Sharing the Load: Amish Healthcare Financing (2016)
ncbi.nlm.nih.govFor an example of how most of these cost-sharing plans go, see this article on the implosion of a commercial plan that preyed on the Mennonites of southern Ohio: https://www.propublica.org/article/liberty-healthshare-healt...
Amish economics are weird, because the deep aversion to debt tends to create winner-take-all scenarios: an Amish farmer might become wealthy from mineral and gas rights on his property, for example, and plow those funds into setting up a general store, which creates funds that go into a restaurant — and from there a hotel, a gas station, a gift shop, and pretty soon half the county is working for him. Since no Amish would consider a bank or SBA loan, new business starts are confined to either English outsiders or a small number of very wealthy Amish. (One guy in the cabinet business had a Rolls Royce with solid rubber tires — don’t ask — and an English driver whose name the car was officially in. Technically, not a violation of religious strictures!)
Aside: Hoovies Garage on YouTube taught me that keeping a old Rolls or Bentley in perfect working order costs literally tens of thousands of dollars a year in parts and maintenance - nothing stays ‘fixed’ for very long.
Someone should do a kit car with Toyota mechanicals and a Rolls style body!
We call them “Lexus”
Rolls is on a whole different level when it comes to fit and finish. The interior and ride quality is why they cost as much as an Italian sports car and weigh as much as an armored vehicle. Adding a bit of leather trim and brushed aluminium buttons doesn't get you into the same league.
It is funny that the old ones are so mechanically unreliable though, when you consider that Rolls also has a long history of making aircraft engines.
Your own article indicates it really has nothing to do with the research piece posted:
Health care sharing ministries have existed since the early 1900s, primarily among Mennonites and the Amish. The idea was simple: Members chip in what they can to help cover a neighbor’s costs when someone breaks a leg, say, or falls ill. It was the financial equivalent of a potluck dinner, with everyone contributing something to the table and sharing the spread.
Few outside those communities knew or cared that health care sharing ministries existed. They were tiny, didn’t advertise for new members and posed no threat to corporate insurance. Most importantly, no one envisioned making money from a ministry.
Would have been impressive if he put the RR in neutral and got it pulled by horses.
I worked in insurance for over five years. This is a very good read.
1. They keep costs down in part by pursuing home remedies for a lot of things instead of seeing a doctor. They have established sources of information and support for this practice.
2. When it comes to medical care, they are not Luddites and are willing to use cutting edge technologies to care for medical issues.
3. I was struck by the repeated mention of genetic disorders. It makes me wonder if this is a big issue in the Amish community. If so, one solution would be to encourage young people to marry outsiders, which is probably not encouraged as it tends to be a threat to the culture of groups like this. By I see it as extremely irresponsible to knowingly pursue practices that increase the odds of children being born with genetic disorders.
Neither Amish Hospital Aid nor congregational alms funding cover health care needs that result from prohibited activities within the Amish community. One interviewee mentioned an incident that occurred with a teenage boy in her congregation who was injured in a snowmobiling accident. The use of motor vehicles (e.g., cars, tractors, snow mobiles) is strictly forbidden in Old Order Amish culture.
This may sound harsh to some people, but all insurance policies have exemptions which (at least for accident policies) more or less boil down to "if you are behaving irresponsibly and get yourself hurt through taking undue risks, we are not paying for the consequences of your foolish behavior" -- only, you know, in legalese that is defensible in court if necessary.
I will note that as someone who processed accident claims, minors who lost limbs driving recreational vehicles like snow mobiles always broke my heart. If you have children and you own anything like a snow mobile, please make sure it is secured and they cannot go for a joy ride on Saturday morning while you sleep in.
"They keep costs down in part by pursuing home remedies for a lot of things instead of seeing a doctor."
Two other factors for low cost would be their healthy lifestyle and end of life care choices. The Amish get about 20k steps in per day - double the recommended 10k steps that most English fail to meet. Rates of many chronic diseases are lower. When they do get old, they don't drag things out and they generally don't go into longterm care facilities. Most English tend to want the doctor to "do everything you can".
