In Clarion County’s Licking Township there are vibrant green hills, windy narrow roads and traffic signs posted just as much for the trucks and tractors as for the horses and buggies.
It's a small, rural farming community north of Pittsburgh.
When you pull up to Emmanuel Schmidt’s home, you see acres of land, his woodworking shop and carriages. The 49-year-old Amish farmer knows Obamacare is coming, but he doesn’t quite know what that means.
"I’ve wondered, I’ve really wondered what’s going to happen with the health care, I don’t know," he said.
On Oct. 1, the health insurance exchanges open. The exchanges, a compare-and-contrast marketplace, are a key part of the Affordable Care Act, the landmark federal legislation that’s making health insurance mandatory for Americans — most of them anyway.
"The Amish have from the beginning been excused from Social Security on the grounds that they would refuse to collect it that they practice their own kind of Social Security," said Karen Johnson-Weiner, a professor of anthropology at the State University of New York at Potsdam.
She has been studying Amish culture for decades. The Amish don’t pay into Social Security and Medicare, and they don’t receive benefits from those plans. And they will be exempt from buying insurance on the health exchanges.
There are an estimated 280,000 Amish in the United States. The states with the largest populations are Pennsylvania and Ohio.
Emmanuel Schmidt said while the Amish like to rely on holistic practices, sometimes they just need to see a doctor.
"We like to go with natural, but if I cut my arm off, I have to go get medical help," he said. "I have to do the correct thing."
Since the Amish don’t have health insurance, when serious medical issues arise, they find ways to pay costly hospital bills.
"Our group, the whole Amish group across America helps each other," Schmidt said. "Whenever there is one little group like us that needs help, they’ll write up to 50 other churches to get enough money to do it. So its been working pretty good."
Schmidt handles medical business for his community, the members of his church. He described the way traditional health care is paid for as backwards.
"We usually just gather up the money to pay it after it happens," Schmidt said. "We don’t do it before it happens."
Schmidt’s community has worked out a deal with UPMC Northwest in Senaca where they pay cash for services, and if they pay within a month’s time, they only have to pay a percentage of what the total bill is.
"Like our Amish group has made an agreement with the hospital that our group as a whole, the elders and all, are responsible for each individual bill," Schmidt said. "If I make a hospital bill and can't pay it, then it’s the whole group's responsibility to pay that bill see. And then they give us a substantial discount."
UPMC wouldn’t comment on the deal except to say that yes, since 2008, it has worked out deals for several Amish and Mennonite communities in northwestern Pennsylvania, and it's not UPMC’s practice to discuss the particulars of those agreements.
Others in the Amish community say the deal has helped tremendously.
"With our last baby we were in for five days in the ICU. It was a bill we could handle this way, otherwise it would have been pretty difficult," said Danny Zehr, who owns a hardware and roofing store. "Just last year my brother-in-law fell about 8 foot and ruptured his spleen, and he was in the hospital for five days or something like that, and instead of being 100,000 (dollars), it was 20 (thousand dollars) or whatever, so that’s a big difference."
Taking Health Care on the Road
Because the Amish don’t operate cars, when they go to the hospital they rely on Mik Robertson to drive them.
As a township supervisor of a majority Amish community, Robertson serves as a bridge to the outside world for them. But some of the questions they ask, like about the Affordable Care Act, he doesn’t know the answers to, and he doesn’t always know where to go to get those answers.
Robertson, a farmer, operates the taxi van with his wife Maggie. He originally bought a van to transport seedlings.
"We got the van, I don’t think we had the van two days, and one of the Amish neighbors came over and said, 'Oh I see you got a van,'" he said laughing. "'We wanna go to...' wherever they wanted to go to that evening, 'Can you take a bunch of us over there?' And it kind of started from there."
Even when they do go to hospitals, experts say there are other issues. The Amish, who speak Pennsylvania Dutch, speak English as a second language. There aren’t translators. And even if they do speak English, because there isn’t much interaction with the English-speaking world, they don’t understand all of the medical and legal terminology.
One way this gap has been bridged is through Dr. Homer Schreckengost, a concierge physician in Kittaning.
Twice a month he travels to Licking Township, sets up at Danny Zehr’s shop and provides health care to the Amish on a first-come, first-served basis.
"It is like a home visit or house call throughout the community, except they all come to one location so I don’t have to bounce from house to house," he said.
Schreckengost sees about 30 patients a visit and maintains about 400 active Amish medical charts. While he’s there, he does everything from checking newborns to sebaceous cyst removal to blood testing. A visit averages around $50.
"I think the Amish community is different than the traditional medical community just because they don’t run to the doctor for every little thing, and things can be let go for a long time before they show up in front of you," Schreckengost said. "So we tend to see a much more advanced disease process when we see it. So from extreme cases of Lyme disease, where most people think they get bit by a tick and they get a bulls eye rash and joint pain, we see the neurological consequences there, the end stage of that disease process."
Danny Zehr said there was hesitation at first to let Schrekengost in.
"He come in here one day and says, 'Hey you guys need a doctor?'" Zehr said. And we said, well what do we need a doctor at the Amish farms for?"
Schrenkengost immediately diagnosed some serious medical illnesses, earning the community’s trust. He started off in Zehr’s kitchen. Since then, the doctor has had two rooms built in the basement of the hardware store. That was nearly three years ago.
Like Schmidt, Zehr doesn’t know much about the health care law. He hopes there isn’t anything he has to do.
"It might affect me more than I think," Zehr said, "but to us, it's something we hope someone else takes care of … not very involved in how it works or what it's all about."