Health care sharing ministries (HCSMs) are drawing renewed attention as alternatives to traditional health insurance following the expiration of federal tax credits that previously lowered Affordable Care Act (ACA) marketplace premiums. These organizations, which are typically faith-based, allow members to share medical expenses but do not operate under the same federal regulations as standard insurance providers. Because they are not classified as insurance, they are not required to cover pre-existing conditions or essential health benefits.
The shift toward these alternatives comes as approximately 25 million Americans face higher costs for marketplace plans. Federal tax credits that subsidized these plans expired at the end of 2025, leading to premium increases that, in some cases, have more than doubled. According to preliminary data from the Centers for Medicare & Medicaid Services (CMS), marketplace enrollment has already decreased by at least 1.4 million people as of early 2026.
Unlike ACA-compliant plans, HCSMs often require members to adhere to specific religious or lifestyle statements. These organizations can legally exclude coverage for services that conflict with their stated values, such as contraception, fertility treatments like in vitro fertilization (IVF), or pregnancies occurring outside of heterosexual marriage. Members often pay lower monthly "shares" than insurance premiums but may be required to pay medical providers upfront and seek reimbursement later.
Research from the Georgetown University Center for Health Insurance Reforms indicates that these organizations often see a surge in enrollment when comprehensive coverage becomes more expensive. However, the lack of consumer protections means there is no legal guarantee that claims will be paid. Some members, like Alycin Berry of Texas, have reported significant administrative hurdles and months-long delays when seeking reimbursement for maternity-related care, such as miscarriage follow-up services.
For the estimated 1.7 million people currently enrolled in HCSMs, the day-to-day reality of healthcare changes from a co-pay system to a cash-pay system. At the doctor’s office or hospital, these individuals are often treated as "self-pay" patients. While this can sometimes lead to lower "prompt-pay" discounts, it also means patients may need to have thousands of dollars in liquid savings to cover a hospital stay or emergency surgery upfront before seeking reimbursement from their ministry. For pregnant patients, this can mean navigating a complex "needs" sharing process for prenatal care and delivery that does not carry the same legal appeals process as a denied insurance claim.
The long-term impact involves a potential "adverse selection" cycle in the broader insurance market. As healthier individuals move to lower-cost sharing ministries, the remaining pool of people in ACA-compliant plans may become sicker on average, further driving up premiums for those who require comprehensive coverage for chronic conditions. What happens next depends on congressional action regarding the expired subsidies. Without a legislative extension, the 2026 enrollment period will serve as a test for whether sharing ministries can absorb a large influx of new members and whether state regulators will move to increase oversight of these currently exempt organizations.