Alycin Berry’s husband had just started a new job in early 2018 when the couple started to dig into his benefits. The amount they’d have to pay for health insurance, they realized, was “ridiculously expensive” — more than they could reasonably afford.

Neither Berry, a stay-at-home mom, nor her husband had any major health conditions. They didn’t use medical care often. She had just had her first child and hoped to get pregnant soon with another. She just wanted to make sure they could get coverage for her maternity care. 

The couple looked for something cheaper, ultimately settling on a health care sharing ministry. They would contribute hundreds of dollars per month, which was still less than the insurance premium. With major medical bills, participants in the ministry paid upfront, seeking discounts medical providers often offer to people who don’t have insurance. The health care sharing ministry would reimburse them after the fact.

The benefits weren’t as generous as health insurance, but the ministry fit better in Berry’s family budget. The organization advertised its maternity benefits, specifically, and more broadly promised coverage for hospital visits and surgeries. There were stipulations: To enroll, members had to sign a declaration that they would align their lifestyles with its Catholic values. Those religious views played out in policy too: The health share wouldn’t cover a pregnancy conceived through in vitro fertilization, for instance. But Berry, a Catholic herself, wasn’t worried. 

“It did feel like it was comparable to health insurance if not better than health insurance. They pitched it that way,” she said. 

Then she tried to use it. 

In 2019, Berry, now 37, miscarried at home, her first of three lost pregnancies. After visiting a doctor for follow-up care, Berry sought reimbursement from her health share. She was eventually able to get payment, but doing so required reams of paperwork, she said, including verifying that her pregnancy was conceived without fertility treatment. The process took several months.

“It was kind of like, ‘What? This is crazy. We’re grieving this loss, we’re jumping through hoops to get this miscarriage care covered,’” she recalled. 

Ministries like the one Berry joined are part of a constellation of alternatives to health insurance, cheaper and less regulated than those covered by the Affordable Care Act, and with far fewer consumer protections. Now, as Congress struggles to make a deal to extend subsidies for plans offered via the health law’s individual marketplace, those alternatives could see a surge in interest and enrollment.

Tax credits used to help lower what consumers pay for marketplace insurance, which covered about 25 million Americans last year. But those credits expired at the end of 2025. Without them, marketplace premiums skyrocketed — many are more than doubling. 

Final figures won’t be available for months, but preliminary government data suggests that enrollment in health insurance has fallen as a result, down by at least 1.4 million. A December survey from KFF, the nonpartisan health policy research, polling and journalism group, found that 1 in 4 marketplace enrollees said they would go without insurance if their premiums doubled. And historical trends suggest that some will try to fill in the gaps with skimpier but cheaper alternatives, including ministries like the one Berry used.

“Whenever the costs go up, it’s just a golden marketing opportunity for sellers of anything other than comprehensive coverage to make the pitch they have a more affordable option,” said JoAnn Volk, a research professor at Georgetown University’s Center for Health Insurance Reforms, who has studied these organizations extensively. ”Health care sharing ministries are one of those.”

Under the Affordable Care Act, health insurance is required to cover particular sets of benefits, including preventive care, maternity, mental health. Plans cannot impose lifetime caps on coverage. They can’t discriminate against preexisting conditions. They must spend at least 80 or 85 percent of premiums on medical care, depending on the type of plan. Insurance offerings that could violate those requirements face government scrutiny or even penalties.

Those requirements don’t exist for health care sharing ministries, and there is no regulatory body tasked with overseeing them. Health care sharing ministries work on a theoretical sharing model: members pool resources, and the ministry decides what health expenses to cover. Ministries or health shares are usually religious, and allowed to deny coverage if it doesn’t align with their stated values. That in practice means significant limitations for women and queer people: Ministries typically don’t cover contraception or pregnancies that are not conceived by a heterosexual couple. Many won’t cover injuries or illnesses they deem the result of immoral choices —  including drug and alcohol use, which is more common among LGBTQ+ people. And ministries often exclude coverage for mental health needs, another area where LGBTQ+ people and women are more likely to require care.

