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Zion HealthShare, according to CEO Nathan Udy, encourages its members to share their burdens with one another. Zion says it welcomes all comers regardless of faith, but many of its peer companies in the health share industry note that their core imperative is set down in Scripture. “Carry each other’s burdens,” Paul the Apostle says in Galatians 6:2, “and in this way you will fulfill the law of Christ.”
Zion aids this cause by giving people a chance to pay monthly into its collection. Then, when a member faces a medical expense—a broken arm, say, or a hospital stay—that member can submit a sharing request to the community to draw on this pool of money to help with the bill. “Rather than functioning through policies and premiums,” Zion tells prospective members, “health shares are built on the concept of shared responsibility.”
Founded in late 2018, the St. George, Utah-based group has grown rapidly in recent years, with reported annual revenue jumping tenfold from 2020 to 2024—the latest year on record—to $93 million. It reports 1,222 members in Oregon and 75,000 members nationwide, spanning nearly every state.
One reason Zion is not in literally every state, however, is because a few years ago it hit a snag. Although the group describes itself as “the affordable alternative to health insurance,” the Washington State Office of the Insurance Commissioner determined that it was in fact just plain health insurance—albeit health insurance operating without a license, with benefits that did not satisfy basic insurance regulations.
One fairly important benefit it did not provide: any requirement that the collective pay for a member’s medical treatment.
Zion countered that it was not, in fact, insurance, and that it is quite clear about this point in its guidelines. “Zion HealthShare is not an insurance program, but members share major medical costs with one another as a community,” Zion wrote in one disclaimer to prospective members. Zion also told members it “has shared all eligible medical expenses of its members to date” even as it cautioned that the “guidelines do not create a legally enforceable contract between Zion HealthShare and any of its members.”
Time went by. Authorities ruminated. Then, a few weeks ago, the Washington State Court of Appeals issued its verdict. “No one can change the nature of insurance business by declaring in the contract that it is not insurance.” The words in the Feb. 5 ruling were drawn from decades-old precedent. Today, Zion, like many similar health shares, no longer accepts members in the state of Washington.
Oregon is a different story. Of the eight health share arrangements (at least) that Washington’s insurance office has effectively chased from the state since 2020, most continue to accept members here. In the same time frame, the Oregon insurance office says it has taken regulatory action against two such groups.
To some, this speaks well for Oregon. Health shares, they argue, have much to recommend them. They appeal to the devout believer who does not want to pay into insurance plans that fund acts that offend them. (Zion, for example, notes that expenses for an abortion are “ineligible for sharing.”) They also appeal to relatively healthy people who want something that is like health insurance, but on the cheap.
From this perspective, Washington is the nanny state, while Oregon wisely stays out of its residents’ private affairs. “It’s your responsibility as a consumer to do your due diligence to your research,” state Rep. Emily McIntire (R-Klamath Falls) said at a hearing on the matter last year.
From another vantage, however, the split screen suggests an Oregon insurance commissioner’s office that is a bit drowsy on the watch—or at least conflict averse—and which might stand to learn something from its zealous neighbors to the north.
Before his recent retirement, the Washington state insurance commissioner for two-plus decades was Mike Kreidler.
In going after health care sharing arrangements for operating as unlicensed insurers, he saw himself as protecting consumers from misleading, dangerous, and aggressive marketing of a highly complex and important product. And yet, he says, the offending health shares often quickly reconstitute under a new name. And at a time when health insurance premiums are skyrocketing, he says, health shares are pitching themselves with verve.
“I see a lot more advertising being done than I saw before,” Kreidler told WW by phone the other day, as he was taking a stroll. “I think they’re trying to pick up people who are desperate, who want to have some kind of coverage.”
A few thousand miles across the country at Georgetown University’s Center on Health Insurance Reforms, JoAnn Volk has been making a similar observation. “When premium goes up for [Affordable Care Act] coverage, we see much more marketing of non-ACA options, including health care sharing ministries,” she says in a video call.
She adds, “I see new names of ministries all the time.”
There is a history here. Certain religious communities, like Mennonites, have a genuinely deep-rooted tradition of rejecting certain modern financial products, like health insurance. The 2010 Affordable Care Act, which set down a financial penalty for those who did not purchase health insurance, averted a direct clash with this tradition by carving out members of “health care sharing ministries”—a term it defined by several parameters, including the somewhat arbitrary quality of having existed continuously since Dec. 31, 1999.
