What are your views on health insurance?

[Soloist]

Szd I think I disagree with you on several points here.

One of the things I’m observing in this conversation, is that mutual aid systems rely heavily on the larger insurance and Medicaid system in order to be successful.

For example:

1) Hospital charity pools are a public-mandated government subsidy funded by tax deductions and Medicaid reimbursements that offset uncompensated care. If Medicaid reimbursements shrink, it becomes harder for hospitals to offer charity care.

Generally I think its tax deductions and I think the hospitals have a "quota" they want to hit to get the taxes lower. I don't think the medicaid reimbursements have anything to do with it and based on my father's experience as a physician, medicaid is terrible.

2) Mutual-aid and church plans are able to bargain down costs because providers assume they will be able to offset the lost costs through Medicaid reimbursements or private insurance costs elsewhere. Again, if that income stream shrinks or disappears, how likely will these church plans be able to negotiate lower costs?

The posted price isn't hardly ever paid. Its like a game with the insurance companies. The church groups basically are tapping into the same idea and getting the "reasonable" price that the insurance company ends up paying anyway.

3) It’s my understanding that a lot of mutual aid and church plans will not cover pre-existing conditions or put significant limits on maternity care. How do those costs get covered? Do those costs get absorbed by providers?

I can't speak to "plans" but if someone needs help paying a medical bill, they get help. The maternity assistance is great, 50% and 80-100% is insane. Most churches do not pay for having babies.

4) Even clinics in Holmes County rely on Medicaid and Medicare reimbursements from other patients in order to offer more affordable services to conservative Anabaptists.

All of this suggests that mutual aid / church plan healthcare isn’t a completely independent or self-sufficient system but rather piggybacks on institutional goodwill and Medicaid reimbursements from other patients in order to function. Without public and private dollars indirectly subsidizing conservative Anabaptist healthcare, I don’t think these plans would be nearly as viable.

I don't know how the clinics there operate but I'm telling you, the medicaid/medicare reimbursements are terrible compared to private pay, even with discounts. They aren't having to off set the cash pay or self pay patients through those systems.

[JohnH]

One of the things I’m observing in this conversation, is that mutual aid systems rely heavily on the larger insurance and Medicaid system in order to be successful.

No, they don't.

For example:

1) Hospital charity pools are a public-mandated government subsidy funded by tax deductions and Medicaid reimbursements that offset uncompensated care. If Medicaid reimbursements shrink, it becomes harder for hospitals to offer charity care.

Mutual aid doesn't rely on "charity care". It pays for the cost of services, so if anything, it is paying for charity care for other people.

Of course, if someone is eligible for charity care, they can go and apply for that. If they are covered by mutual aid, they won't be eligible. Perhaps you should talk to some people who actually use mutual aid to find out more about how that works?

2) Mutual-aid and church plans are able to bargain down costs because providers assume they will be able to offset the lost costs through Medicaid reimbursements or private insurance costs elsewhere. Again, if that income stream shrinks or disappears, how likely will these church plans be able to negotiate lower costs?

Szd, the standard cash price for my doctor for a standard 20 minute primary care visit is $746. Do you think that (a) anyone ever actually pays this amount, and that (b) it's somehow wrong or "charity" to negotiate a lower price?

My own church's mutual aid plan is struggling financially since they are unable to negotiate as hard as Medicare & Medicaid and the big insurance companies do, and so their members typically pay more than an insurance patient does. So the reality is that mutual-aid patients are the ones paying for everyone else.

3) It’s my understanding that a lot of mutual aid and church plans will not cover pre-existing conditions or put significant limits on maternity care. How do those costs get covered? Do those costs get absorbed by providers?

Your understanding is wrong. My church's just changed some of their policies around pre-existing conditions, mostly to reduce incentives to not participate in the plan and then try to get on it when someone wants help with a pre-existing condition. That's not how mutual aid should work. The maternity coverage was excellent - including paying for some Amish-run medical birth center that isn't covered at all by insurance. (You'll be glad to know there was no reliance on insurance or Medicaid at that facility; they do not code bills for insurance, won't submit to insurance, do not negotiate their prices - pricing is established up front, and the doctor that attends there does things the same way.)

It is true that mutual aid plans won't pay for things like abortions.

4) Even clinics in Holmes County rely on Medicaid and Medicare reimbursements from other patients in order to offer more affordable services to conservative Anabaptists.

Our family doctor we had for several years doesn't do Medicaid reimbursements at all and doesn't code his bills well enough to get them run through any kind of insurance. So no, he doesn't rely on Medicaid or Medicare at all. Once we were on Medicaid, we couldn't be his patients anymore due to how state laws work unless we signed a special waiver form.

