An updated version of this column is available here.
The Affordable Care Act (ACA) prohibits discriminatory insurance practices in pricing and coverage in the individual market. Before the law was enacted, women routinely were denied coverage or charged more for insurance based on so-called pre-existing conditions. For example, in the individual insurance market, a woman could be denied coverage or charged a higher premium if she had been diagnosed with or experienced HIV or AIDS; diabetes; lupus; an eating disorder; or pregnancy or a previous cesarean birth, just to name a few. The ACA provided women with protections for pre-existing conditions and access to comprehensive, affordable, and fair health services.
But recent efforts to eliminate key ACA protections, discussed below, would put millions of women and girls once again at risk of being charged more or denied coverage for individual insurance.
Efforts to eliminate ACA protections threaten the security of women with pre-existing conditions
Recently, the U.S. Department of Justice refused to uphold the law in Texas v. United States, when it argued that the community rating and guaranteed issue provisions of the ACA are unconstitutional. Without guaranteed issue, women could be denied coverage based on their medical history, their age, and their occupation, among other factors. Without community rating, women could be charged more, or priced out of the insurance market altogether, based on their health status or other factors. Insurance companies could also try to reinstate gender rating, a common pre-ACA practice in which insurance companies charged women higher premiums than they did men, even though other parts of the ACA protect women from discrimination in the health care system.
Now, think tanks and conservative opponents of the ACA are introducing proposals to repeal the ACA yet again. If implemented, these proposals would similarly put women at risk of being denied coverage or charged more because of their health status.
More than half of all women and girls have pre-existing conditions
The authors estimate that more than half of women and girls nationwide—more than 67 million—have pre-existing conditions. There are also nearly 6 million pregnancies each year, a commonly cited reason for denying women coverage on the individual market before the ACA. The two tables available for download below provide state-level detail for the number of women and girls with pre-existing conditions and the number of pregnancies.
A large share of women have coverage through an employer or Medicaid and would, therefore, not face discriminatory practices such as medical underwriting or denials based on health conditions. But the data make clear that allowing insurers to return to pre-ACA practices could lead to millions of women and girls being denied coverage or charged more based on their health status if they ever sought coverage in the individual market.
Theresa Chalhoub is a senior policy analyst for the Women’s Health and Rights Program and Health Policy at the Center American Progress. Aditya Krishnaswamy is an intern for Health Policy at the Center. The National Partnership for Women and Families is a nonprofit, nonpartisan advocacy group dedicated to promoting fairness in the workplace, reproductive health and rights, access to quality health care, and policies that help women and men meet the dual demands of work and family. More information is available at NationalPartnership.org.
To download the tables with the estimated number of women and girls with pre-existing conditions and estimated number of pregnancies by state, click here.
The estimates for the number of women and girls with pre-existing conditions who could be charged more or denied coverage for individual insurance were based on American Community Survey (ACS) data. First, the authors used the 2016 ACS to find the total number of women and girls under age 65 in each state. They removed the number of nonelderly women covered by Medicare according to the ACS because women covered by Medicare would not be subject to possible discrimination based on a pre-existing condition. Finally, the authors calculated the number of women who may have at least one pre-existing condition based on a 2017 U.S. Department of Health and Human Services report. It estimated that 51 percent of women and girls have a pre-existing condition that would have subjected them to coverage carve-outs, higher rates, or coverage denials prior to the ACA.
The estimates for the number of pregnancies are based on the Guttmacher Institute’s 2011 data for the number of pregnancies in each state among women ages 15 to 44.