Demographics of People with a Pre-existing Health Condition

Under the Affordable Care Act, no American can be denied coverage, charged a higher monthly premium, or sold a policy that excludes coverage of important health services just because he or she has a pre-existing condition. This is called pre-existing condition discrimination, and without the provisions in the Affordable Care Act that prohibit this, a lot of Americans would be affected.

Families USA has posted a new set of state-by-state infographics illustrating the number of people who would be at risk of pre-existing condition discrimination by insurance companies without the Affordable Care Act.

Millions of non-elderly Americans would be denied coverage without the Affordable Care Act

The estimates of the number of people who (without the Affordable Care Act) would be at risk of discrimination because of a pre-existing condition vary by methodology. But the fact is that everyone, as they grow older, will eventually move into this category.

Families USA issued a report in 2012 that used a conservative methodology looking at a given point in time (rather than at people’s health over the past year or longer) and only at diagnosed significant health problems that we know could have triggered a denial of coverage in 2012. Even with this conservative approach, we found that one out of four non-elderly Americans (under the age of 65) could be denied coverage without the Affordable Care Act.

The U.S. Department of Health and Human Services (HHS) has also estimated the impact of the Affordable Care Act’s pre-existing condition protections, as featured in Families USA’s new state-specific infographics. To determine how many Americans would be helped by these protections, HHS examined the total number of people in each state who:

• Had a diagnosis of a serious health condition that would trigger a denial of coverage (very similar to our report’s methodology);
• Have ever been diagnosed with four common conditions: arthritis, asthma, high cholesterol, or hypertension; or had a current diagnosis of obesity, as these conditions were found to lead to denials of coverage, premium increases, or exclusions of coverage for certain services in insurers’ guidelines for evaluating applicants for coverage (known as “underwriting” guidelines);
•  Are currently being treated for a range of mental health conditions, or have ever been diagnosed with attention deficit hyperactivity disorder (conditions also mentioned in insurers’ underwriting guidelines as triggers for denials, premium increases, or coverage exclusions).

The magnitude of both HHS’ and Families USA’s estimates underscores the importance of the pre-existing condition protections for millions of Americans in the Affordable Care Act.

Before the Affordable Care Act, every age group was at risk of pre-existing condition discrimination, but the odds increased with age

The demographics of the population who had a diagnosed significant pre-existing condition in 2012, as examined by Families USA, confirm what common sense tells us: that the likelihood of being diagnosed with a pre-existing condition grows substantially with age.

Families USA found that, among adults aged 55 to 64, nearly 50 percent have a diagnosed significant pre-existing condition. But even among young adults aged 18 to 24, nearly 20 percent have a diagnosed significant pre-existing condition. The percentage rises to nearly 25 percent for adults aged 25-34 and to more than 30 percent for adults aged 35 to 44. By the age of 45, the percentage is closer to 40 percent.

Who else will benefit?

There are even more people who will benefit from the Affordable Care Act’s pre-existing condition protections who aren’t captured in any of these estimates. This is because there are more people who have a pre-existing condition without knowing it (they have yet to be diagnosed). And often, these individuals lack health insurance.

For example, the uninsured are more than five times more likely to lack a regular source of care than people with private insurance (55 percent versus 11 percent). Likewise, uninsured adults are more than four times as likely as adults with private insurance to postpone seeking care due to cost—30 percent versus 7 percent. As a result, the uninsured may go with undiagnosed pre-existing conditions for much longer than individuals with health insurance.

Pre-existing condition discrimination: bad for the economy

Before 2014, the fear of being denied health coverage in the individual market led many Americans to make decisions about their job based on whether it provided health insurance. This phenomenon is known as job lock—when workers who have health problems are less likely to leave a job that offers health coverage, even if that job is not where they can be most productive or most prosperous. A study published in the Journal of Policy Analysis and Management found that chronically ill workers who rely on their employer for health coverage are about 40 percent less likely to leave their job than chronically ill workers who do not rely on their employer for coverage. In addition, workers with a history of health problems, such as diabetes, cancer, or heart attack, and those with substantial medical expenses stay at their jobs significantly longer because of their job-based health coverage, even if staying is not the best option for their careers or their families.

The bottom line is this: The protections from pre-existing condition discrimination benefit both young and old, those who have a health problem now, and all of us who are likely to have one eventually. We’ll all need these protections sooner or later in our lives. For people with a health problem, the only answer was to stay in a job with health benefits until they became eligible for Medicare. That was pre-Affordable Care Act. Today, the Affordable Care Act opens the door for new opportunities for all of us regardless of our health status, even as we grow older.

So, as we approach the end of the first open enrollment period for marketplace coverage, please share your state’s infographic widely to encourage everyone, regardless of health status, to get enrolled today!