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Pre-Existing Conditions

Measure Overview

Pre-existing conditions are medical diagnoses that an individual has before health insurance coverage begins. Before the Affordable Care Act (ACA) was implemented, there were few protections in place for those with pre-existing conditions, meaning that insurers could deny someone health insurance coverage if they had a pre-existing condition.

Individual market insurers maintained lists of declinable medical conditions; those with a current or past diagnosis of one or more of these conditions were automatically denied coverage. In addition to automatically declinable conditions, underwriters also examined individual applications and medical records for other conditions that could generate significant claims expenses. So not only could coverage be denied outright, but insurers could also charge higher premiums for individuals with pre-existing conditions and deny coverage of specific services. This measure shows users the percent of adults with pre-existing conditions by state to understand how populations could be impacted if ACA protections were changed or overturned.

Percent of Adults with Pre-Existing Conditions by State: Breakdowns and Data Source

State Health Compare provides state-level estimates of 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. Estimates for this measure come from the Behavioral Risk Factor Surveillance System (BRFSS) survey. This measure is separated into two categories: Automatically Declinable Conditions and Conditions Subject to Underwriting.

This measure includes the following as automatically declinable conditions: diabetes, cardiovascular disease, heart attack, stroke, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, cancer, kidney disease, arthritis, rheumatoid arthritis, gout, lupus, fibromyalgia, depression, current pregnancy, obesity (BMI greater than or equal to 40), or excessive alcohol consumption. This measure includes the following as conditions subject to underwriting: automatically declinable conditions, being overweight (BMI greater than or equal to 25), asthma, hypertension, and high cholesterol.

Four breakdowns are available for measure: Coverage Type, Education, Race/Ethnicity, and Sexual Orientation.

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Definitions

Prior to the Affordable Care Act (ACA), individual market insurers maintained lists of declinable medical conditions. Individuals with a current or past diagnosis of one or more of these conditions were automatically denied coverage. In addition to automatically declinable conditions, underwriters also examined individual applications and medical records for other conditions that could generate significant claims expenses - these are conditions subject to underwriting.

This measure estimates those with automatically declinable conditions as the percent of adults who report ever having one or more of the following chronic conditions: diabetes, cardiovascular disease, heart attack, stroke, chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis, cancer, kidney disease, arthritis, rheumatoid arthritis, gout, lupus, fibromyalgia, or depression; or adults who are currently pregnant, obese (BMI greater than or equal to 40), or report excessive alcohol consumption for the civilian non-institutionalized population 18 years and over.