All of this suggests that mutual aid / church plan healthcare isn’t a completely independent or self-sufficient system but rather piggybacks on institutional goodwill and Medicaid reimbursements from other patients in order to function. Without public and private dollars indirectly subsidizing conservative Anabaptist healthcare, I don’t think these plans would be nearly as viable.

As I documented above, the exact opposite is true. The bulk of plain Anabaptists are Amish, and the way they do things reduces the burden on the Medicaid and Medicare systems. By not participating in Medicare, they save the federal government a great deal of money; Medicare taxes don't come close to paying for the cost of Medicare. By not participating in Medicaid, which I estimate the majority of Amish families would qualify for due to their large family sizes they save the federal government even more money.

Instead, they fund their own private clinics and pay their own private doctors who operate completely outside of the Medicaid, Medicare, and insurance system.

You may want to read the book "House Calls & Hitching Posts" to learn more about this, and educate yourself.

[JohnH]

Generally I think its tax deductions and I think the hospitals have a "quota" they want to hit to get the taxes lower. I don't think the medicaid reimbursements have anything to do with it and based on my father's experience as a physician, medicaid is terrible.

To qualify as a nonprofit (which has huge tax benefits for a hospital system), they have to expend somewhere around 55% of their services on charity care. They usually find a way to do this by having very, very high cash prices for their medical services, and then taking a credit for all charity care to meet that 55%.

The structure of state laws in Ohio with HCAP (charity care) is such that for-profit hospitals have to do something similar, or else they are not eligible for Medicaid reimbursements. Medicaid is a large amount of money and a large fraction of patients, so there isn't any hospital in the state that doesn't participate in it, other than the Amish-run "para-hospitals". Most large systems also participate in HCAP across the board.

The simple fact is that if a provider doesn't want to take Medicaid, Medicare, and private insurance... they aren't going to have any patients other than Amish people.

[Szdfan]

Generally I think its tax deductions and I think the hospitals have a "quota" they want to hit to get the taxes lower. I don't think the medicaid reimbursements have anything to do with it and based on my father's experience as a physician, medicaid is terrible.

To qualify as a nonprofit (which has huge tax benefits for a hospital system), they have to expend somewhere around 55% of their services on charity care. They usually find a way to do this by having very, very high cash prices for their medical services, and then taking a credit for all charity care to meet that 55%.

The structure of state laws in Ohio with HCAP (charity care) is such that for-profit hospitals have to do something similar, or else they are not eligible for Medicaid reimbursements. Medicaid is a large amount of money and a large fraction of patients, so there isn't any hospital in the state that doesn't participate in it, other than the Amish-run "para-hospitals". Most large systems also participate in HCAP across the board.

The simple fact is that if a provider doesn't want to take Medicaid, Medicare, and private insurance... they aren't going to have any patients other than Amish people.

John is actually making my argument here. I’m not saying mutual aid doesn’t work. I’m saying it’s not as self-sufficient as people assume. These systems rely on the same healthcare infrastructure that the wider public does. When hospitals and clinics depend on Medicaid and ACA reimbursements to stay solvent, cuts to those programs will inevitably affect church-based plans too. The pain from these systemic changes isn’t going to skip over you just because your funding model looks different.

[JohnH]

John is actually making my argument here. I’m not saying mutual aid doesn’t work. I’m saying it’s not as self-sufficient as people assume. These systems rely on the same healthcare infrastructure that the wider public does. When hospitals and clinics depend on Medicaid and ACA reimbursements to stay solvent, cuts to those programs will inevitably affect church-based plans too. The pain from these systemic changes isn’t going to skip over you just because your funding model looks different.

Do you have an actual point? Maybe next you'll tell us that plain people are not self-sufficient in terms of housing because they rely on hardware stores and lumberyards that also serve non-plain people.

As I documented for you, over and over, in large plain areas, there are quasi-hospitals and clinics and providers who don't participate in Medicaid, ACA insurance plans, or Medicare at all and only serve plain people or the occasional odd cash pay type of person.

The pain from these systemic changes isn’t going to skip over you just because your funding model looks different.

Can you please explain to us what the "pain from these systemic change" is? You keep bringing up "Medicaid cuts" over and over; what are the actual cuts? Please use an example other than requiring people to work or volunteer at least 20 hours a week if they do not have any dependents, are able-bodied, and are not recently unemployed.

