Protecting People with Pre-Existing Conditions

Copy link to quick take

Some higher-cost health conditions, like cancer, diabetes, or even pregnancy, left people trying to buy their own health coverage “uninsurable” before the Affordable Care Act. We estimated that 27% of nonelderly adults had at least one of these declinable health conditions.

Less severe conditions also posed barriers to insurance coverage. For example, depending on how many ear infections your child had last year, one insurer might have charged a 50% higher premium, while another would charge a condition-specific deductible, and yet another would deny coverage altogether. Certain jobs (like first responders) and activities (like rodeo participation) were also reasons to be charged more or denied coverage.

Both Donald Trump and Kamala Harris have said they would protect people with pre-existing health conditions, but their records vary. The Biden-Harris Administration built on the ACA framework, while Trump supported repeal efforts that would have, among other changes, loosened benefit mandates and scaled back subsidies. His administration also expanded short-term plans that discriminate against people with pre-existing conditions. More recently, Trump said he had “concepts of a plan” to replace Obamacare, with running mate J.D. Vance suggesting sicker people be moved into a separate risk pool, which could have the effect of lowering premiums (before subsidies) for healthier people, while raising premiums for sicker people.

There are certainly alternative ways to structure a health system that maintain protections for pre-existing conditions. And there are certainly ways the ACA could work better for sick people who might struggle with narrow provider networks or high deductibles.

It is worth a refresher on how the ACA protects people with pre-existing conditions. It’s also worth asking whether and how an alternative would do the same.

10 Ways the ACA Protects People with Pre-Existing Conditions

1. Guaranteed Issue: Insurers cannot deny coverage to people based on their health status
2. Community Rating: Insurers cannot charge higher premiums based on health status. Premiums can only vary by age (with limits), location, and tobacco use
3. No gender-based premiums: Insurers cannot charge higher premiums based on gender (for example, women of reproductive age)
4. No Pre-ex Exclusions: Insurers cannot deny claims for treatment of pre-existing conditions
5. Guaranteed Renewability: Insurers must offer all individuals and groups the opportunity to renew their existing coverage without regard to health status
6. Limiting Rescissions: Insurers have only limited circumstances in which they can revoke coverage (like fraud)
7. Essential Health Benefits: Insurers selling to individuals and small businesses must cover a minimum set of benefits, like prescriptions, hospitalizations, and pregnancy care
8. Out-of-Pocket Maximums: Insurers must limit out-of-pocket costs to set amounts
9. No Annual or Lifetime Limits: Insurers cannot set dollar limits on the amount of coverage
10. Subsidies: Federal tax credits make comprehensive private coverage more affordable to individuals

For more on how the ACA works, see KFF’s Affordable Care Act 101.