What are your views on health insurance?

[Soloist]

Most conservative Anabaptists don't use Medicaid or state aid at all. I am in one of the very few conferences that does do so.

For those that do not use medicaid, what do they do if they have a large family? Do they buy health insurance on the open market or just hope nobody in the family has to go to the hospital? Probably majority of the times the children will not require much health care, but if somebody in the family has to be hospitalized and there is no health insurance it could be a big problem and a large bill.

I have a slightly complicated position, I generally speaking do not believe in using insurance and I think that heading that way as churches is a bad idea.
I had an ER visit which they tried to charge me 28k for and it got reduced “generously” down to like 13k or so. Eventually it was 4k.
I could have used some convoluted program to reduce the cost to somewhere like 3-4K but that only worked if you filed the same month and… they processed it the same month. I know that from personal experience.
These hospitals generally have charity programs of some kind and they really put you in a tough spot with how they work down here. They covered the 4k eventually but it took a lot of work and constant phone calls/stress before it finally was confirmed 5 months later. Conveniently it would cover all medical costs for 6 months and I was able to have it cover surgery as well.
I had to borrow money from someone in the church to pay for it after having to awkwardly ask the church for help (which they declined, not a member) was the loaner’s request before he would.
This was repaid after the charity eventually came through.
The hospital of course is still sending me bills for all sorts of non covered fees and I think I ended up paying around 2k not covered for both surgery and the ER visit.

Churches can generally have negotiating power and the bigger the pool of money they can put together, the easier it is to negotiate it down.
My wife was unexpectedly hospitalized from her pregnancy (overly paranoid midwife) and the church paid everything related to that visit (she is a member). Pilgrim pays 50% for pregnancy related costs and 100% emergent costs related to pregnancy or 80% other medical costs.

Forgot to mention, my 3 year old is still getting billed for that same hospital system I went to’s urgent care. We brought her in on a Saturday because she had a giant loquat seed in her nose (we didn’t actually know what it was at the time), doctor was in there less than three minutes and got it out first try with his tweezers (pretty impressive, I admit, given the size), and we paid the price listed on the wall, which was like $150. She also got a lollipop.

Several months later, we get a bill that was “generously” knocked down from over $1000 and was currently two or $300 for that visit. Since there was no sedation, no vitals or anything like that, we can only assume it was the root beer lollipop. We’re going to try to contest it, but our church would probably help us pay for it (although I don’t think we would bother for that).

[Szdfan]

Ironically, it’s the people least equipped to handle these changes, like large, rural, self-employed Anabaptist families that are exactly the ones most likely to lose coverage with Medicaid cuts and work requirements.

1) A lot of self-employed farming and ranching families don’t have verifiable wage documentation (like W-2s or pay stubs) to prove they’re working the required twenty hours. When people work for themselves, they rarely pay themselves a formal, documented wage. (I’m chaperoning my school’s FFA chapter to their fall conference — I just confirmed this with the group sponsor whose family owns a ranch).

Have you ever actually applied for Medicaid when self employed?

You have to fill out quite a bit of paperwork to verify/document income - if you don't have a reasonable tax return. If you do, you can just turn in last year's tax return. That's required already and has nothing to do with 20 hours. As far as confirming the 20 hour work requirement... the law has a provision that any self employed person is assumed to be meeting the 20 hour requirement. (I don't know how they will handle "negative income" or "zero income" self employed people. I was negative income one year without a tax return filed for the prior year yet which was even more paperwork to fill out, but it wasn't impossible. The benefits you get when in negative-income are very generous.)

When people work for themselves, they rarely pay themselves a formal, documented wage.

I'm not sure where you get ideas like this. When people work for themselves, they often get a 1099, which is formal documentation. Otherwise, they file income tax returns, which are another form of documentation of what they pay themselves.

It's true that if someone plans to cheat on their taxes and not document or report accurately what they pay themselves, it will be more challenging to qualify for Medicaid. Medicaid offices generally are stricter than the IRS when it comes to documenting income. But that doesn't mean it's impossible. For example, in my state, if you don't file tax returns and aren't sure what your business expenses are, you can simply report your gross income (from 1099s or a bank statement or PayPal account, etc showing deposits) and you are allowed to compute 50% of that as expenses. This is a very common situation for people like someone who drives for DoorDash.

2) Farming is also highly seasonal work. With more frequent eligibility checks, farm families may cycle in and out of Medicaid when their seasonal income spikes, even though their annual income remains too low to afford private insurance.

