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How Obamacare Enabled a Multibillion-Dollar Christian Health Care Cash Grab
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Joe Guarino rescued an entire industry with help from what some called “divine” intervention.
A little-known lobbyist from Virginia, Guarino was hired in 2007 by the Alliance of Health Care Sharing Ministries, the trade association for nonprofit alternatives to medical insurance founded on Christian principles. Health care sharing ministries take fees from members, which are then used to pay other members’ health bills.
At the time, the industry had been tainted by a scandal involving one of the largest ministries in the country, the Christian Brotherhood Newsletter, based outside Canton, Ohio. State authorities won $14 million in civil judgments against two of its top leaders for enriching themselves instead of paying the medical bills of its members. A ProPublica investigation last month revealed that many of the Brotherhood’s executives, including Daniel J. Beers, were involved years later in the launch of a second scandal-plagued ministry, Liberty HealthShare.
The Washington-based alliance was looking to Guarino to repair the industry’s reputation and pass laws to fend off a looming movement to regulate the business. The lobbying effort is an example of how the ministries have quietly worked over the years to shield themselves from consumer protection laws and preempt government oversight.
Guarino decided to launch a state-by-state campaign to pass so-called safe harbor laws that exempt health care sharing ministries from insurance regulation. The carve-outs were justified, the alliance argued, because ministries don’t set prices and coverage based on risk calculations or pool people’s money, as insurance companies do. In the United States, many of the rules for health insurance are set by the states in which companies operate.
Guarino met with lawmakers in Virginia, Arkansas and Idaho. “Most of the time I was hiring local lobbyists, training them, and then they got the bill passed for us,” Guarino explained.
Although it did not attract much attention, the campaign was a remarkable success. By 2008, 15 states had passed safe harbor laws. Then, a new threat emerged. In 2009, President Barack Obama proposed his sweeping reform of the health care system. Central to the law was a provision referred to as the “individual mandate,” which required that every American obtain health insurance or face a fine. The mandate presented a direct threat to health care sharing ministries: If members were forced to buy insurance, they would likely leave en masse.
Although Guarino was embarrassingly outgunned by the health insurance lobby, he was determined to slip some version of a safe harbor carve-out into whatever the Democratic-controlled Congress handed the president. “I went and saw 150 congressional staffers during that time,” Guarino said.
The turning point came when Guarino reached out to a GOP state legislator he knew in Iowa and asked if she could put him in touch with Republican Chuck Grassley, the state’s longtime senator who wielded power as a member of the Senate Finance Committee. The lawmaker had known Grassley’s family since childhood and agreed to set up a meeting. “Lo and behold, that happened,” Guarino said. “As a Christian, I look at this and say, ‘Oh, this is God’s way of orchestrating things.’”
Guarino told ProPublica that he and his clients got on the phone with Grassley. Together they crafted an amendment to Obamacare that exempted members of sharing ministries from having to obtain health insurance on religious grounds. Behind the scenes, Grassley got that carve-out into the Senate version of the bill, Guarino said. (Grassley did not return a request for comment.)
The passage of the Affordable Care Act was chaotic and, for ministries, that was fortuitous. The House version, which many Democrats preferred, didn’t include Guarino’s exemption. If the House bill prevailed in negotiations between the two chambers, ministries would be extinct.
But with the sudden death of Sen. Ted Kennedy, Democrats lost their filibuster-proof majority in the Senate and could not pass the House version. They were forced to go with the Senate bill that included the carve-out.
The exemption — just 200 words in a 900-page bill — survived tense negotiations between the chambers, going virtually unnoticed. Obama signed the ACA into law in March 2010.
“That’s our language right in the bill,” Guarino told ProPublica.
One friend told him that he’d just saved an entire industry. The larger Christian health share community hailed it as a miracle. “If you’re a person of faith, some of us might say it was kind of divine,” said Tony Meggs, then CEO of Medi-Share, one of the groups that formed the Alliance of Health Care Sharing Ministries.
Meggs estimates membership grew tenfold after 2014, when the individual mandate went into effect. Four years later, the alliance announced that about a million Americans belonged to its member ministries. Some bought into the ministries because they disliked Obama and associated him with the law. Others did it for economic reasons. The ministries offered cheaper plans than insurance sold on the ACA marketplace, which were expensive for anyone who did not qualify for subsidies or Medicaid. Many self-employed people and small business owners fell into this category.
“All of a sudden people started getting religion because they could save $700, $800 a month,” Meggs said.
Both Meggs and Guarino say they believe that most health care sharing ministries do right by their members and the insurance alternative can work when it’s under ethical management. But both acknowledge the industry has been vulnerable to abuse. “Obviously, that kind of growth is going to attract bad actors and people who look for opportunity to enrich themselves,” Meggs said.
