by Miranda Spindt
After turning 26 in December, I was expected to get a health insurance plan for the first time, and I did not like my options. Whether through my previous employer or the Affordable Care Act (ACA) Marketplace, the plans available required paying thousands in annual premiums and deductibles to receive meaningful benefits. For a healthy young adult, it was difficult to justify.
Millions are currently facing the same issue. ACA Marketplace premiums skyrocketed for many enrollees this year after temporary enhanced federal subsidies expired. The number of people signing up during the open enrollment period fell by 1.2 million, and more cancelled in the first few months after seeing their monthly payments. It is projected that potentially 5.8 million people will lose their coverage in 2026.
Many families are choosing to drop their coverage and risk having no coverage at all like the Tobiassen’s in North Carolina. But this is actually a false choice. Multiple affordable alternatives can provide access to routine care and financial protection against unexpected medical expenses.
Personally, I chose a direct primary care (DPC) clinic—a membership model where patients pay a flat monthly fee instead of billing insurance—for my everyday needs. I paired it with a health share plan—a nonprofit community where members voluntarily share one another’s medical expenses—for unexpected, high-cost events.
This costs me 60% less than health insurance, and I believe it gives me better access to care. My DPC membership includes unlimited appointments with no co-pays for nearly all routine and even urgent care services, and direct communication with my doctor. The health share plan protects me in case of emergencies or hospital stays, with no network restrictions.
Though I am technically uninsured, I was able to secure access to routine care and financial support for major medical expenses through a combination of alternative models.
These alternatives are not niche experiments. Millions of Americans have adopted models such as Health Care Sharing Ministries, Direct Primary Care, and Farm Bureau Health Plans because they offer different approaches to accessing and paying for care. Between 2014 and 2021, the number of people using a Health Care Sharing Ministry grew from about 160,000 to 1.5 million.
The percentage of family physicians who were part of or transitioning to a DPC practice jumped from 3% in 2022 to 11% in 2023. Farm Bureau Health Plans (FBHP) —medically underwritten health coverage products offered through state Farm Bureaus rather than insurance companies— are another option. In Tennessee, which has the longest operating FBHPs, there are over 200,000 members.
Unfortunately, many Americans cannot choose these options. Several states either restrict them, regulate them inconsistently, or don’t authorize them at all. DPC, for example, is a completely insurance free service model that keeps a smaller panel of patients. Without an explicit exemption, a DPC practice could be accused of violating insurance antidiscrimination rules for turning away new patients once their panel is full.
Health Care Sharing Ministries (HCSMs) face a similar problem. Because HCSMs are voluntary sharing communities rather than insurers, applying insurance regulations to them makes their model unworkable. Without an exemption, states can force them to follow insurance rules they are not designed for, like keeping huge cash reserves or covering mandated benefits, which would make their structure inoperable.
DPC is exempt in 34 states, and HCSMs are exempt in 31 states. In the remaining states, lawmakers should look to model policy developed by members of the American Legislative Exchange Council as a helpful resource for exempting HCSMs, and similar action should be taken for DPC.
FBHPs have a greater uphill battle. Currently, only 14 states allow them to operate health plans for their members. These plans can be 30-50% more affordable than Marketplace insurance and are especially valuable in rural areas with limited options.
These models aren’t meant to be a perfect fit or replace traditional insurance for everyone, but they should be available for anyone who would benefit from them. As millions of people are priced out of health insurance, states should not stand in the way of alternative options. By modernizing state laws on alternative health care models, lawmakers can give families real choices instead of impossible tradeoffs.
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Miranda Spindt is the Director of the Health and Human Services Task Force at the American Legislative Exchange Council (ALEC) and a Health Policy Fellow for Independent Women. Follow her on X @miranda_spindt.
