An estimated 54 million Americans ages 19 to 64 have a pre-existing condition that qualifies as a “potentially declinable” illness or disorder, according to a report by the nonprofit Kaiser Family Foundation (KFF). With recent changes to the tax code, along with legal challenges to the Affordable Care Act (ACA), the US healthcare industry is on the brink of returning to a system where would-be policyholders pay higher rates or are denied health insurance due to a pre-existing medical condition. MoneyGeek crunched the KFF report numbers and concluded that there are 12.5 million Americans who have potentially declinable health conditions and are either uninsured or obtain coverage through the ACA Marketplace.
These are the people who may be the most at risk of losing coverage if regulations around pre-existing conditions are changed.
The States With the Most At-Risk Residents
MoneyGeek found that rollback of rules around pre-existing conditions would be felt most acutely in the South. Texas, Florida, Georgia, North Carolina and Tennessee have the highest numbers of adults under 65 who are either uninsured or buy individual insurance. These states represent 46% of the nation’s population that have pre-existing conditions and would face difficulties if laws about pre-existing conditions were changed. In all, 5.8 million potentially uninsurable people live in these 15 states.
At Risk Population (000s)
% of Pop.
- At Risk Population = Estimate of non-elderly adults (19-64) with a declinable condition and are either uninsured or insured via direct insurance.
- % of Population = % of the non-elderly adult (19-64) population
Declinable Pre-Existing Conditions
Before the Affordable Care Act took effect, private insurers cited a variety of common diseases and conditions, such as pregnancy, as a reason to deny coverage, according to research by the Kaiser Family Foundation. The KFF looked at a dozen insurance carriers and found that more than half denied coverage to potential policyholders with the following conditions:
Examples of Declinable Conditions
- Alcohol abuse/drug abuse with recent treatment
- Arthritis, fibromyalgia or other inflammatory joint disease
- Cancer (usually in past decade)
- Cerebral palsy
- Congestive heart failure
- Coronary artery/heart disease, bypass surgery
- Crohn’s disease/ulcerative colitis
- Chronic obstructive pulmonary disease/emphysema
- Diabetes mellitus
- Gender dysphoria
- Hepatitis C
- Kidney disease, renal failure
- Mental disorders such as bipolar disorder, eating disorders
- Multiple sclerosis
- Muscular dystrophy
- Obesity, severe
- Organ transplant
- Parkinson’s disease
- Pending surgery or hospitalization
- Pneumocystis pneumonia
- Sleep apnea
State of Declinable Conditions Legislation
The Affordable Care Act made it illegal for insurers to deny coverage to consumers based on pre-existing health conditions. In recent years, however, a challenge to the ACA has been working its way through the federal courts. The U.S. Supreme Court announced in early March 2020 that it would hear the matter, although not until late 2020 at the earliest. If the justices rule in favor of the ACA opponents, pre-existing conditions could once again disqualify people from coverage.
Full Dataset of Pre-Existing Conditions by State
MoneyGeek’s full state-by-state analysis shows the percentage of the population with pre-existing conditions and identifies the most impacted populations. Massachusetts, which touts the lowest uninsured rate in the nation, has the lowest rate of potentially declinable residents. Florida, which has the highest ACA enrollment numbers of all states, stands to lose the most if ACA pre-existing regulations are removed, with 28% of its residents being potentially declinable for health insurance.
To create our estimates, MoneyGeek relied on data from the Kaiser Family Foundation, the U.S. Census Bureau and the U.S. Department of Health and Human Services. To estimate the number of individuals with a potentially declinable condition on direct insurance, we used the Kaiser Family Foundation’s state-level study and multiplied by the HHS’ published ratio of declinable conditions by insurance type. We used the same methodology to estimate the population with a declinable condition and no health insurance. This analysis utilizes the population of adults between the ages of 19 and 64 for all calculations and comparisons.
About Jeff Ostrowski
- HealthInsurance.org. "Florida health insurance marketplace: history and news of the state’s exchange." Accessed March 3, 2020.
- HealthInsurance.org. "Massachusetts health insurance." Accessed March 3, 2020.
- Kaiser Family Foundation. "2019 Employer Health Benefits Survey." Accessed March 3, 2020.
- U.S. Supreme Court. "Petition for Writ of Certorari in The States ... v. State of Texas." Accessed March 3, 2020.