One reason for this is that prices for medical devices, procedures, and tests seem to change with arbitrariness: they often vary by how much a patient or his or her insurer is able or willing to pay rather than by the provider’s costs (Makary 2019, 167–71). Some argue that underlying costs of care are unknown and unknowable (Babcock 2019, 93), but if that is the case, it would seem that the only way for hospitals to stay financially afloat would be to always charge more than a conservative estimate would establish.

One form of overcharging is when a seller could make a reasonable profit by offering a good at a normal price but instead increases the price when a buyer is at a great need; this is especially harmful when the buyer thereby incurs a great loss (Aquinas 1955, ST II-II, q. 77, a. 1). This appears to be the case for many hospitals, which often inflate prices for no stated reason, as when the price for a joint replacement surgery increased 76.8 percent in a single year (Makary 2019, 29). Studies show that some “charity” hospitals, assisted by different tax status, frequently gouge prices (Bai, Yehia, and Anderson 2020); their ominous financial straits are often a factor (Archer 2017). On the side of the insurance policy, patients may know the expected co-pay and deductible but remain unsure of how much an insurance policy will ultimately pay for a complete treatment because industry billing standards and bills are confusing at best (Rosenthal 2017, 168–69).

Lack of transparency in medical charging and coverage casts doubt on the full moral validity of a contract with a hospital and a policy with an insurer. Ideally, a contract is made such that the parties fashion an agreement suited their needs and personal tolerance for risk (Rougeau 2010, 126). However, as one researcher points out, in society there exist “imbalances of power, income, education, and social status […] that might routinely place some individuals on the losing end of private agreements in a culture that prizes individual autonomy and free markets” (Rougeau 2010, 126). Such imbalanced agreements often occur in healthcare settings, for there is clearly unequal bargaining power between a potential healthcare patient and a medical provider. Negotiating before signing a release form is often impossible either because the patient is unable to do so or because health care is often provided under a take-it-or-leave-it condition. Outside of emergencies, a person who is in serious fear for his health and signs a release form or other contractual document may be doing so without the full knowledge and freedom that are requisite for a morally binding contract (Liguori 1953, lib. 3, tr. 5, c. 3, dub. 1, no. 716). Consequently, the lack of transparency in healthcare agreements may lead to what American law—reflecting moral standards held in common with the Catholic Church—calls “grossly unfair” and “unconscionable” contractual agreements (Rougeau 2010, 129). In cases like these, Catholics might argue that the patient is a victim of force and injustice (see Finn 2010, 147–48; Leo XIII 1891, 45).

“Privatized Socialized Medicine”

Some question whether certain collusion between insurance companies and healthcare providers constitutes corruption (Silver and Hyman 2018, 101). Corruption here is understood as a secret arrangement among providers to keep prices artificially high or among providers and officials whose policies guarantee profit for certain providers (Antoninus 1740, tit. 1, c. 16, § 2, col. 252D-E). Subsidized health insurance encourages collusion between the government and insurance; conflicts of interest are widespread. The tax system encourages greater healthcare spending (Silver and Hyman 2018, 102–4, 303–4; Makary 2019, 211–13). Billions are spent by the companies in political lobbying and “donations” to politicians who help the businesses maintain their oligopoly (Rosenthal 2017, 198–200; Silver and Hyman 2018, 144–45; Makary 2019, 177–84). Mandated insurance in the environment of a nontransparent system in turn creates greater demand for services, including unnecessary services, and increases the prices of all services and medicines (Silver and Hyman 2018, 283–95).