[Szdfan]

John is actually making my argument here. I’m not saying mutual aid doesn’t work. I’m saying it’s not as self-sufficient as people assume. These systems rely on the same healthcare infrastructure that the wider public does. When hospitals and clinics depend on Medicaid and ACA reimbursements to stay solvent, cuts to those programs will inevitably affect church-based plans too. The pain from these systemic changes isn’t going to skip over you just because your funding model looks different.

Do you have an actual point? Maybe next you'll tell us that plain people are not self-sufficient in terms of housing because they rely on hardware stores and lumberyards that also serve non-plain people.

As I documented for you, over and over, in large plain areas, there are quasi-hospitals and clinics and providers who don't participate in Medicaid, ACA insurance plans, or Medicare at all and only serve plain people or the occasional odd cash pay type of person.

The pain from these systemic changes isn’t going to skip over you just because your funding model looks different.

Can you please explain to us what the "pain from these systemic change" is? You keep bringing up "Medicaid cuts" over and over; what are the actual cuts? Please use an example other than requiring people to work or volunteer at least 20 hours a week if they do not have any dependents, are able-bodied, and are not recently unemployed.

Actually, the hardware store comparison is a good one. You're right that plain people aren't completely self-sufficient, since nobody is self-sufficient in a modern economy. You can build your own house, but the materials, tools, and regulations that make it possible all come from the outside world. The Amish rely on the same supply chains as everyone else.

The same is true for healthcare. Independent clinics and doctors may serve Plain communities, but they still depend on the public ecosystem around them like licensing, hospital partnerships, supply chains, and emergency transfers. Even in this thread, you’ve acknowledged counseling people to adjust their income to qualify for Medicaid. That’s not an isolated system. It’s one connected with the policies you’re dismissing.

The effects of the One Big Beautiful Bill are already visible. States are tightening Medicaid eligibility, and rural hospitals and clinics are closing or cutting services. As uninsured rates rise and charity care shrinks, mutual aid systems will eventually be affected by it. None of us are insulated from systemic change, just exposed to it in different ways.

[JohnH]

I have, more accurately, counselled people to choose a lower middle class lifestyle instead of an upper middle class lifestyle, and in exchange pay their workers more / invest more capital into their business.

I am still waiting to hear of who, exactly, is able to work or volunteer but refuses to do so and why we should dole out scarce benefits to them.

And no, regulations do not make it possible to build a house. They do make it harder to build homes, though.

[ohio jones]

I have, more accurately, counselled people to choose a lower middle class lifestyle instead of an upper middle class lifestyle, and in exchange pay their workers more / invest more capital into their business.

That may (to an extent) be reasonable advice for a business owner. For an employee, though, who has no workers or opportunities for capital investment ...

I am still waiting to hear of who, exactly, is able to work or volunteer but refuses to do so and why we should dole out scarce benefits to them.

... an employee who is approaching the income limit for benefits might stop working in order to continue to qualify for Medicaid or SNAP or whatever. And if the business owner pays them more per hour, that just means they stop working earlier in the week or year.

[JohnH]

I have, more accurately, counselled people to choose a lower middle class lifestyle instead of an upper middle class lifestyle, and in exchange pay their workers more / invest more capital into their business.

That may (to an extent) be reasonable advice for a business owner. For an employee, though, who has no workers or opportunities for capital investment ...

I am still waiting to hear of who, exactly, is able to work or volunteer but refuses to do so and why we should dole out scarce benefits to them.

... an employee who is approaching the income limit for benefits might stop working in order to continue to qualify for Medicaid or SNAP or whatever. And if the business owner pays them more per hour, that just means they stop working earlier in the week or year.

Yes, that’s a structural problem with the ACA.

For a lot of people with families though they aren’t coming close to making enough for it to be a problem.

[Szdfan]

I have, more accurately, counselled people to choose a lower middle class lifestyle instead of an upper middle class lifestyle, and in exchange pay their workers more / invest more capital into their business.

That may (to an extent) be reasonable advice for a business owner. For an employee, though, who has no workers or opportunities for capital investment ...

I am still waiting to hear of who, exactly, is able to work or volunteer but refuses to do so and why we should dole out scarce benefits to them.

... an employee who is approaching the income limit for benefits might stop working in order to continue to qualify for Medicaid or SNAP or whatever. And if the business owner pays them more per hour, that just means they stop working earlier in the week or year.

Yes, that’s a structural problem with the ACA.

For a lot of people with families though they aren’t coming close to making enough for it to be a problem.

So basically, behavior you’d condemn as “dependency” in others becomes “stewardship” when it’s you. It’s the exact same thing, you’re just rebranding it. I call that moral laundering.