This past March, you may have seen a video of President Trump bounding onto the stage at the 2019 Conservative Political Action Conference and hugging the American flag. And if you looked in the corner of the some of the shots, you would have seen the name “Liberty HealthShare.”

Liberty is one of the faster-growing players in the world of health-care sharing ministries, through which an estimated 1 million Americans pay their medical bills. The company has exhibited at CPAC for a number of years, and in 2019 paid $250,000 for a platinum sponsorship. In the past, it’s explained its participation in the far-right conference as an opportunity to share its offering with “an audience that is invested in religious and economic liberty.” When CEO Larry Foster also spoke at the 2019 conference, he told them, “Health sharing is a uniquely American idea that’s based on choice, freedom and access.”

The “freedom” on offer? Freedom from health insurance and the Affordable Care Act. Sharing ministries are not health insurance. They are not bound by government insurance regulations. They need not maintain the financial reserves required of a health insurer. They frequently fall into “a regulatory vacuum,” in the words of JoAnn Volk, a professor at Georgetown University’s Center on Health Insurance Reforms.

In fact, the months after Liberty promoted itself at CPAC, complaints about unpaid member bills proliferated, so much so that Foster felt compelled to address the issues in a September blog post. When I recently asked why Liberty would spend money to sponsor CPAC even as members were facing unprocessed medical claims, company spokesperson Terrie Ipson told me in an email, “Marketing dollars do not come from the members’ sharing dollars so it has no impact on the sharing of medical expenses.”

The growth of health-care sharing ministries is one of the more surprising stories of the world made by the Affordable Care Act. A cross between a GoFundMe, a mutual aid society and a lending circle, people who are enrolled pay the medical bills of other members. The groups, which originated during the 1980s in small religious communities like the Mennonites, were exempted from following coverage guidelines mandated by the ACA. At the time, they were used by an estimated 100,000 Americans.

So what accounts for the large increase in membership? Well, health-care sharing appeals to the American tradition of self-reliance, and the belief that personal charity can substitute for government action. But more importantly, it gives enrollees the chance to save a buck.

As costs increased for plans on the ACA exchanges, health-care sharing plans experienced more moderate inflation. A family would pay $529 a month for Liberty’s Complete offering, which offers $1 million in coverage per medical incident, after the family meets an “annual unshared amount” of $2,250. Compare that with the exchanges, where a family not eligible for subsidies would almost certainly pay — at a minimum — several hundred dollars more a month.

So how can they do this? Well, a traditional health insurer needs to take all comers and offer a basic package of benefits. Health-care sharing ministries, exempt from the ACA, don’t have to do any such thing. They don’t need to — and almost always don’t — pay for birth control or abortion services. They can say no to mammograms and mental health services. They can impose yearly and lifetime caps on spending.

They may also ask for religious or behavioral commitments. There are ministries that demand enrollees attend church services regularly or make an explicit religious commitment, or that they refrain from taking illegal drugs, drinking alcohol, smoking or engaging in premarital sex. Liberty won’t even pay for injuries resulting from what they term “hazardous hobbies” such as rock climbing.

The health-care sharing ministries are, for the most part upfront about the fact they are not health insurance and state that fact clearly on both their websites, enrollment forms and membership cards. But confusion persists among many people about how they are different.

Take Lindsay Bideaux, an Omaha hairdresser. Liberty cost her half of what an ACA exchange plan would, she told me. The ministry, which Bideaux first heard about from a co-worker, “was the kind of insurance that would work for me.” But unlike insurance, “neither the organization or any participant can be compelled by law to contribute toward your medical bills,” as Nebraska’s Department of Insurance put it in a consumer alert issued last year.

When Bideaux got pregnant, there were months-long lags in the payment of some of her medical invoices. Pediatrician bills for her daughter, born in March, remain entirely unpaid. Two providers, including the pediatrician’s office, reported Bideaux to a collection agency when no payment came after several months. “They’ve definitely left me in a bind,” she said. Randy Romanik, Bideaux’s partner, who has his own separate policy with the company, has called Liberty constantly, trying to get resolution. (The company told the family Thursday those bills finally had been processed.)