This is the cycle: the government requires insurance; insurance companies, healthcare systems, pharmaceutical companies, and other medical-related industries profit; some of that profit in turn is funneled back to the government in the forms of lobbying, campaign donations, and other favors; politicians then help members of the medical–industrial insurance complex maintain control over healthcare provision, which increases profits and continues the cycle (Silver and Hyman 2018, 82–84, 143–47). For example, preceding the enactment of the ACA, the pharmaceutical industry promised up to US$80 billion of its expected future revenue and sponsored up to US$100 million in ads supporting the legislation (Silver and Hyman 2018, 145). The projected growth of the industry at the time was US$10–US$35 billion due to the passing of the legislation (Milne and Kaitin 2010). The pharmaceutical company has blamed insurance companies for increased prices (Rowland 2019). Meanwhile, insurance deductible premiums increased an average of 54 percent between 2016 and 2020 (Clason, Kopp, and McIntire 2020). Even when Medicare and Medicaid work to keep patient bills low, a cost-shifting effect drives up charges in private insurance transactions (Rosenthal 2017, 82). The collusion is even more concerning because private insurance companies now act as middlemen that hand off money from government-funded programs to healthcare providers. The result is that the more people pay for health care, the more private insurance companies keep for themselves (Belk and Belk 2020, 192).

The present system of healthcare delivery and financing has been called “state healthcare,” as distinguished from a truly free market system (McKalip 2016, 425–26). Doctors Belk and Belk (2020) argue more pointedly that government-mandated health care and the intervention of insurance middlemen lead to “privatized socialized medicine” (p. 177–202). Economic complexities certainly call for cooperation among individuals and businesses to promote the common good. Cooperation often entails some authority structure to guide decisions, but such authority need not be entirely composed of government officials; indeed, a mixture of government and private oversight is probably best (Grisez 1997, 418). The vast majority of healthcare spending is presently under the power of government and third parties outside of the patient–physician relationship (McKalip 2016, 426). As a result, government and medical supply allies comprise “privatized socialized medicine,” presently controlling more than 17 percent of the gross domestic product, with a large expected increase in the next few years (Mikulic 2020; Sawyer and Cox 2020). This situation tends to breed socialism because “the need for means of preventing, curing, and struggling with disease and accidental damage to the human person is as limitless as human ability to invent such means” such that “there is no way of setting a term to the expansion of healthcare resources” (Grisez 1997, 418). If there is no way to limit government-funded healthcare power, and health care extends to nearly all aspects of life, the result will be a symbiosis between the two until both government and health care become entangled in the bones and marrow of a citizen’s life.

Socialism, by definition, is a political system whereby private industries become in some way owned or controlled by the state (Leo XII 1891, 14–15). A healthcare insurance mandate helps build up a “Social Assistance State,” which has significant drawbacks described by John Paul II (1991): “By intervening directly and depriving society of its responsibility, the Social Assistance State leads to a loss of human energies and an inordinate increase of public agencies, which are dominated more by bureaucratic ways of thinking than by concern for serving their clients, and which are accompanied by an enormous increase in spending” (para. 48). The Social Assistance State, or Welfare Society, creates conditions ripe for socialism, although by itself it does not constitute an entire socialistic system. Catholics are rightly concerned about how the collusion between politicians and the medical–industrial insurance complex affects the common good and individual autonomy, for the Catholic Church since 1891 has condemned socialism as inescapably unjust (Leo XII 1891, 9; Pius XI 1931, 117; John Paul II 1991, 13–14). As McKalip (2016) argues, the present “pay for performance” model of healthcare rationing, deeply entangled with the insurance mandate and agencies such as the Center for Medicaid Services, violates Catholic principles regarding human dignity, the common good, subsidiarity, and solidarity—all “for the benefit of the government, private insurance companies, private corporations, and doctors themselves who get a bonus” (p. 427–30).

