What Are Pre-Existing Conditions? A Brief Overview of the ACA, Pre-Existing Conditions, and How They Connect

Basics Blog

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The Affordable Care Act (ACA) was passed just over 15 years ago in March 2010. As we review in our 15^th Anniversary of the ACA blog, “the ACA represents the largest expansion of health insurance coverage since the creation of Medicare and Medicaid in 1965.” 

While it is widely known for the creation of new programs like state marketplaces for subsidized individual-market health insurance, the ACA is also responsible for implementing protections for individuals with pre-existing conditions.

In this blog, we are going to provide a brief overview of pre-existing conditions, including a definition, their connection to the Affordable Care Act, and how you can explore data on pre-existing conditions on State Health Compare. 

What Are Pre-Existing Conditions? 

Pre-existing conditions are medical diagnoses that an individual has before health insurance coverage begins. 

For example, an individual looking for health insurance coverage that has diabetes would be considered to have a pre-existing condition. Pre-existing conditions could also apply to past diagnoses – for example, an individual who had a heart attack in the past would be considered to have a pre-existing condition.

Before the Affordable Care Act was implemented, there were few protections in place for individuals with pre-existing conditions – meaning that insurers were able to deny health insurance coverage if an individual had a pre-existing condition. 

Not only were they able to outright deny coverage, but insurers were also allowed to charge higher premiums for individuals with certain pre-existing conditions as well as deny coverage of certain services. 

Automatically Declinable Conditions

Prior to the Affordable Care Act (ACA), individual market insurers curated lists of “declinable” medical conditions.

Examples of conditions on these types of lists included:

• Diabetes
• Cardiovascular disease
• Heart attack
• Stroke
• Chronic obstructive pulmonary disease (COPD)
• Cancer
• Arthritis
• Depression
• Current pregnancy
• Excessive alcohol consumption

Individuals with a current or past diagnosis of one or more of these conditions were automatically denied health insurance coverage.

Conditions Subject to Underwriting

In addition to automatically declinable conditions, underwriters (professionals at insurance companies that evaluate the risks of insuring individuals or groups) would also examine applications, medical history, and records for evidence of pre-existing conditions that could generate what they considered to be significant expenses via claims. 

Examples of pre-existing conditions subject to underwriting included:

• Acne
• Allergies
• Being overweight
• Migraine headaches
• Menstrual irregularities
• High cholesterol
• Tonsillitis

While many of these types of pre-conditions were not considered automatically declinable, insurers could charge higher premiums or even deny coverage of services to treat those conditions.

Pre-Existing Conditions: The Impact of Affordable Care Act Protections

With the implementation of the Affordable Care Act (ACA), a number of protections were put in place for people with pre-existing conditions. Just some of these include:

• Prohibiting insurers from declining coverage or charging more based on pre-existing conditions or health status
• Prohibiting insurer / plan refusal to pay for or cover health benefits for pre-existing conditions
• Only allowing insurers to vary insurance premiums by age, geographic location, tobacco use, and family size – not by condition, health status, occupation, etc.

With these protections in place along with the expansion of coverage, there are now more Americans than ever before with health insurance coverage. Uninsurance has decreased in every state, and many coverage inequities have been reduced.

Pre-Existing Conditions in 2023 – The Data

State Health Compare (SHC), SHADAC’s interactive & free data tool that allows you to create charts, maps, data tables, and customizable data sets on a number of health measures, includes a ‘Pre-Existing Conditions’ measure. 

This measure provides a state-level look at the percent of the adult population who have a condition that could result in them being denied health insurance coverage if protections under the ACA were overturned. This measure allows you to explore both the percent of adults with automatically declinable pre-existing conditions and adults with conditions subject to underwriting. We have also included a number of breakdowns, including by education, coverage type, and more.

Let’s take a look at the percent of adults in the U.S. with an automatically declinable pre-existing condition by state in 2023.

Figure 1. Percent of Adults in the U.S. with an Automatically Declinable Pre-Existing Condition by State, 2023

Accessibility Note: Access the data yourself along with other visualization options on State Health Compare.

Using State Health Compare, we can see that in 2023, 38.1% of adults in the U.S. had an automatically declinable pre-existing condition, including those with conditions like cancer, depression, and diabetes. As you can see from the map above, this ranges by state, with some states having almost half of their population with an automatically declinable condition. 

When looking at conditions subject to underwriting, we see an even wider impact. 

Figure 2. Percent of Adults in the U.S. with a Pre-Existing Condition Subject to Underwriting by State, 2023

Using State Health Compare, we can see that in 2023, 79.9% of adults in the U.S. had a pre-existing condition subject to underwriting.

This means that, without ACA protections, almost 8 in 10 Americans had a health condition subject to underwriting in 2023 – meaning they could be subject to higher premium costs and/or denial of certain health care services. 

Continue Exploring the Data on State Health Compare

With the implementation of the Affordable Care Act, we saw protections put in place to prevent denial of coverage and cost adjustments based on pre-existing conditions and health status.

But public health and policy can shift rapidly – it is important to continue to monitor and understand the prevalence of pre-existing conditions today to understand how health insurance costs and coverage could be impacted by policy changes. 

Continue to monitor this data, make connections, exploring these measures on State Health Compare.