No, they won't, because Medicaid is based on annual income, including seasonal income. If your income is variable, you document that and turn it in. For self employed people including farmers, a tax return is enough to show annual income. You do have a legal obligation to report if you think you're going to make more money this year. For many people that's just not a problem!

There are not "more frequent eligibility checks". You requalify once per year, and then halfway through the year do a redetermination. On the redetermination, you simply sign something saying "nothing's changed", or if it has changed, you say what the change is.

Food stamps already had a 20 hour per week work requirement so all the infrastructure already existed for this. People really want their food stamps and are willing to do the extra paperwork needed to qualify. It's not burdensome or onerous.

3) Conservative Anabaptists often rely on rural medical providers that depend heavily on Medicaid reimbursements. With these cuts, many of those providers won’t survive. I’ve already heard of three clinics closing in the Shenandoah Valley this September and my local hospital has been cutting services. There are questions over whether it will close. That not only means lost local jobs but also that people here would have to travel an hour or more for medical care.

Szdfan, you're basically full of nonsense - sorry to put it that way, but I'm not sure how else to say it. Most conservative Anabaptists don't use Medicaid or state aid at all. I am in one of the very few conferences that does do so.

Holmes County (the largest Anabaptist concentration there is) is very well served by many different providers, some of which are cash pay only (and work with mutual aid plans), and some of which take Medicaid and insurance. There really isn't much of a problem at all with "rural" medical providers in Ohio where Anabaptists live; if anything, it's one of the best places in the country due to the diverse range of options. I don't think I could honestly get better medical care anywhere else.

In PA, a group of Amish are busy building their own health center which will have their own providers. That's another option conservative Anabaptists can do, particularly ones who don't want to participate in state aid plans.

One of the ironies I notice in your posts, John, is the assumption that when you or your circle receive federal aid it’s good stewardship, but when others do, it’s dependency or gaming the system. You're own recommendation that conservative Anabaptists keep their income below $65,000 in order to get "free" healthcare suggests a certain amount of gaming the system itself.

There’s frequently an assumption in your posts that the pain caused by these systemic changes will affect someone else, but that’s not necessarily true. When Arkansas implemented a Medicaid work requirement in 2018, more than 18,000 people lost coverage, not because they were unwilling to work, but because the new reporting system was confusing and difficult to navigate. What happened wasn’t laziness, but the fragility of access when bureaucracy becomes overbearing.There's no federal requirement that states assume that self-employed workers are compliant with work requirement rules. Last year's taxes and 1099s are not going to work in states that require 6-month redeterminations or periodic data checks, because they are going to require real-time documentation, not last year's. Last year's tax return shows what you earned last year, not what you earned halfway through this year.

In order to comply with these new regulations, small farm operations will file paperwork at least twice a year (or more), depending on state requirements, which is not an insignificant effort. Proving eligibility mid-year will be one place where farmers will fall off eligibility if verification cycles don't match how agricultural income is tracked.

In regards to rural clinics, I'm glad you live in a wealthy rural area where you have plenty of options. This is not the reality in many poorer, more sparsely populated rural communities like one that I live in.

[JohnH]

Most conservative Anabaptists don't use Medicaid or state aid at all. I am in one of the very few conferences that does do so.

For those that do not use medicaid, what do they do if they have a large family? Do they buy health insurance on the open market or just hope nobody in the family has to go to the hospital? Probably majority of the times the children will not require much health care, but if somebody in the family has to be hospitalized and there is no health insurance it could be a big problem and a large bill.

They rely on church mutual aid, which in my experience is cheaper and provides better coverage than conventional insurance.

Then when I go to church in the evening, a deacon’s letter gets read asking for extra money and we open our wallets and give what we can.

[JohnH]

These hospitals generally have charity programs of some kind and they really put you in a tough spot with how they work down here. They covered the 4k eventually but it took a lot of work and constant phone calls/stress before it finally was confirmed 5 months later. Conveniently it would cover all medical costs for 6 months and I was able to have it cover surgery as well.

In Ohio, HCAP covers the cost of medical care in fill up to 250% of the FPL and then is a sliding scale after that. Providers basically have to eat the cost of this. Some are nonprofits like CCF where part of their mission is to provide such care.

I frankly wouldn’t live in a state that didn’t have these sort of provisions - not just for myself, but I want my neighbours needs to be met, too.