Scandal and Cooperation with Evil

The need to avoid cooperating with evil is another reason why many Catholics are loath to participate in the decisions of the medical–industrial insurance complex (Catholic Health Association 2014). The federal government, for example, mandates that all health insurance plans provide “preventative health services” at no cost to patients (i.e., with no cost-sharing), which include all Food and Drug Administration approved contraceptive methods. Such methods include contraceptive pills, surgical sterilizations, and abortion-inducing drugs such as mifepristone and misoprostol (https://www.healthcare.gov/coverage/birth-control-benefits/). These preventative services violate Catholic moral teaching because they corrupt the procreative process and in the case of some “morning after” pills kill an innocent life. For Catholics to pay into the mandated medical system constitutes cooperation with evil, albeit in a remote material way (Liguori 1953, lib. II, tract. III, c. II, dub. V, art. III, no. 63; John Paul II 1995, 74). Although paying insurance companies would not directly cause the wrong practices, nor would it constitute formal cooperation, it would facilitate the wrong practices by contributing to the financial cushion and social acceptability that makes them possible. Additionally, a number of jurisdictions in the United States allow children and teens to access certain medical services, including contraception, without their parents’ permission, which creates the situation in which children can obtain objectionable treatments for free, using their parents’ insurance policy, without the parents having any opportunity to intervene.¹ This situation forces insured parents to cooperate in the harm of their own children.

Finally, scandal in Catholic teaching is defined as whatever is done or said that leads a person to perpetrate or participate in evil (Aquinas 1955, ST II-II, q. 43, a. 1). Precisely because Catholics care for their neighbors, they want to avoid seeming to encourage others to accept and participate in a system that entails grave injustices (Liguori 1953, lib. III, tract. V, c. II, dub. II, no. 561). Funding institutions is often a form of “voting with one’s checkbook,” and paying defective insurance companies weaponizes Catholic dollars against Catholics and their good intentions (see Aquinas 1955, ST II-II, q. 71, a. 3). Many Catholics would therefore consider it scandal if they were forced to support these forms of insurance. Mandated support for health insurance thereby may violate their religious freedom as well as their basic political rights. No person should be forced contrary to his or her religious convictions to buy something for another person, just because a government bureaucracy thinks that the item in question is needed.

Healthcare Sharing Ministries and Foundations for Systemic Solutions

An alternative to health insurance, healthcare sharing ministries operate according to a set of religious beliefs and help participants pay for health care needs by sharing healthcare expenses among the participants of the ministry. In order for the healthcare expenses to be eligible for sharing, members need to pay a monthly contribution that may be used for their own healthcare expenses or assigned to another member who is in need of assistance. The following analysis considers only healthcare sharing ministries informed by a particular religion, in which members sign a statement of faith to participate. Healthcare sharing is not insurance, and the ministry must explicitly state the difference for it does not assume responsibility for payment of, or indemnification for, medical expenses. It publishes guidelines under which members share each other’s expenses, but these members are not legally bound to do so. For Catholics, a healthcare sharing ministry might possess a number of moral advantages over government-mandated health insurance. These benefits might outweigh the risks of nonguaranteed coverage for healthcare costs.

Issues Concerning Risk

Insurance policies are sometimes called aleatory contracts, from the Latin alea, meaning risk, chance, a game of dice. The term “aleatory” indicates that both the insurer and the insured make a contract based on the risk inherent in uncertainties. To state the obvious: the insured pays a premium and risks losing the money if he or she does not need medical services, and the insurance company risks paying out more money than was received from the premium payments. Insurance companies have a vested interest in gathering as much information about a person as possible in order to weigh potential payouts versus the revenue which maintains the business. Insurance companies have every moral right to investigate claims thoroughly and to judge them exactly. If an insurer knows before offering a policy that a given individual’s medical needs will not be covered by the premiums, especially if the expenses will be extraordinarily high, then it has the moral right not to insure that person because justice does not require a business to operate at a loss. Some ethicists argue that the vast amount of precision information available to insurers practically guarantees that they will always make a profit, even at the significant loss of the insured, because they can predict with high levels of accuracy the potential medical bills of an individual (McHugh and Callan 1958, 282). It would be undoubtedly immoral if an insurance company received premiums from an insured person with the intention to avoid paying medical bills according to the terms of the policy, or with the practice of changing or rescinding an existing policy on fallacious grounds to avoid payouts, or of colluding with medical providers to ensure higher prices and consequent loss to the insured; all of these constitute forms of theft (McHugh and Callan 1958, 284–85). Insurance contracts are not immoral merely from the fact that the odds are very much in favor of the insurance company’s profit rather than the insured member’s savings. An insurance policy is not a benefit plan but a protection against potential loss through a binding promise to pay under certain well-defined conditions (McKalip 2016, 435–37).