The Alliance of Health Care Sharing Ministries, a trade group that represents the vast majority of these groups, declined to comment.

Enrollment in these ministries has soared since the passage of the Affordable Care Act, more than 15 years ago. The health law, which required individuals to have insurance, included an explicit carveout for these ministries. People wouldn’t be subject to the mandate if they used a ministry, so long as it existed prior to 1999. The idea was to accommodate small religious cost-sharing arrangements, which at the time only counted maybe 200,000 members.

A 2023 report published by the Colorado Department of Insurance identified at least 1.7 million people across the country using ministries for their health coverage, though the authors said that was likely an undercount. Many of these arrangements instructed members to first ask medical providers for charity care — free or discounted treatment, which is reserved for those who don’t have health insurance, typically lower-income people — before submitting bills for reimbursement. A report that same year from the Government Accountability Office suggested that a disproportionate share of participants are from low-income households. National data is difficult to come by because no federal body tracks health care sharing ministries. 

“There’s an ongoing affordability crisis in health care that is being made worse by the lapse of this extra premium help, so people are looking for options,” said Katie Keith, who heads the Center for Health Policy and the Law at Georgetown University’s O’Neill Institute. “People don’t realize what they’re getting. It’s the marketing materials, it’s the way these are being advertised. Some brokers sell ministries, and people don’t understand that it is not a typical health insurance product.”

Thirty states have explicitly passed laws saying ministries aren’t the same as insurance and don’t need to be held to the same standards, freeing them from some government scrutiny. Some lawmakers have made an effort to regulate individual ministries. Both Massachusetts and Colorado have passed laws requiring ministries to share data on their enrollment, finances and marketing with the state insurance departments. 

Washington state’s insurance commissioner blocked one ministry from selling its products in the state, arguing that the company was selling illegal insurance that did not cover particular preexisting conditions. The state of California has entered a settlement with a ministry accused of “creating, operating and selling sham insurance.” The Department of Justice has settled with another one, based in Missouri, that was accused of fraud. 

In one 2020 class action, three plaintiffs alleged that their health share had falsely represented itself as insurance and then refused to pay for medical expenses it had promised to cover, including one who said she could not receive reimbursement for bills related to pregnancy and childbirth. (The lawsuit was closed when the health share declared bankruptcy.) A report from NBC News identified four families who struggled to receive reimbursement for their pregnancy-related medical bills.

In some cases, members pay their medical costs upfront with the promise of reimbursement from their ministry. Receiving payment can be straightforward. But if it isn’t denied completely, it can also resemble Berry’s experience — taking months of back-and-forth.

Pregnancy is of particular concern. In its 2023 report, the GAO found that every health care sharing ministry it reviewed required new members undergo a waiting period before qualifying for pregnancy-related health coverage. A 2018 review from the Commonwealth Fund, which studies health policy, found that many large ministries only covered pregnancy-related costs under particular circumstances, including requiring members wait a set number of months, that pregnancies be conceived in wedlock, or that members be enrolled in more expensive cost-sharing options.

The costs of childbirth are steep. An analysis by KFF, the nonpartisan health policy research, polling and journalism organization, found that a privately insured birth costs more than $20,000, with about $2,700 in out-of-pocket expenses. Someone without insurance or seeking future reimbursement could pay less than that; hospitals and health providers typically charge less for people who are uninsured. 

By the time Berry got pregnant, in the fall of 2021, she was able to avoid that risk.  After years of negotiating for reimbursements, a process that often took months, she and her husband decided that January to switch to insurance. 

Still, seeking payments to cover the maternity expenses she’d incurred before changing — particularly an approximately $4,000 global fee from her birth center — took more than a year of emails and phone calls, per communications she shared with The 19th. 

Her experience since switching to health insurance has been far simpler, she said, adding that she would never recommend the health share to anyone else. Since leaving her health share, she has joined several Facebook groups devoted to sharing experiences from others who have navigated health shares like hers. She’s spoken to many who struggled to receive reimbursement for much larger maternity bills.

“The way they marketed it was this is an alternative to insurance and so it seemed like it was just a different way to get the same kind of coverage — and obviously that’s not true,” she said.