[barnhart]

Most conservative Anabaptists don't use Medicaid or state aid at all. I am in one of the very few conferences that does do so.

For those that do not use medicaid, what do they do if they have a large family? Do they buy health insurance on the open market or just hope nobody in the family has to go to the hospital? Probably majority of the times the children will not require much health care, but if somebody in the family has to be hospitalized and there is no health insurance it could be a big problem and a large bill.

They join a church and the church helps pay the medical bills. And if the church can’t pay it, then the church reaches out to other churches to help. And if the church is an independent, and can’t cover it, I don’t know what they do.

After that the health care provider is forced to offer steep discounts in hopes of recovering as much as possible and shift costs to others.

[Soloist]

After that the health care provider is forced to offer steep discounts in hopes of recovering as much as possible and shift costs to others.

While this is true, the provider at least back in 2009 got 10 cents on the dollar for medicaid so... I'm guessing the agreed discount still makes the hospital money.

I forgot to mention, I use a direct primary care as well, basically I pay a monthly subscription and have a doctor available to call or see. At the ER visit I had a female NP who honestly was not very skilled and we ended up switching away later. My current doctor would have kept me out of the ER and responded for my almost ER last time. He is literally available whenever I call unless he specifically tells me he's on vacation.

[JohnH]

One of the ironies I notice in your posts, John, is the assumption that when you or your circle receive federal aid it’s good stewardship, but when others do, it’s dependency or gaming the system.

When have I done that? I have supported a public option for a long time although I do think it should be need based to an extent. Incidentally I have counselled and even helped people apply and set up their small business self employment paperwork to help them get care - of people who aren’t conservative Anabaptists.

I’m opposed to the ACA covid extension because I don’t think billions of dollars needs given to big private insurance companies who then turn around and deny claims. I want to see people get care and I think government is part of that equation, although not the only part.

You're own recommendation that conservative Anabaptists keep their income below $65,000 in order to get "free" healthcare suggests a certain amount of gaming the system itself.

It’s not a game. The government gives you a choice: pay yourself big time, or, pay yourself a bit less - invest in equipment, pay your employees a bonus, etc - and then the government is okay with helping you more with medical costs. I think that’s a good thing to spread it around and invest in the community instead of just cashing out a big salary.

There’s frequently an assumption in your posts that the pain caused by these systemic changes will affect someone else, but that’s not necessarily true. When Arkansas implemented a Medicaid work requirement in 2018, more than 18,000 people lost coverage, not because they were unwilling to work, but because the new reporting system was confusing and difficult to navigate. What happened wasn’t laziness, but the fragility of access when bureaucracy becomes overbearing.There's no federal requirement that states assume that self-employed workers are compliant with work requirement rules. Last year's taxes and 1099s are not going to work in states that require 6-month redeterminations or periodic data checks, because they are going to require real-time documentation, not last year's. Last year's tax return shows what you earned last year, not what you earned halfway through this year.

Szd, I guided someone else through the work requirement for the last 3 years (for snap). It is simply not that onerous. We did set up a simple s corp and payroll tho just to streamline things - and it was better for her to have a regular pay amount (however small) instead of a vague idea of profits. Extra money at the end of the year goes into needed expenses like a new laptop computer or vehicle repairs. I recommend this to anyone. It’s worth the trouble and there are online services that barely cost anything that will help you do it all.

If Arkansas’ state government is poorly run I can’t speak to that. Ohio’s seems to efficiently run and is not onerous. They do require a lot of documentation though. I have to re-do identity checks for my whole family at the end of the month including citizenship paperwork for myself since I was born abroad. I am fine with this, because it’s good to ferret out fraud and abuse from the system. They are making sure I actually exist.

In order to comply with these new regulations, small farm operations will file paperwork at least twice a year (or more), depending on state requirements, which is not an insignificant effort. Proving eligibility mid-year will be one place where farmers will fall off eligibility if verification cycles don't match how agricultural income is tracked.

Szd, I just did the midyear redetermination. It took five minutes to fill out by hand. I did it in person at the JFS office since I procrastinated a month until the last day it was due. It is much much less paperwork than everything else involved in having a farm.

In regards to rural clinics, I'm glad you live in a wealthy rural area where you have plenty of options. This is not the reality in many poorer, more sparsely populated rural communities like one that I live in.

My area isn’t wealthy and in fact is listed in the list of “poverty stricken” places. Many people are poor. I suppose it isn’t as sparsely populated as the west, though.

