These aid societies did more than provide relief from doctors’ bills, lost wages or funeral expenses. They also divided the “deserving” poor from miscreants who suffered through their own fault. Their bylaws stressed “thrift, leadership skills, self-government, self-control and good moral character,” the historian David Beito has written. Lodges required members to hold an “honorable” job, banned women of “immoral or questionable behavior,” and limited the use of alcohol and drugs.

Today, Medi-Share requires members to “live by biblical standards:” no tobacco or illegal drugs and no sex “outside of traditional Christian marriage.” Samaritan Ministries, with headquarters in Peoria, Ill., requires a pastor’s approval of medical expenses (and refuses to cover treatment for S.T.D.s unless “contracted innocently”). Liberty HealthShare, based in Independence, Ohio, is the only Affordable Care Act-exempt ministry open to people of many faiths. It asks them to affirm that “it is my spiritual duty to God and my ethical duty to others to maintain a healthy lifestyle.”

Members say these rules are marks of the kind of community that government programs undermine. “This is a solution for those of us who see the A.C.A. as a problem,” said Daniel Alders, 28, a Samaritan member who lives in Nacogdoches, Tex., and has turned to the ministry to pay for the births of his two children. Samaritan members send their monthly share directly to another member with medical expenses. “When we receive money, nine times out of 10 there’s a note attached saying they’re praying for us and the health of the baby,” he told me.