One of the people who took advantage of the opportunity is Beers, the patriarch of the family that started Liberty HealthShare just as Obamacare’s individual mandate drove thousands of people to health care sharing ministries. The ProPublica investigation found that Beers acts as a shadow lord over an empire built with money from Liberty HealthShare. Some of the family grew rich while Liberty’s members were left with tens of millions of dollars in unpaid health bills.
Beers’ name does not appear on any official documents related to Liberty, and he denied involvement in family businesses that profited from the ministry. Attorneys representing Beers and members of his family also disputed ProPublica’s finding that they controlled or influenced the sharing ministry or did anything wrong. Liberty is now under new management that does not include Beers or his relatives.
For those in the ministry industry, however, Beers’ involvement has been an open secret for years.
Meggs told of a surprise encounter he had around 2014 with Liberty’s then-CEO, its vice president and Beers, all key figures in the Brotherhood. The group wanted to propose a partnership between Meggs’ ministry and Liberty, which was experiencing explosive growth
At the meeting, Beers was clearly in charge, Meggs remembers, so no matter what they were selling, he wasn’t buying.
Liberty, he said, looked too much like the Brotherhood.
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Some Election Officials Refused to Certify Results. Few Were Held Accountable.
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A week and a half after last November’s vote, members of the Board of Elections in Surry County, North Carolina, gathered in a windowless room to certify the results. It was supposed to be a routine task, marking the end of a controversial season during which election deniers harassed and retaliated against the county’s elections director. Not long into the meeting, however, a staffer distributed a letter from two board members stating that they were refusing to certify.
According to the letter, the two members had decided — “with regard for the sacred blood shed of both my Redeemer and His servants” and “past Patriots who made the ultimate sacrifice”— that they “must not call these election results credible and bow to the perversion of truth.”
In their view, a federal judge who’d struck down a North Carolina voter ID law for discriminating against minorities had transformed the state’s election laws into “a grotesque and perverse sham.” Tim DeHaan, one of the two board members who signed the letter, explained at the meeting, “We feel the election was held according to the law that we have, but that the law is not right.”
This argument failed to win over the three Democratic board members, according to a recording of the meeting. DeHaan eventually agreed to join the three on a technicality, and the board certified the election with a 4-1 vote. Jerry Forestieri, the Republican board secretary who also signed the letter, held out.
DeHaan and Forestieri declined to comment and did not respond to written questions.
Before 2020, local election officials seldom voted against certifying results. But in 2022, conservative officials in North Carolina, Arizona, Nevada, Pennsylvania and New Mexico refused to do so. Some admitted to refusing to certify for political reasons. In all the 2022 cases, the election results eventually were certified, sometimes under a court order.
Election law experts say that these disruptions reveal a weakness in the American electoral system, which relies on thousands of local officials to certify the totals in their counties and municipalities before their results can be aggregated and tallied for state and federal elections.
Local elections officials “could create chaos” all the way up the chain by refusing to certify, said Alice Clapman, a senior counsel in election law at the Brennan Center for Justice. “And in that chaos you have more room for political interference.” Five legal experts described to ProPublica scenarios in which legislatures, courts, secretaries of state or governors could use a failure to certify at the local level to exert partisan influence.
Clapman said that even if refusals to certify don’t affect election outcomes, they can violate state laws and can amplify and validate harmful misinformation that feeds election denialism because of the imprimatur of the officials’ offices.
A ProPublica review of 10 instances of local officials refusing to certify 2022 results in four states found that, for the majority of them, the state election authority did not ultimately pursue official consequences. Two of them have been referred for criminal prosecution, but the attorney general in that state would not comment on whether there is an open investigation. And two — the ones in Surry County — are facing potential removal from their posts by the State Board of Elections.
“There needs to be some sanction when there is lawlessness,” said Richard L. Hasen, an election law professor at the University of California, Los Angeles, and director of the Safeguarding Democracy Project. “If you allow these things to take place without any sanction, then you invite more serious rule-breaking in the future.”
After the DeHaan and Forestieri letter, Bob Hall, the former executive director of the watchdog group Democracy North Carolina, submitted a complaint to the State Board of Elections to start a disciplinary process, as permitted by North Carolina law if board members commit an alleged breach of duty. An attorney for Hall argued in a subsequent document that “if left unchecked, Forestieri and DeHaan may be the first of many board members throughout the state and across the political spectrum who cannot be trusted to faithfully certify election results.”
That led the state board to summon Forestieri and DeHaan to its headquarters in the capital, a roughly three-hour drive from their rural home, for a hearing last month.
At the beginning of the proceeding, DeHaan argued that the hearing itself was “illegal” because it was supposed to be held in the county the board members are from. The Democratic board chairman agreed and voted with a Republican colleague to move the hearing to Surry County. A date has not yet been set. “The relocation to Surry County shows that this isn’t normal,” said Christopher A. Cooper, a professor specializing in North Carolina politics at Western Carolina University. “There isn’t a long history of examples of this sort of thing to lean on.”