I noticed the podiatrist up in Akron has the same last name as our local grocery store. I looked up her credentials and she went to medical school & college locally. Another obstetrician here did the same and her last name is the same one you’ll see on a lot of auction signs. We do have families here who raise children willing to serve the local community. And yes both doctors fully participate in Medicaid and other programs for needy people.

[JohnH]

After that the health care provider is forced to offer steep discounts in hopes of recovering as much as possible and shift costs to others.

My church’s mutual aid plan pays significantly more than Medicaid. Their target is to get within 20% (higher) than the standard Medicare price.

[Szdfan]

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.

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?

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?

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.

[Szdfan]

One of the ironies I notice in your posts, John, is the assumption that when you or your circle receive federal aid it’s good stewardship, but when others do, it’s dependency or gaming the system.

When have I done that? I have supported a public option for a long time although I do think it should be need based to an extent. Incidentally I have counselled and even helped people apply and set up their small business self employment paperwork to help them get care - of people who aren’t conservative Anabaptists.

I’m opposed to the ACA covid extension because I don’t think billions of dollars needs given to big private insurance companies who then turn around and deny claims. I want to see people get care and I think government is part of that equation, although not the only part.

You're own recommendation that conservative Anabaptists keep their income below $65,000 in order to get "free" healthcare suggests a certain amount of gaming the system itself.

It’s not a game. The government gives you a choice: pay yourself big time, or, pay yourself a bit less - invest in equipment, pay your employees a bonus, etc - and then the government is okay with helping you more with medical costs. I think that’s a good thing to spread it around and invest in the community instead of just cashing out a big salary.

There’s frequently an assumption in your posts that the pain caused by these systemic changes will affect someone else, but that’s not necessarily true. When Arkansas implemented a Medicaid work requirement in 2018, more than 18,000 people lost coverage, not because they were unwilling to work, but because the new reporting system was confusing and difficult to navigate. What happened wasn’t laziness, but the fragility of access when bureaucracy becomes overbearing.There's no federal requirement that states assume that self-employed workers are compliant with work requirement rules. Last year's taxes and 1099s are not going to work in states that require 6-month redeterminations or periodic data checks, because they are going to require real-time documentation, not last year's. Last year's tax return shows what you earned last year, not what you earned halfway through this year.

Szd, I guided someone else through the work requirement for the last 3 years (for snap). It is simply not that onerous. We did set up a simple s corp and payroll tho just to streamline things - and it was better for her to have a regular pay amount (however small) instead of a vague idea of profits. Extra money at the end of the year goes into needed expenses like a new laptop computer or vehicle repairs. I recommend this to anyone. It’s worth the trouble and there are online services that barely cost anything that will help you do it all.

If Arkansas’ state government is poorly run I can’t speak to that. Ohio’s seems to efficiently run and is not onerous. They do require a lot of documentation though. I have to re-do identity checks for my whole family at the end of the month including citizenship paperwork for myself since I was born abroad. I am fine with this, because it’s good to ferret out fraud and abuse from the system. They are making sure I actually exist.

In order to comply with these new regulations, small farm operations will file paperwork at least twice a year (or more), depending on state requirements, which is not an insignificant effort. Proving eligibility mid-year will be one place where farmers will fall off eligibility if verification cycles don't match how agricultural income is tracked.

Szd, I just did the midyear redetermination. It took five minutes to fill out by hand. I did it in person at the JFS office since I procrastinated a month until the last day it was due. It is much much less paperwork than everything else involved in having a farm.

In regards to rural clinics, I'm glad you live in a wealthy rural area where you have plenty of options. This is not the reality in many poorer, more sparsely populated rural communities like one that I live in.

My area isn’t wealthy and in fact is listed in the list of “poverty stricken” places. Many people are poor. I suppose it isn’t as sparsely populated as the west, though.

I noticed the podiatrist up in Akron has the same last name as our local grocery store. I looked up her credentials and she went to medical school & college locally. Another obstetrician here did the same and her last name is the same one you’ll see on a lot of auction signs. We do have families here who raise children willing to serve the local community. And yes both doctors fully participate in Medicaid and other programs for needy people.

That’s an interesting description, John. You’re saying that by keeping income below a certain amount and reinvesting the rest, the government subsidizes your medical costs. That’s how the system is gamed, but framed as wise or moral stewardship. It’s a good example of how personal virtue and structural dependence coexist in ways people often don’t want to admit.