Respecting Cultural Differences:
Alternatives for the Amish Community to Combat Health Care Costs

Christopher B. Sherman
University of Tampa

Keywords: Amish, Mennonites, Health Care, Medical Expenses, Hospitals, Cultural Differences


Medical bills represent a growing concern for the Amish population. Their unique culture compels them to decline any government funding for medical care and deters them from purchasing insurance. Like any one, individuals in the Amish community occasionally incur health care issues. Yet, unlike the general population, the Amish are far more likely to encounter a particular disease called Crigler-Najjar Syndrome. Undoubtedly, this situation results in significant difficulties for the Amish to pay the extraordinary out-of-pocket costs associated with medical bills, given their limited monetary funds. Solutions to this seemingly impossible situation include reduced monthly payments, lump sum alternatives, food services, and trading commodities.


Seventy-one-year-old Christian Esh, in accordance with Amish values, does not have medical insurance, and he "owes about $400,000 in bank loans he's taken out on his farm for medical bills" (Anand, 2008). Esh, being elderly and severely disabled, holds no savings nor does he have any means to acquire the income to pay the monthly loan payments. He faces constant inquiries and harassment from debt collectors. Esh's situation represents a growing phenomenon among the Amish community. This paper provides background on the Amish culture, details the growing problem of their inability to pay health care costs, and presents four solutions, including reduced monthly payments, lump sum alternatives, food services, and commodity trading.


The Amish society has a rich and distinctive culture as compared to the mainstream American society. The Amish first arose from a schism on various issues with the Mennonites from Switzerland. The more progressive Swiss Mennonites and conservative leader Jakob Ammann could not reconcile their differences. As a result, Ammann seceded from the Mennonites and began a new branch that became known as the Amish (Donnermeyer & Friedrich, 2002).

The Amish first settled in Lancaster Country, Pennsylvania in the early 18th Century, after migrating to the United States, as they were fond of the opportunity to own land and to practice the religious freedom within their cultural bounds (Donnermeyer & Friedrich, 2002). They speak a mixture of languages that consist of German, English, and Pennsylvania Dutch. However, they also refer to "the non-Amish community as 'English' because that is the language used by others around them" (Beachy et al., 1997). After the Civil War broke out, they expanded to other areas including Ohio, Indiana, Iowa, Illinois, and Kansas along with other predominantly Midwestern states within the United States.

The Amish follow five simple rules that include "adult baptism, separation of church and state, ex-communication from the church for those who break moral law, living life in accordance to the teachings of Christ, and refusal to bear arms, take oaths, or hold political office" (Weyer et al, 2003). In most cases, they live in rural areas surrounded by farmland they own. In addition, the Amish do not use any form of electricity, yet batteries are acceptable for use in diesel engines for cooling milk tanks and operating workshops.

The Amish culture places a strong emphasis on family, clings to traditional gender roles, and follows a unique educational pattern, all-the-while holding deep-seated religious values. The Amish value the importance of family and not merely the core family but rather the extended family as well as full church community. The typical Amish family tends to live with "six or more persons that often include extended family members" (Weyer et al, 2003). In this community, it is common for uncles, aunts, and cousins to live next door or down the road. They also "do not believe in retirement homes; instead, they reside at home where they are cared for by their family" (Palmer, 1992). In many instances, after retirement, grandparents often move to a house near one of their sons or daughters, called a dowdy house (Donnermeyer, Kreps, & Kreps, 1999). After their children get married and start their own families, the proximity of the dowdy houses allows grandparents to help raise their grandchildren and assert the cultural norms. The Amish society values taking care of "their own,"—their own family as well as other Amish families (Weyer et al, 2003). This close-knit, family-centered value serves as a unique characteristic of their culture.

Following time-honored, conservative family roles, Amish males usually become farmers. This tradition stems from the Old Testament passage in Genesis that states, "God commanded Adam and Eve to 'dress' and cultivate the garden" (Genesis 2:15 King James Version). Even though Amish men are typically farmers, some serve as carpenters, carriage makers, laborers, and other craftsmen. They prefer not to work for outsiders but rather within family-owned Amish farms and businesses (Weyer et al, 2003). Additionally, Amish men shave until marriage, and then they continually grow a beard. With the exception of their upper lip, which is required to be clean-shaven, the church law forbids them to shave their beards after marriage. Like their male counterparts, the Amish females adhere to traditional roles. The Amish community believes that females "are responsible for the young, elderly, and the sick" (Weyer et al, 2003).

Amish children also follow a regimented, traditional life. The formal education system consists of grades one to eight taught by Amish teachers. The teachers require only an eighth-grade level of education and are usually chosen by the School Board. Amish parents do not send their children to high school for fear that their children would abandon the traditional cultural values; they believe it would alter their way of thinking and behavior patterns in ways that are inconsistent with Amish culture and beliefs (Weyer et al, 2003).

