Abstract

Issue: Prior to the Affordable Care Act (ACA), people with preexisting health conditions could be denied insurance coverage or charged higher rates. If the law is repealed, these protections could be diluted or lost altogether.
Goals: Assess the ACA’s impact on coverage and access for people with preexisting conditions and compare their coverage gains with state high-risk-pool enrollment pre-ACA.
Methods: Analysis of Behavioral Risk Factor Surveillance System data for the period 2011–13 to 2015.
Key Findings and Conclusions: Between 2013 and 2015, 16.5 million nonelderly adults gained coverage following full ACA implementation. Of those, 2.6 million had preexisting conditions that could have otherwise precluded them from coverage because of discriminatory denials and pricing; 9.4 million had conditions that could have otherwise affected insurance cost. We found strong correlations between these coverage gains and access to care. Coverage and access gains for people with preexisting conditions were unrelated to the size or existence of the state high-risk pools that 35 states funded for such individuals pre-ACA. Our findings suggest that proposals to replace current protections for people with preexisting conditions with high-risk pools are unlikely to be sufficient to maintain the ACA’s gains.

Background

Americans with chronic health conditions are at the center of the debate over access to health care coverage. The U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation (ASPE) estimates the number of Americans with such “preexisting conditions” ranges from 19 percent to 50 percent of all nonelderly Americans.^1,2 This range represents the difference between conditions that fit into a “narrow” definition of preexisting conditions (19%), and a “broad” definition (50%). The narrow definition includes very costly health conditions that would cause insurers to refuse coverage absent the Affordable Care Act’s (ACA) provisions; the broad definition includes slightly less expensive chronic health conditions that could nevertheless make the cost of insurance in the individual market without the ACA largely unaffordable for most patients.

In 2016, the Henry J. Kaiser Family Foundation, in its review of pre-ACA medical underwriting practices, estimated that 27 percent of nonelderly American adults had health conditions that “would likely leave them uninsurable if they applied for individual market coverage.”³ Similarly, a Commonwealth Fund study found that, in 2010, 36 percent of adults ages 19 to 64 who had tried to buy a plan in the individual market over the prior three years were turned down, charged a higher price, or had a condition excluded from their coverage because of a health problem.⁴

The presence of preexisting conditions is particularly important for the millions of Americans who have gained coverage under the ACA, which Congress and the Trump administration are seeking to repeal.⁵ The Commonwealth Fund study found significant improvements in the ability of people with health problems to purchase plans on their own in 2016 relative to 2010.⁶

In this issue brief, we observe whether the coverage gains for people with preexisting conditions also have resulted in better access to care. Better access is defined as a greater likelihood of having a regular health care provider (whether one or more than one clinician) and having less trouble seeing a provider because of the cost.

Prior to passage of the ACA, many states had high-risk pools that sought to provide coverage to individuals locked out of the individual insurance market because of expensive preexisting conditions. Between 2010 and 2013, the ACA funded the Pre-Existing Condition Insurance Program, a set of federally funded high-risk pools to provide interim coverage for those with such conditions. If these pools had been successful in addressing coverage for those with preexisting conditions, we would expect to see a smaller gain in access to care for this population in those states that had previously enrolled substantial shares of the nongroup market in the pools.

Under the ACA, Americans with Preexisting Conditions Gained Coverage and Better Access to Care

For this brief, we considered both the narrow and broad definitions of preexisting conditions. Among the general population surveyed between 2011 and 2015, data from the Behavioral Risk Factor Surveillance System (BRFSS) indicate that 20 percent of Americans have preexisting conditions under the narrow definition and 61 percent of Americans have these conditions under the broader definition. Using the BRFSS data, we estimate that 16.5 million more people were insured in 2015 than in the 2011–2013 period.⁷ Among this newly insured group, 2.6 million had one or more preexisting conditions under the narrow definition and 9.4 million had one or more under the broader definition (Exhibit 1).