Not really
> Amish mortality patterns were not systematically higher or lower than those of the non-Amish, but differed by age, sex, and cause. Amish males had slightly higher all-cause MRs as children and significantly lower MRs over the age of 40, due primarily to lower rates of cancer (MR = 0.44, age 40-69), and cardiovascular diseases (MR = 0.65, age 40-69). Amish females MRs for all causes of death were lower from age 10-39, not different from 40-69, and higher over age 69. https://pubmed.ncbi.nlm.nih.gov/7315833/
Basically, Amish boys are more likely to die young. There are no long term lifestyle benefits for Amish women.
And "English" by which I assume you mean Americans don't have infinite funds.
Your quote agrees with the thing you are rebutting:
Rates of many chronic diseases are lower.
Amish males had ...significantly lower MRs over the age of 40, due primarily to lower rates of cancer (MR = 0.44, age 40-69), and cardiovascular diseases (MR = 0.65, age 40-69).
Also, mortality rates and costs are not synonyms.
Women had no such benefit. Women got more issues as their aged. Health of children mattter too and costs too. Young males dying more often is not healthy for them.
The men over 40 subset of population has slightly lower mortality and no one else. The numbers even out.
That is not consistent with "healthier lifestyle overall" as if they generally got benefits.
You: Women had no such benefit. Women got more issues as their aged.
Also you: Amish females MRs for all causes of death were lower from age 10-39, not different from 40-69, and higher over age 69.
Women only "got more issues as their aged" after age 69. Before that, they were either better off or about the same. This also agrees with the point the parent comment was making that they generally have healthy lifestyles and don't go into long-term care facilities in old age. Instead, they accept death when the time comes.
Women got no benefit after 40. Healthier lifestyle as cause would had them having this benefit at that age range too. It is exactly that age when men started to have benefits. In case of women you have slight benefit at the age range when men are dying more.
69 years old women are not in the long term facilities for that matter eitminor Nor are men. In UK, 66 years old is retirement age. This is age when strength and health declines, but nowhere near the level necessary to be in some kind of facility. These are self sufficient people, able to care about themselves, able to care about relatives or animals.
None of that are numbers that overall superior healthier lifestyle. Just a minor shifts around.
I see that as direct evidence contrary to your point. Achieving comparable mortality with less Healthcare and Associated cost would imply that they are in fact healthier.
Part of the confusion is that you are conflating mortality with health.
If two people live to the same age, but one requires many surgeries, drugs, and treatments, I dont think you would say they are equally healthy.
What do you mean "not really"? It seem you just posted what I was saying for lower rates of many chronic diseases.
"significantly lower MRs over the age of 40, due primarily to lower rates of cancer (MR = 0.44, age 40-69), and cardiovascular diseases (MR = 0.65, age 40-69)"
As they said, cause differs. When looking at costs, causes are very important. Things like cancer and cardiovascular diseases tend to cost a lot of money to treat as they drag on. If you die young in an accident, it's likely to cost less.
Women had literally zero benefits. And young boys die more. There is only one segment of population that is getting some benefit and that benefit is small.
In order for lifestyle to be healthier, I would want to see more benefits then just some middle aged men mortality shifted onto young ones.
The Amish suffer from genetic disorders due to inbreeding. From the Wikipedia article someone linked to:
Some of these disorders are quite rare, or unique, and are serious enough to increase the mortality rate among Amish children.
I criticized the practice of inbreeding in my first comment.
We're talking about costs, not mortality. You also can't equate mortality with healthy or unhealthy lifestyle. Many of the things in the lifestyle are healthy, the two biggest being more physical activity and less processed foods. You can "live" in a nursing home for a long time. But quality of life is an important factor not captured in your mortality figures, including things like some of the lowest obesity rates (and chronic illnesses that go with that).