Like the importance of family, the church symbolizes a central part of Amish life. In fact, the rules of the church are known to take precedence over family relationships (Huntingdon, 1993). Marriage outside of the Amish community is prohibited as is divorce, and separation is extremely rare for couples in this culture.

Health Care Philosophy

In accordance with their culture, the Amish society accepts responsibility for their own actions and chooses not to depend on services offered by the state (Fisher, 2002). For example, Amish communities opt out of the government-funded insurance, including the Affordable Care Act. This Act allows employees of large companies to acquire health insurance and allows insurance options for low-income individuals and families. As Amish Community Health Clinic President, Mr. Dennis Lehman, stated, "The Amish are religiously opposed to commercial insurance and they pride themselves on taking care of their own" (Lehman, 2013). Lehman's statement exemplifies the importance of family and church in relation to their culture.

As a result, this society thrives on helping each other and sharing each other's burdens. This value is referred to in Galatians 6:2—" bear one another's burdens" (Galatians 6:2 King James Version). To assist one another, they willingly offer donations when a member of their community becomes ill. When illness arises, persons often tend to postpone seeking treatment until the last minute. Critics sometimes suggest that this situation could have been avoided with preventative care, but that practice is in conflict with Amish values (Donnermeyer & Friedrich, 2002). When the family cannot afford the medical costs, the family will give the medical bill to one of the members in the church for payment (Lehman, 2013). Amish communities often work with bill negotiators to help reduce prices. If the Amish community cannot pay the bill, the deacons communicate with neighboring communities for assistance. Occasionally, auctions are held to raise the funds; members of the community donate food, furniture, quilts, and livestock.

If a family cannot garner enough money through these various methods, the Amish find themselves deep in debt. At the same time, hospitals and health care facilities prosecute Amish and Mennonite families to recover outstanding medical bills. In some extreme instances, individuals may be forced to give up their only asset, their farmland. This land often has been in the family for generations, and it holds the only means of livelihood. This process of seizure of land leaves the farmer and his family with nothing, and it strips them of their culture and means of survival.

To help understand the significance of this challenge, the next section addresses the rich culture of the Amish, their inability to pay their medical bills, and the rare genetic diseases that they face. These challenges can be solved by a series of potential solutions that help both the Amish and the health care industry.    

Monetary Challenges

One of the main challenges facing the Amish society has to do with the inability to pay for medical expenses. In some cases, members of the Amish community may owe up to hundreds of thousands of dollars in hospital bills. Hospitals often offer public aid to individuals who are not able to afford the medical care. Public aid consists of a government-funded program that can be used in various ways, such as monetary payments, subsidies, health services, or housing. As stated earlier, the Amish "strive to take care of their own" and refuse to receive help from the government (Weyer et al, 2003). Therefore, without this payment from public aid, hospitals do not receive monetary compensation and have to write off bills as uncollectible accounts. This potentially causes the hospital to lose millions of dollars in revenue each year. In the majority of the cases, the hospitals sue for outstanding balances. For example, in Denver, Pennsylvania, one of the Older Order Mennonites spent nearly $400,000 at non-profit hospitals because nine out of his eleven children suffered from a serious genetic disease (Anand, 2008)

Moreover, Geeta Anand, a journalist for the Wall Street Journal, reported on a Lancaster General Hospital claim against Mr. Martin, an Old Order Mennonite patient who owed $287,000 (2008). The Lancaster General Hospital proceeded to use a collection agency for this case. At the same time, Mr. Martin owed money to other health care organizations, including Hershey Medical Center, which had issued a lawsuit against Mr. Martin. Due to the court proceedings and mounting unpaid medical bills, a lien was ultimately attached to his farm, forcing Mr. Martin to sell or mortgage the farmland to pay his debt.

The challenge from this scenario involves finding a solution to prevent the Amish from losing property and their livelihood due to unpaid medical bills. If the family loses the farm, they will be left with nothing. The former Director of the Clinic for Special Children, Dr. Holmes Morton, said, "If things continue at this rate, hospital bills will overwhelm this community's ability to pay and these peoples' whole way of life will be lost forever" (Anand, 2008). Morton helps us understand the magnitude of the problem that will diminish the Amish lifestyle entirely, as they are not able to afford the astronomical health costs.

Health Concerns

The Amish community encourages persons to marry distant relatives, and, in some cases, the parents are as closely related as first cousins (Anand, 2008). These close relationships potentially lead to "certain mutations, or mistakes in coding—rendering them more likely to suffer from certain diseases and less likely to have others" (Anand, 2008). Marrying close cousins compounds the problem because it typically increases the chances of that same gene mutation passing onto their children (FitzGerald, 2002).