The legal differences between an insurance company and a healthcare sharing ministry entail significantly different risks for both. Members in a healthcare sharing ministry agree to divide healthcare costs among them, but they are not legally bound to cover the medical costs of any of its participants, and there can be little legal recourse if a participant’s healthcare cost is not paid. The result is that the ministry’s risks are fairly low in comparison with those of insurance companies, whereas the patient might undergo a higher risk by participating in the ministry. It is reasonable that the premium rates of an insurance company be proportionately higher as a way to cover the increased risk for the company. Additionally, for-profit insurance companies have a fiduciary duty to stakeholders who put their own money at risk by investing in the business. Consequently, unlike healthcare sharing ministries that have no such duty to make a profit, insurance companies are morally bound to arrange the business to ensure that dividends or the equivalent can be paid. These constitute some of the morally legitimate reasons for an insurance company to maintain large amounts of money (Davis 1943, 402). At the same time, a policy ought to reflect the real costs associated with the various risks involved, including the medical risks of the individual, and should not be inflated beyond that reasonably estimated value. One issue noted anecdotally by CFOs of hospitals is that when the healthshare ministry or program gives money to a patient for healthcare costs, it is the hospital’s responsibility to recover the money. However, this is not always successful. At times, the patient pockets the money and the hospital goes unpaid. The hospital then has no recourse for payment. This too is an injustice and constitutes theft. To avoid such unjust actions of patients, ministries should consider having a policy that expels members who do not pay hospitals with the reimbursement money. Such a policy would require some feedback mechanism whereby the ministry can measure whether or not it is successful in helping both the healthcare provider and the patient, such as a patient sending a copy of a paid-in-full receipt of medical care.

When considering different ways to pay for potential future medical costs, individuals are free to weigh the relative riskiness of insurance contracts versus participating in healthcare sharing ministries. Before deciding in favor of one or the other, a person (and his family) should evaluate various factors that could make one choice more prudent than another. In the absence of a more formal measures, persons should calculate as accurately as possible factors related to future medical needs. These would include age, previously existing conditions, family history, present state of health, high-risk jobs such as law enforcement, and regular high-risk activities. For persons who have a high likelihood for medical bills beyond the threshold covered by a healthcare sharing ministry, it may be that “an individual who does not take out insurance gambles more than one who does” (McHugh and Callan 1958, 281). For persons who have low risks all around, a healthcare sharing ministry may be the best option, especially when fiduciary duties entail tight budgeting and the need to avoid overpaying unnecessary insurance premiums. As noted, no one should risk impoverishing him- or herself, or his or her family for a trivial medical matter, and everyone has a right to refuse medical services on the grounds that they would be gravely financially burdensome. Ultimately, one’s life goals will affect what constitute the more important factors such that an individual chooses in accordance with what can potentially bring about the greatest good with the minimal risk and minimal cost.

Healthcare Sharing Ministries

In considering the moral elements of healthcare provision, healthcare sharing ministries might more adequately fulfill the requirements of justice for decision-making. The principle of patient autonomy can be respected insofar as participants in such ministries are able to exercise their right to choose which medical treatments and services they believe are best for them and in accordance with their faith. Because members of healthcare sharing ministry are not at the mercy of the decisions of insurance companies, they are more empowered to avoid coercion in subsidizing illicit treatments or services for others.