Americans' insistence on living to their last possible machine-assisted breath makes healthcare very, very expensive. Something like a third to half of the healthcare costs of an individual are incurred in their last year. Americans are terrified of dying.
This is why I have a hard time taking cost comparisons seriously between the US and Europe - European healthcare systems will pull the plug a lot earlier, saving the money (and the indignity) involved in dying as slowly as possible.
Ironically, doctors in the US have some of the lowest end-of-life care costs, because they know their actual chances and don't seem to be so afraid of dying.
Highly physical work can easily cause damage. Sure, it's bad to sit behind a computer for 8-10 hours a day. But it's also bad to be constructing barns 8 hours a day. You want a happy amount of physical activity. It's easy to look up to the people on the far side of goal as being healthier, but US tradespeople in their 40s and 50s tend to be pretty messed up in the knees/back.
I had an anthropology professor in college who did some work on genetic diseases in the Amish. It is a problem. This Wikipedia has a short overview and a lot of references:
Anecdotal, but I once had a friend and roommate that came from an ex-Mennonite family of 12 siblings with two sets of twins. He and one of his brothers both developed late-onset Tay-Sachs disease. Although relatively high-functioning and able to do most tasks such as hold down a job and drive a vehicle, there were some unfortunate consequences.
For instance, the brothers had lack of coordination, ataxia, and minor speech problems. They were constantly getting pulled over by the local cops for minor violations (like driving too slowly) and nearly every time the cops would insist that they were drunk even though they didn't have a drop of alcohol. To the untrained eye, their affect looked very similar to an intoxicated person: slurred speech, bobbing while standing in place, stumbling when walking or getting out of the car, &c. So yes this is a big problem in these communities.
The Amish are aware of their small population problem. I believe their population bottleneck was a few hundred people.
They do sometimes adopt children from outside their population. I don't know how common that is and whether it makes a difference.
> This may sound harsh to some people, but all insurance policies have exemptions which (at least for accident policies) more or less boil down to "if you are behaving irresponsibly and get yourself hurt through taking undue risks, we are not paying for the consequences of your foolish behavior" -- only, you know, in legalese that is defensible in court if necessary.
Some accident policies may have those features, but zero health insurance ones do.
All insurance policies have limits on what they will pay. Those limits come in various forms, such as:
1. What you pay out of pocket before insurance coverage kicks in.
2. No coverage for out-of-network providers.
3. Caps on how much they will cover.
Insurance is a numbers game. Rest assured, all insurance policies and all insurance providers find ways to limit how much they pay out.
You may find some means to limit payments more distasteful than others, but they all do this. It's the only way they can possibly stay in business.
Which are all an entirely different thing.
Its crazy that there are laws against offering health insurance in the open market. There is no reason you couldn't shop around for a plan just like you do for car or home owners insurance.
Trust me, it's worth it. Most people have no idea the kind of unethical shit that HIPAA and then the ACA regulated out of existence—stuff that would make you say "How in the name of all that is holy was that legal until 1996???"
One of the necessary casualties of that is restrictions on who is able to offer what and when. It's a good trade.
Are there laws against offering health insurance in the open market? I'm pretty sure you could start up nonethewiser's insurance company and start taking enrollees. Or do you mean you'd have to sell them through a government portal? Or that you have to really offer a certain minimum level of care and coverage? And register with the state insurance commission? Because I'm pretty sure, except for the first one, that's a requirement for other insurances as well.
There has to be some kind of oversight. Otherwise, you get thousands of people victimized by fraud who the rest of us have to bail out.
I can buy car insurance or pretty much any kind of insurance on the market, and there is suitable oversight. This does not exist for medical insurance.
What I mean by that is if I work for a large company, I can get access to health insurance that I cannot buy on the market myself. If that company changes insurers to a crappy one, my only choice is to change employers to one that provides access to a better insurer. If I self employ, I cannot get access to those plans.