In particular, the Amish face a deadly genetic disease called Crigler-Najjar Syndrome, which is extremely rare with less than 200 documented cases in the world. This rare liver disease causes a dangerous amount of bilirubin. Bilirubin whitens the eyes, yellows the skin, and endangers the life if there is too much in the body (FitzGerald, 2002). For instance, FitzGerald reports that Old Order Mennonite parents Katie and Miriam Martin in Lancaster County, Pennsylvania have two children named Amy (10) and Derrick (12) with Crigler-Najjar Syndrome. Each and every night Amy and Derrick sleep under rows of special four-foot fluorescent lights used to break down the bilirubin in their bodies (FitzGerald, 2002). Without these special lights, they could suffer yet another problem and die from brain damage.

The Amish community experiences a statistically significant number of Crigler-Najjar syndrome cases compared to any other people in the world. In Pennsylvania, three of Amy and Derrick's cousins have this disease, along with sixteen Amish and Old Order Mennonite children in the area. A local doctor in Lancaster has counted a total of thirty-eight instances in Amish children; twenty-three diagnoses were found in Mennonites and are not commonly found in the general population (FitzGerald, 2002). This evidence suggests that the Amish and Mennonites are more prone to this rare disease than the general population. Because of their susceptibility to this rare disease, Amish and Mennonites have a specific need for medical care. This need can result in hundreds of thousands of dollars in hospital bills that they cannot afford. With this debt, the Amish and Mennonites risk losing their pride possession: their farms.


Fortunately, there are several options for the Amish community to prevent this tragedy from occurring and losing what their family worked to have for decades.

Monthly Installments. The first option for the Amish and Mennonite communities involves asking hospitals for reduced rates and a payment plan. Hospitals make substantial profits and can absorb a long-time payment schedule. For example, Lancaster General Hospital, cited earlier in this paper made profits of up to 137 million, and the Hershey Medical Center made 59.3 million (Anand, 2008). Hospitals occasionally accept monthly payments for all of their customers. Additionally, the Amish may use a bill negotiator to consider different possibilities that the hospital may accept, which can include affordable monthly payments for the family.

Lump Sum Option. If the hospital declines equal monthly payments, another solution involves a lump sum payment with the remaining balance spread over equal monthly payments. Often to be able to provide a large lump sum payment requires a compromise for the Amish. They may need to sell a relatively small portion of the farm, or mortgage it. As a result, they can pay a large portion of the medical bills, which allows the family to keep the farm—a primary goal.

Food Services. A third option involves trading organic food for hospital services. The Amish and Mennonite societies are exceptionally talented in farming and tend to live healthy lifestyles by growing organic foods, particularly fruits and vegetables. This option allows hospitals to provide healthy meals for patients by accepting organic fruits, vegetables, and milk daily from the Amish in lieu of a monetary payment. As a result, the farmers commit to providing these services to the hospital for a certain amount of time depending on the extent of their medical bills and the number and quantity of items they are able to provide. Additionally, the hospital could also advertise the healthiness of the cafeteria and the quality of the food as well as the partnership with the Amish. This exchange can yield hospitals great publicity, including high-quality reviews in magazines.

Alternatively, the Amish and Mennonites may sell these goods to local produce markets and then give the profits to the hospital to pay their bills. For example, stores, such as Whole Foods Market, buy organic foods from local farms.

Trading Commodities. A final option involves trading commodities for the money owed, such as quilts, sheets, clothing, canned goods, floral arrangements, toys, and baked goods. For example, the intricate, creative quilts alone can be worth over $1,000 dollars each because they are made by hand with colorful designs and patterns that individuals love. Profits will go towards paying off the debt to the hospital. If a discussion and acceptance are offered, the Amish may charge the hospital for only the materials to make the necessary sheets and quilts. However, the labor will considerably reduce their medical bills. This trade benefits both the hospital in having a quality handmade product, and it helps the Amish pay their bills. Alternatively, Amish women could seek out stores willing to purchase quilts for money and then give the proceeds to the hospital to pay bills.


The Amish communities consist of diligent and conscientious working individuals that pride themselves on their rich culture extending back many generations and on taking care of each other. The Amish face high medical bills due to unfortunate illnesses as well as a rare genetic disease. This tight-knit community continues to help one another when monetary funds are not available. In the long run, the Amish community will continue to support each other to provide assistance when needed.

Four options were discussed for dealing with rising medical costs and maintaining the Amish culture. The first option allows the Amish family affordable monthly payments. The second option allows the hospital to accept a lump sum payment with the remaining payments spread over a set time frame. The third option considers trading organic food for hospital services. The fourth option allows the Amish to sell goods such as quilts, sheets, clothing, canned goods, floral arrangements, toys, and baked goods that would help lower their medical costs.

These four options provide a range of solutions for the Amish and for hospitals. These alternatives offer an array of possible ways to raise money in order to reduce their medical costs and to afford medical care for their families with genetic diseases. These alternatives would benefit the Amish community significantly as they continue to take care of one another by working together as a whole community to sell or trade goods for services. Above all, these options open a path that releases the Amish families from the battle against extravagant medical costs, allowing them to continue to enjoy a life and culture that they have built for generations.


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