Health Care Financing Practices Among U.S. Amish

The Amish are a rapidly growing Christian ethnoreligious group located in the U.S. and Canada. Characterized by self-reliance and a caution regarding the acceptance of modern technologies, the Amish have traditionally relied on community-based mutual aid to finance health care expenditures instead of commercial insurance or public assistance options. However, the cost, structure, and efficacy of Amish mutual aid programs are not well-described. We surveyed 1006 Amish households in 12 states using a 31-question instrument that asked respondents about demographic information, their health, and participation in mutual aid organizations. Statistical analysis was performed with returned surveys. One hundred fifty-five surveys were returned for a response rate of 15.4%. 81% of respondents reported mutual aid membership. The reported annual health care spending ranged from $500 to $18,000 among nine mutual aid organizations. More than 90% of respondents indicated that they "agree" that their community will help them pay for health care, though 39% reported "sometimes" avoiding recommended medical care due to cost. There were statistically significant differences in treatment avoidance due to cost and perceptions of affordability between Indiana Amish and those in Michigan and Wisconsin. The financing mechanisms employed in our cohort included negotiating organizations, subscription models, and voluntary donation. Though mutual aid mechanisms were ubiquitous, the success of individual organizations may depend on Amish population distribution and relationship with health systems. Providers treating this population should understand Amish practices regarding medical billing. Further studies are necessary to develop institutional best practices for Amish and other self-pay populations.