Insurers should be forced to sell in a single market all the plans they offer. Insurer like to talk about "economy of scale" with large employers, but that is an artificial limit. Why should insurance pools be limited to who works at a company?
“Insurers should be forced to sell in a single market all the plans they offer. Insurer like to talk about "economy of scale" with large employers, but that is an artificial limit. Why should insurance pools be limited to who works at a company?”
Very true. There should be one insurance pool. Either state or nationwide.
There we're state pools until Obamacare wiped those away.
I presume you're referring to state high risk pools, which were horrific.
Correct, and ACA EPO plans aren't an improvement, by many measures.
Not really. A lot of people never were able to get insurance at all or lost it once they got sick.
There should be one pool where everybody can get insurance regardless of agr, employment status or preconditions. Insurers should compete for that pool.
That being said, I think uninsured drivers should go to jail/pay hefty fine/lose driving privileges, but many do not. Maybe one pool for car insurance as well?
That's what the ACA already fixed. Insurers are forced to sell into that single market all the plans they offer in your state that are open to individuals. If you don't like your employers plan, you can just buy insurance on the ACA marketplace and decline your employers plan. Your risk pool will be other people of the same sex and age in your state.
If your complaint is that employers have access to better insurance plans on private offer, well that's true. Walmart also has self-insured property/auto coverage not available to smaller companies. But COBRA let's you stay on your employers plan if you leave for up to a year (at a pretty high cost) so that's a thing.
That... ...isn't what I was talking about?
Is that not what I do when comparing plans on healthcare.gov?
You cannot purchase plans across state lines. You cannot purchase the same plan you would get if you worked at a large company.
The law is basically written by the insurers, and favors them. It allows them to segregate people based on who they work for, etc.
In an ethical system, there would be just a single, non-segregated pool of people called a 'market', and anyone would be able to purchase any plan they want from that market, regardless of which state they lived in and regardless of who they did or did not work for.
Federal employees have such a system, and prior to obamacare, there was actually bipartisan agreement forming around enabling everyone to participate in that system. It's probably why obamacare was rushed through quickly by the insurance companies.
The state line thing makes a degree of sense in the context of the (extremely broken) network system. Your insurer has a network of providers with whom they have negotiated rates. If you live far away from your plan’s intended market, you won’t be near the network, and everyone loses except the medical providers who get to overcharge you and your insurer as a result.
It should be quite evident that everything about this system is broken, but this is part of how broken systems get entrenched.
I should remind everyone it is a republic and if you think state insurance commissions will let go of their fiefdoms I have some land in Florida I'll make you a great deal on. Kathleen Sebelius comes to mind!!
That’s exactly what it is except they have base “minimum essential coverage” laws that these ministries don’t abide by.
“HCSMs are not regulated by the ACA. The coverage you get will vary from one HCSM to another, but they are not required to cover pre-existing conditions, cap out-of-pocket costs, or cover essential health benefits. And they can still have annual and lifetime benefit caps.”
Since they’re not regulated entities, there’s no enforcement mechanism if you get sick and they decide not to pay out or delay your reimbursement.
Sort of. ACA set ground rules for one segment of the market and did a good job doing so. There is a real competitive process in most states.
Taking about free markets in the context of US health insurance in general is a waste of time.
I mean kind of. There’s a ton of restrictions on who can have what plan where though, it’s not a very “free” free market.
Peter Santenello has a good video series with interviews of Amish.
https://www.youtube.com/watch?v=z6SlJZk5guI&list=PLEyPgwIPkH...
One of the more interesting discussions was how they handled covid.
These plans are not ACA qualified, are underwritten on an annual basis and do not cover pre existing conditions. They are for healthy people to cover something for the duration of the plan, which it sounds like it did. The next year the Agent or Broker (there is a legal difference) should have steered this lady to a Marketplace Plan - Fully Insured plan which covers pre-ex. Problem solved.
Who's the agent/broker here? He/she is required to have E&O.