Are Pre-existing Conditions Covered By Insurance – As attention once again focuses on the possibility that the Affordable Care Act (ACA) could be repealed, millions of people with pre-existing conditions have reason to worry. Among many other provisions, the ACA prohibited private health insurance from discrimination based on health status; Insurers are prohibited from turning people away, charging them more, or changing coverage to exclude pre-existing health conditions.
What are pre-existing conditions and who has them? In its simplest definition, a pre-existing health condition is any health condition a person had before enrolling in health insurance. One can know about a pre-existing condition; for example, if she knows she is pregnant. People may also unknowingly apply for insurance coverage when they have an undiagnosed condition; For example, tumor cells may be growing inside them, but the diagnosis may not be made until months or years later. A pre-existing condition may be mild; for example, seasonal allergies or acne treated with simple medications. Or it may be more serious or require more costly treatments, such as for diabetes, heart disease or cancer.
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In 2018, approximately 54 million nonelderly adults (27%) in the United States were estimated to have “deniable” preexisting conditions that would make them “uninsurable” in the pre-ACA individual health insurance market. Deniable conditions were identified through analysis of health insurance underwriting guidelines. Insurers kept lists of health conditions for which applicants would routinely be excluded from coverage. Deniable conditions included AIDS/HIV, congestive heart failure, diabetes, epilepsy, severe obesity, pregnancy, and serious mental disorders. Clearly, not all of these 54 million adults are covered by individual health insurance anymore. But the individual market is where people go when they’re torn between jobs that offer health benefits and those that don’t qualify for public plan coverage like Medicare or Medicaid. If most states revert to medically insured coverage, as they did before the ACA, those 54 million adults could become uninsured if they were laid off from their jobs and lost their job-based health benefits.
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Other estimates put the number of nonelderly adults with preexisting conditions as high as 102 million, 122 million, or 133 million. In addition to deniable conditions, these estimates also took into account conditions that would not have resulted in a denial of one’s individual health insurance application at the time but could trigger other adverse actions. Hypertension (high blood pressure) is an example of a common pre-existing condition that affects more than 33 million adults under the age of 65. A study of medical insurance practices asked individual market insurers to consider a hypothetical applicant who was also a smoker and had high blood pressure. fat. In 60 insurance applications, this individual was rejected 33 times (55%); 25 times (42%) it offered a policy with additional premiums and twice (3%) it offered coverage with no restrictions or premium surcharges. The Fifth Circuit Court of Appeals’ upcoming decision in Texas v. Azar could mean that insurers may once again return to using people’s health status in determining their health insurance eligibility and premiums, at least for coverage purchased in the non-group or individual insurance market. The plaintiff notes that attorneys general and the Trump Administration have argued that the Affordable Care Act is unconstitutional and should be struck down in its entirety. This would include reversing provisions that ensure people with pre-existing health conditions cannot be denied coverage or charged higher premiums because of their health condition.
Given the significant barriers to coverage that could reemerge if these provisions in the ACA are invalidated, we update our prior work by looking at the share of nonelderly adults with health conditions that would cause them to be denied coverage if they applied. For non-group health insurance prior to the effective date of the ACA. And because the financial consequences of these changes would potentially affect the entire family, we expanded our analysis to estimate the percentage of nonelderly families with at least one adult with one or more deniable conditions.
Consistent with our previous analysis, we estimate that 27% of non-elderly adults, approximately 53.8 million people in 2018, had a debilitating health condition. We also estimate that 45% of nonelderly families have at least one nonelderly adult member with debilitating health. . Finally, we update our state-by-state estimates of the reducible prevalence of preexisting conditions with the most current data available; This shows that the share of nonelderly adults with preexisting conditions ranges from 22% in Colorado to 37% in the West. Virginia.
Before the ACA took effect in 2014, people with pre-existing health conditions were often denied coverage or charged higher premiums for individual market coverage. While most people with pre-existing conditions currently have employer-based coverage or public programs, the non-group market as Medicaid is available during times of transition, such as if they lose their job, change jobs, start a business, divorce, their parent’s policy lapses, they retire earlier, etc. This is where they may need to look at insurance coverage. Those at age 65 leave work due to serious illness, find work and lose Medicaid or otherwise lose eligibility for job-based or public insurance. Although we cannot predict what relief the court would provide if these ACA provisions were to be overturned, access to individual market insurance for people with pre-existing conditions could be severely restricted.
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SOURCE: Kaiser Family Foundation’s review of Aetna (GA, PA and TX), Anthem BCBS (IN, KY and OH), Assurant, CIGNA, Coventry, Dean Health, Golden Rule, Health Care Services Corporation (BCBS) field underwriting guidelines IL, TX) HealthNet, Humana, United HealthCare, Wisconsin Physician Service. The conditions in this table appeared on the list of rejectable conditions in half or more of the guidelines reviewed.
NOTE: Many additional, less common disorders that also appear on most deniable condition lists have been omitted from this table.
We used data from the National Health Interview Survey (NHIS) to estimate that 27% of nonelderly adults had a debilitating health condition in 2018; It’s the same percentage we found in our previous analysis for 2015. The participant has been diagnosed with a number of health conditions that would have been denied in the pre-ACA nongroup market. Although we cannot replicate the underwriting processes performed by insurance companies, we think our approach may be reasonable and prudent given that the NHIS does not contain or provide information on all conditions (e.g., AIDS/HIV) used by insurance companies. It’s about the prescriptions insurers use to deny applicants for coverage.
Although each family member was individually insured in the pre-ACA nongroup market, the economic consequences of denying coverage to a family member or being charged additional fees due to their health will likely be felt by all members of the family. We expanded our previous methods to look at the number of people who might be affected and estimated that 45% of nonelderly families in 2018 included a nonelderly adult whose condition could be denied. In this analysis, individuals living in households without relatives are considered a single-person family.
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In 2018, a greater share of non-elderly adult women (30%) than men (24%) had pre-existing conditions, unchanged from 2015. We estimate that 23.7 million men have a pre-existing health condition that would make them uninsurable. Compared to 30.1 million women in the individual market pre-ACA. Pregnancy explains some of this difference (about 2 million women) but not all of it.
The prevalence of treatable disorders in non-elderly adults also increases with age, ranging from 18% in those aged 18-34 to 44% in those aged 55-64.
Rates for reduceable preexisting conditions continue to vary from state to state. At the low end, at least 22% of nonelderly adults in Colorado have conditions that would likely be denied coverage in the individual market under pre-ACA underwriting practices. Rates are higher in other states, especially in the South, such as Arkansas (34%), Kentucky (34%), Mississippi (34%), and West Virginia (37%), which have at least one-third of the non-elderly population. The population will have diminishing conditions.
SOURCE: Analysis of data from the Kaiser Family Foundation National Health Interview Survey and Behavioral Risk Factor Surveillance System.
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NOTE: Five states (MA, ME, NJ, NY, VT) had broad guaranteed access to insurance before the ACA. It is unclear what protections might be available under a repeal-and-replace scenario in these or other states.
Since the effective date of the ACA marketplace changed in January 2014, people with pre-existing conditions have not had to worry about their health conditions affecting their access to health insurance or increasing the premiums they pay. The legislation enables people to access individual market coverage that provides comprehensive benefits through various changes in work and living conditions. This could change quite quickly if ACA marketplace protections for people with pre-existing conditions are invalidated. While many adults with pre-existing conditions still have Medicaid or employer insurance to provide protection, more than a quarter