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In 1965, Congress passed a law giving certain Amish and Mennonite religious orders the right to opt out of Social Security, Medicaid and a host of other government benefits.
"The basic religious reason driving their resistance is that, as a religious faith, the church community should take care of its own members," said Kraybill. "If there's a disaster like a tornado, fire or hospital bill, the community should come together for that."
The Obamacare exemption is an extension of the Social Security exemption.
"We don't want government paying for our things," said an Amish man from Kinzers, Pennsylvania. "We want to pay our own way."
The man from Kinzers said his community relies on two funds. Nearly every family contributes monthly to a hospital aid fund, while large bills are also paid with free-will offerings.
Some Amish carry benefit cards, which identify them as members of a community but do not bear names or photographs, to help hospitals keep track of those discounts.
"It simply says they're a participant," said Eric Buck, president of Preferred Health Care, which manages the Old Order Group coverage plan for Lancaster County Amish.
One factor that helps keep medical bills down is that farm work and other manual labor keep Amish active for most of their lives, making them less susceptible to chronic conditions like diabetes and heart disease that plague the often-sedentary U.S. population, said Bergen, the hospital executive.
Amish children are more susceptible to recessive genetic disorders, the result of a small and largely insular population.
For the heaviest bills, Amish communities often turn to benefit auctions, nicknamed "mud sales" because of the conditions of the fields where they are held.
On a recent Saturday auction in Gordonville, Pennsylvania, 10 miles east of Lancaster, young Amish men bid used buggies up to more than $4,000, while hand-made quilts sold for several hundred dollars each.
Most mud sales and benefit auctions benefit specific institutions. The one in Gordonville helped pay bills for the volunteer ambulance company. But a series of five held across the state each year help fund the Clinic for Special Children, a world-class pediatric genetics clinic.
Many Amish at the auction said they had relied on hospital aid to pay their medical bills