Ipson, the spokeswoman for Liberty, would not comment specifically on Bideaux’s situation, citing medical privacy laws, but did tell me in an email that “implementation of new technology to better manage members’ records earlier this year caused issues with some previously submitted bills.” She added, “We have been transparent with our members in acknowledging the problems and continue to work diligently to identify these bills and share them as quickly as possible.”

Even people who are financially savvy can find themselves surprised by the ins and outs of this coverage. Ryder Meehan, a San Francisco entrepreneur, signed up for one after reading about them on a blog devoted to the FIRE (“Financial Independence, Retire Early”) movement, only to realize after his wife got pregnant that the hospital she hoped to deliver at considered ministry plans the equivalent of self-pay and asked for a hefty deposit up front. This is not uncommon. “We cannot negotiate group rates with [health-care sharing ministries],” says Elizabeth Fernandez, a spokeswoman for the University of California at San Francisco, home to three medical centers. “For hospital procedures, we try to collect the entire amount before service.”

Health-care sharing plans often spin their non-ACA compliance as a positive. As Foster said at the 2019 CPAC, “The simple idea all of us in this room believe is that government doesn’t know best.” I heard variations of this repeatedly while reporting this piece. Rob Hessler, an artist in Savannah, Georgia, told me the insurance broker who sold his family a health-care sharing plan with Aliera Health Care said, “something like they are not subject to all the exact same rules and stuff but he was making that sound as though he was completely presenting that as a positive.”

Some “positive.” Hessler and his wife Gretchen Hilmers spent almost the entirety of her recent pregnancy battling with Aliera over unpaid bills, in part because the firm initially denied many of their claims, saying the couple was no longer enrolled in the plan, a situation that was only partially resolved within the past month. Even more concerning, the family almost lacked any coverage for the baby’s birth. Aliera recently canceled their sharing option, as a result of a court agreement they reached with the ministry the company was partnered with at the time the couple originally signed up. But when Hessler and Hilmers sought to reenroll in another Aliera offering, they discovered Hilmers ’s pregnancy would be considered a preexisting condition. Here they experienced a bit of luck: Because the cancellation was considered a break in coverage, the couple was able to enroll in an ACA-compliant plan before the child’s birth. “Thank God for Obamacare,” Hessler told me.

Aliera spokesman David White told me that privacy laws prevented him from commenting on the specific situation but that, “to be eligible for maternity services … a member would have had to be on the program for 10 months of continuous membership,” adding that the company “will review each situation on a case-by-case basis and exceptions are made.” The next morning, the company called the couple and offered to renew their coverage. They declined.

In fact, Aliera is the rare health-care sharing outfit that’s had its wings clipped by several states. Washington state banned Aliera and its current partner ministry, Trinity Healthshare, from enrolling new members in the state, citing “misleading” sales practices that led to consumers to believe the company’s offering was ACA-compliant. Colorado did the same in August. Aliera has also agreed not to accept new business in Texas, after the state filed a lawsuit making similar claims. Aliera denies all this and sent me a statement saying, “Aliera will continue to vigorously defend against false claims made about the administrative, marketing and other support services.” White also pointed toward a plan brochure that said “This is not insurance” on every page — albeit at the bottom of the page, in very small print.

To be fair, there are thousands of Americans satisfied with health-care sharing. Many ministries attract few member complaints. But satisfied testimonials can’t compensate for a greater truth. For all the talk of charity and biblical values, health-care sharing ministries are promulgating a peculiar notion of collective welfare. The less-than-healthy and those who don’t subscribe to the beliefs of a particular sharing ministry need not apply. At the same time, they are relying on the trope that voluntary charity can replace a government safety net.

It could be argued the growth of these non-insurance health-care offerings is a reflection of the success of the Affordable Care Act. Many health-care analysts believed membership in health-care sharing ministries would drop off after the Trump administration did away with the ACA’s individual mandate. That did not happen. Americans want health-care coverage. The issue is that many believe they can’t afford it. That these plans exist is a consequence of our failure to make health care a right, something that makes the United States unique among first- world countries. No amount of appeals to charity or freedom can make up for that awful truth. True liberty isn’t a health-care sharing ministry. It’s not needing to worry about personal health-care expenses at all.

Read more: