Nearly 54 Million Americans Have Pre-Existing Conditions That Would Make Them Uninsurable in the Individual Market without the ACA

Almost Half of Non-Elderly Families have At Least One Adult with a Pre-Existing Condition

An updated KFF analysis estimates that almost 54 million people – or 27% of all adults under 65 —have pre-existing health conditions that would likely have made them uninsurable in the individual markets that existed in most states before the Affordable Care Act.

The share of adults under 65 with such declinable pre-existing conditions varies significantly across states, from at least a third in West Virginia (37%), Arkansas (34%), Kentucky (34%), and Mississippi (34%) to a little more than one in five in Colorado (22%).

Older working-age Americans (ages 55-64) are the most likely age group to have declinable pre-existing conditions (44%), more than twice the share (18%) among the youngest age group (18-34). Women are more likely than men to have declinable conditions (30% compared to 24%).

Almost half (45%) of non-elderly families include at least one adult with a medical condition who might not be able to buy individual insurance without the ACA’s prohibition of medical underwriting.

The analysis comes as the Fifth Circuit Court of Appeals weighs a decision in the Texas v. Azar case, which seeks to overturn the entire Affordable Care Act, including the provisions that prohibit insurers from denying coverage or charging more to people with pre-existing conditions. The Trump administration has joined the conservative state Attorneys General in arguing that the ACA should be invalidated.

While most people with pre-existing conditions are covered now through employers or public programs such as Medicaid, people may look to the individual market for coverage during periods of transition, such as losing or changing a job, leaving a job due to illness, starting a business, aging off a parent’s policy, retiring before age 65, or losing Medicaid eligibility.

Before the ACA protections took effect in 2014, private insurers in the individual market could use applicants’ health status, history and other risk factors to determine whether and under what terms to issue coverage. Some conditions that could lead to automatic denials of coverage at the time include cancer, diabetes, epilepsy, heart disease, and pregnancy.

Using 2018 data from two large government surveys, the analysis estimates the total number of nonelderly adults in each state with a health condition that could lead to a denial of coverage in the individual insurance market, based on pre-ACA field underwriting guides for brokers and agents. The estimates do not include people with other health conditions that would not necessarily cause a denial, but could lead to higher insurance costs based on underwriting.

Whether and how people with pre-existing conditions could be affected if they seek coverage on the individual market in the future depends on the outcome of the ongoing court challenge, and how federal and state lawmakers respond to the court’s decision.