To download the table showing estimates by state and district for the 116th Congress, click here.
A court case now under deliberation in the 5th U.S. Circuit Court of Appeals could have devastating consequences for people with preexisting health conditions. In Texas v. United States, 18 states’ attorneys general—with support from the Trump administration—are challenging the constitutionality of the Affordable Care Act (ACA), including the law’s consumer protections that prevent insurance companies in the individual market from discriminating against people with preexisting conditions. These protections include a ban on varying rates according to gender or health status, a guarantee that plans issue coverage to anyone who wants to enroll, and a requirement that all plans cover 10 categories of essential health benefits. If the court rules in the plaintiffs’ favor, the lawsuit could bring down the entire ACA in the plaintiff states or for the whole country.
Among those who would suffer from nationwide repeal of the ACA through the courts are the 20 million people who would become uninsured and those, whether uninsured or not, with preexisting conditions. According to new estimates from the Center for American Progress, 135 million people under age 65, or about half of nonelderly people, have a preexisting condition that an insurer could use to discriminate against them if they ever sought coverage through the individual market in the absence of ACA protections. Each congressional district is home to nearly 310,000 people with preexisting conditions, on average. Estimates for each district are in the table available for download at the top of this column and are detailed in the Methodology section.
Before the ACA, people with illnesses, disabilities, or a history of health problems found it difficult, if not impossible, to purchase affordable health insurance on their own. Most states had no restrictions on rating in the individual market, giving insurers unlimited ability to charge more based on characteristics including gender, age, health status, and occupational industry. Insurance companies could charge higher premiums or even deny coverage altogether because of a person’s medical history. The near-elderly were typically charged five times more than young adults, and women faced premiums up to 50 percent higher than those for men.
Another difficulty for people with preexisting conditions before the ACA was that plans commonly did not cover basic categories of health benefits. Nearly 40 percent of plans did not provide coverage for mental health and behavioral health services, and three-quarters excluded inpatient benefits for maternity care. Plans regularly denied claims for care by declaring that it was related to a preexisting condition. Thanks to the ACA, coverage for 10 categories of essential health benefits is now mandatory for all individual market health plans.
For a preview of just how skimpy individual market insurance could become without the ACA, one only need look to today’s market for short-term plans—loosely regulated insurance policies that the Trump administration has made more widely available. Short-term plans, often used to bridge gaps in coverage, generally do not provide comprehensive care while also placing dollar limits on benefits and excluding coverage for preexisting conditions. They are not subject to the ACA’s standards on minimum plan value or requirements to cover essential benefits, and marketing materials and brokers for short-term plans can make it difficult for consumers to understand whether a plan will cover their preexisting conditions.
As the country awaits the decision in Texas v. United States, the future well-being of the millions of people who need the security of preexisting condition protections hangs in the balance. Repeal of the ACA would threaten their health coverage, financial security, and access to health care.
Emily Gee is the health economist of Health Policy at the Center for American Progress.
To calculate the number of people with preexisting conditions by district for the 116th Congress, the author obtained estimates of the nonelderly population from the 1-year 2017 American Community Survey (ACS), then subtracted out the number of nonelderly people who are currently covered by Medicare and would therefore not be subject to possible discrimination based on a preexisting condition. For the four states that have redistricted since 2017—Florida, North Carolina, Pennsylvania, and Virginia—the author used county estimates from the 5-year ACS and a data crosswalk from the Missouri Census Data Center to approximate current district boundaries for the 116th Congress.
The author then applied preexisting condition rates from a report by the U.S. Department of Health and Human Services (HHS) to the ACS data to obtain the number of people in each age group with a preexisting condition that could subject them to coverage carve-outs, higher rates, or coverage denials if they ever turned to the individual market for coverage in the absence of ACA protections. Because the author’s population estimates come from the 2017 ACS, the author’s estimated number of people with preexisting conditions is slightly higher than those in the HHS report and previous CAP estimates, which used older data.