Some groups that meet that criteria still exist. Many that emerged post-ACA clearly don’t—a fact that has considerably muddied the waters since many of them, like Zion, claim the identity all the same. (“We don’t look to government definitions for our identity,” said a spokesperson for the Alliance of Health Care Sharing Ministries, which represents five major health shares. The spokesperson noted the ACA requirement that a qualified group must have been sharing continuously since 1999 “obviously has nothing to do with whether an organization is an actual health care sharing ministry.”)
One appeal of health shares—that they might get their members off the hook of having to buy ACA health insurance—dwindled somewhat in 2019, after President Donald Trump reduced the penalty for not having insurance to zero.
But another appeal remained: Health shares were health insurance-like plans—often charged with righteous purpose—and without the cost or hassle of health insurance rules.
It is easy to forget the pre-ACA health insurance landscape, Volk says, recalling a period when health insurers could reject people for having preexisting conditions, and were not required to offer many of the basic benefits they do today. Health care sharing ministries hark back to that bygone era: “Even though all those things make it seem just like insurance, there’s no obligation to pay, ever,” Volk says.
The problem is that this “not paying” tendency sounds to many people a lot like the behavior of actual health insurance companies. The distinction is largely meaningless to consumers, Volk says. Still, she insists the daylight is actually quite significant.
“One never has to pay,” she says. “One has to pay unless they’ve said it’s not medically necessary for you—and an external party agrees. That’s a very, very different thing.”
Some people have learned this the hard way. One of the two health share ministries Oregon has taken action against is Aliera. In 2019, the state alleged, an Oregon resident filed a complaint that the company denied a claim for an emergency room stay, leaving a $79,595 bill that an ACA insurance plan would have had to cover.
But in Oregon, that enforcement action has been an outlier.
The Oregon Division of Financial Regulation defends its work. “Our process, like many states, is complaint- and resource-driven,” division spokesman Jason Horton tells WW. “We cannot comment on current caseloads, and our activities speak for themselves. Our goal is to always get companies to be in compliance with Oregon laws.”
Notably, Oregon, unlike many states, including Washington, has no “safe harbor law” exempting at least some health care sharing arrangements from normal insurance regulation. Still, the Oregon insurance office has said its hands are tied. Last year at a hearing, a state DFR official outlined the office’s view on the matter: Most inquiries it receives on health care sharing arrangements “relate to issues such as not paying claims or paying claims only partially or very slowly or providing what is alleged to be poor customer service,” he said. “Since these arrangements are not insurance, there’s often little to nothing we can do in those situations.”
Washington, by contrast, seems to have more closely scrutinized health shares’ claims to not be insurance. And perhaps as a result, it has fewer of these arrangements. Judging by the latest data, at least 12 health share arrangements exist in Washington, compared with at least 19 in Oregon. Still, public statistics on the industry’s market share are collected by only a couple of states, like Colorado.
Last year, a group called “Secular Strategies” suggested Oregon Rep. Rob Nosse (D-Southeast Portland) propose a bill for the state to require health shares to report similar information. It would have placed no additional burden on the arrangements, but after bringing it forth, the health committee chair quickly learned the issue was spicier than he knew, as Republican colleagues balked and talked of their own experiences mulling health sharing plans, and an Alliance of Health Care Sharing Ministries official descended on Salem to pillory the proposal.
The bill died. But as Nosse pointed out at the committee hearing, the prevalence of health care sharing groups raises core questions about the role of government in the private lives and moral decisions of the public. In court in recent years, Zion HealthShare raised this issue too, when it argued that Washington’s requirement that it get an insurance license would have a coercive effect on its reason for being: to encourage its members to share their burdens.
The Washington state court saw things through a different prism. If Zion got licensed, the judges noted, it would be required to cover preexisting conditions and a wider array of medical services and procedures. Yes, this would mean higher monthly contributions from members. But, the court noted, it would be consistent with Zion’s ostensible purpose.
“Being subject to Washington State insurance law,” the court wrote, “would encourage greater sharing of medical burdens with one another.”