A replica sheriff’s car from “The Andy Griffith Show” drives through downtown Mount Airy, North Carolina, in Surry County. (Cornell Watson for ProPublica)Experts point out that efforts to hold local officials accountable for not certifying their elections have been of a patchwork nature across the nation. “I think states are trying to figure out what to do and are approaching it differently, like a prosecutor making a judgment on a case-by-case basis whether to bring a case or not,” said Derek T. Muller, a professor at the University of Iowa College of Law who has researched legal options for ensuring that local officials certify elections. “States need to figure out how to bring these cases in a fair, consistent and lawful way.”
In Cochise County, a rural part of Arizona on the Mexican border, a pair of county supervisors refused to certify their November 2022 results despite state officials warning them multiple times that doing so would be illegal under state law. In early December, a court ordered them to certify, but one supervisor, Tom Crosby, still skipped the vote.
The next day, the state elections director, at the urging of a former Republican Arizona attorney general, sent a letter to the state attorney general referring the supervisors for criminal investigation, arguing that they had committed “potential violations of Arizona law.” The letter concluded, “This blatant act of defying Arizona’s election laws risks establishing a dangerous precedent that we must discourage” by taking “all necessary action to hold these public officers accountable.” A spokesperson for the Arizona Attorney General’s Office wrote that they “cannot confirm or deny any potential investigation” that may have resulted from the letter.
In January, a group of Cochise County voters launched a petition to recall Crosby. As of late February, it had approximately a quarter of the 6,000 signatures it would need by early May to result in a new election, according to Eric Suchodolski, the chairperson of a committee leading the effort. “It’s our best recourse as citizens,” he said. “I didn’t think the authorities would ultimately do something, and even if they did, it can take awhile.”
In response to a request for comment, Crosby said: “If I get into defending myself it will never end. I’ve already answered all this stuff.” In the past, he has disputed the validity of the certification of the county’s voting machines, despite assurances from the state.
While in North Carolina and Arizona there are ongoing efforts to hold accountable local officials who didn’t certify their elections, Nevada and New Mexico decided not to pursue such efforts.
In Nevada, one Republican commissioner in Washoe County and another in Nye County refused to certify, though in both cases the other four commissioners outvoted them. A spokesperson for the Nevada Secretary of State’s Office said that “our office is not aware of any legal consequences for that action” by the commissioners.
In Otero County, New Mexico, the county’s three commissioners initially voted unanimously against certifying the June 2022 primary elections. This followed months of disputes about election security driven by conservative activists who also fueled protests in Surry County.
New Mexico law requires commissioners to approve election results unless they can point to specific problems. The Otero commissioners only raised debunked concerns about hacked voting machines, with one of the officials, Couy Griffin, referencing his “gut feeling.” The New Mexico secretary of state subsequently asked the state’s Supreme Court to step in, and it ordered the commissioners to certify. The secretary of state also sent a letter to the state’s attorney general notifying him of “multiple unlawful actions by the Otero County Commission” and asked for “a prompt investigation.” Faced with this, two of the commissioners switched their votes, certifying the election. Griffin did not. (In Sandoval County, on the other side of the state, one commissioner voted against certification, though the four others on the panel outvoted him.)
Griffin did not respond to a request for comment.
The New Mexico Secretary of State’s Office decided not to further pursue “punitive action” against the officials who did not certify, according to Alex Curtas, its communications director, because “our concern was getting the election certified, so that’s where that ended.”
“Once it became clear that we had that state Supreme Court precedent and this wasn’t really a widespread thing, just two hard-right commissioners, we felt comfortable that this wouldn’t be a major problem in the general election,” he said, “and in our perspective it became a bit of a moot point.”
Griffin eventually was subsequently removed from public office and banned from holding it by a judge’s order as part of sentencing for participating in the Jan. 6 insurrection.
Part of the challenge for states seeking to crack down on officials who refuse to certify elections is that many of the laws that provide recourse were written more than a century ago. “We’re dealing with modern issues with very old statutes,” said Quinn Yeargain, a professor at the Widener University Commonwealth Law School in Pennsylvania.
Some states recently enacted new regulations. Last year, Colorado legislators passed the Election Security Act, which mandates that the secretary of state certify a county’s results if it misses the deadline to do so. In Michigan, voters passed a wide-ranging voter-protection ballot proposal in November that made certification a “ministerial, clerical, nondiscretionary duty.” This clause was in response to conservative members of a county canvassing board for Detroit refusing to certify the 2020 presidential election for a few hours, momentarily threatening to throw its certification into chaos.
Election legal experts note that holding local election officials accountable for voting against certifying elections will continue to be complicated. Muller, the Iowa law professor, favors what he calls the “least invasive process,” one that would allow courts to replace local officials who refuse to certify elections with other officials who would do their duty.
But he said any process that results in an official being forcibly replaced is likely to carry political risks, including the potential to abuse the system to disempower political opponents.
“We haven’t seen fallout from local election officials being removed yet, because these processes are just beginning,” Muller said. “But we could see that soon.”
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