Transparency and honesty ought to be virtues throughout the medical–industrial insurance complex, but they seem to be promoted more by independent agents and cooperatives. For example, upon being overcharged for medical care, Jeffrey Rice founded a “Healthcare Bluebook” after the Kelley Blue Book which indicates fair prices for cars (Makary 2019, 172–73). Not only does this Healthcare Bluebook collect pricing data from participating employers, it also reviews actually paid prices and flags providers who charge more. This sort of endeavor would be welcomed by healthcare sharing ministries because it helps patients exercise informed consent to medical billing. Because the paying power of a healthcare sharing ministry has relative independence from the medical insurance system, its members can more easily exercise their right to informed consent for all treatments, services, and medical billing. Insured patients usually have no way of predicting the full price of services prior to choosing care and remain at the mercy of pricing contracts between hospitals and insurance companies; it should be noted that individual physicians often do not have this information either. Additionally, a healthcare sharing ministry in advance discloses the rates they will reimburse. If a provider refuses that rate, the ministry will negotiate for a different rate directly with that provider on behalf of the member. By having representatives negotiate prices with healthcare providers, the ministry facilitates honesty in the exchange of information and can reduce conflicts of interest. In the interests of transparency, healthcare sharing ministries themselves should be transparent about how often a member fails to pay a physician—which will affect the ability of other members to get hospitals and physicians to work with them—or how often members refuse to send in their “share” of costs and other members are left to make up the difference.

The primary aim of Catholic healthcare sharing ministry is to facilitate healthcare sharing among Catholics and like-minded participants, but it may have an indirect, significant effect on the reform of health care as a whole. Although the ACA has provided subsidized coverage to more than 20 million people, many millions of people who do not qualify for subsidies cannot afford the unsubsidized premiums that have doubled since the law’s inception (Eisenberg 2015; Editorial Board 2017). Millions of Americans also lost previously affordable plans because these plans were not ACA-compliant. These conditions, combined with Congress’s 2017 elimination of the ACA penalty for not purchasing insurance, have led to unprecedented growth in healthcare sharing ministries. The more the healthcare sharing increases, the more the insurance companies will be pressured.

Presently, the biggest healthcare sharing ministries exist under the aegis of Protestant Christian belief systems. With an independent Catholic healthcare sharing ministry, Catholics have a viable alternative to the health insurance paradigm. Consequently, they can avoid even remote material cooperation with what contradicts their deeply held beliefs. They can also avoid scandal and the counterwitness endemic to supporting financially a system that may violate their consciences.

A faith-based healthcare sharing ministry would give Catholics a platform in which they can fulfill Christ’s mandate to help one’s neighbor in a fully moral way. The “Good Samaritan principle” entails that all Catholics are called to offer assistance to their neighbors, including in healthcare concerns. By facilitating the sharing of healthcare costs, a sharing ministry offers a concrete way in which charity toward others may be exercised.

Catholic social teaching also recognizes the virtue of “solidarity,” which is an explicit concern not only for other individuals but also a personal commitment to serve the common good in justice and charity (John Paul II 1988, 37, 40). Solidarity can be exercised by “the more influential” who have more access to goods and services by sharing that access responsibly; the “weaker” in turn “should not adopt a purely passive attitude or one that is destructive of the social fabric, but, while claiming their legitimate rights, should do what they can for the good of all” (John Paul II 1988, 39). The present insurance system might undermine physician–patient solidarity, and the physicians’ ability to offer charity to patients, because it pressures physicians to pursue profit above all even when their prudential judgment might call for a more charitable allocation of time or resources (McKalip 2016, 438–39, 441–42).

Perhaps an insurance system based on the principles of “subsidiarity within solidarism” can overcome challenges to a profit-centered healthcare system as well as the inefficiencies and injustices of socialistic systems (Babcock 2019, 99). Similarly, Catholic healthcare sharing ministries can encourage participants of all economic and social levels to exercise virtue and help each other flourish.

Biographical Note

Ezra Sullivan, OP, is a Dominican friar and professor of moral theology at the Angelicum in Rome. He has published articles on bioethics, moral theology, and ecclesiastical history in scholarly journals including The Linacre Quarterly, Nova et Vetera, and Logos Journal. He is currently the director of the Character and Common Good Project in partnership with the Thomistic Institute in Rome. His forthcoming book is entitled Habits and Holiness: Ethics, Theology, and Biological Psychology (2020 CUA Press).