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Fact Sheet

ACA At 11: Protections For People With Pre-Existing Conditions

By March 18, 2021No Comments

Protect Our Care Is Marking the 11th Anniversary of the Affordable Care Act With 11 Days Celebrating the Success of the Health Care Law

Eleven years ago, the Affordable Care Act (ACA) became the law of the land and millions of people gained coverage and critical protections as a result. Because of the ACA, insurers in the individual market can no longer drop or deny coverage, or charge people more because of a pre-existing condition. More than 135 million Americans have a pre-existing health condition, such as asthma, diabetes, or cancer. 

After four long years of Republican efforts to repeal and sabotage the law, President Biden and Democrats in Congress are now working to build on the strong foundation of the ACA to expand coverage, lower costs, and reduce racial disparities in health care. On March 11, President Biden signed the American Rescue Plan into law, historic legislation that includes the most significant health care expansion in a decade. Solidifying and expanding the ACA is especially important as millions of Americans have contracted the COVID-19; without the health law’s protections, survivors of COVID-19 would likely be deemed as having a pre-existing condition and be at the mercy of their insurance companies who could refuse to pay for needed care. 

At the same time, millions have lost their jobs and their employer-sponsored coverage during the pandemic, and experts say an overwhelming majority have been able to get covered under the ACA — through the marketplaces or through Medicaid expansion. Every single one of these individuals now relies on the ACA’s protections for pre-existing conditions. 

The ACA Includes Four Key Provisions That Protect People With Pre-Existing Conditions: 

  • COVERAGE GUARANTEE: Rule that forbids insurance companies from denying coverage to people with pre-existing conditions. 
  • COST: Rule that prevents insurers from charging people with pre-existing conditions more. 
  • ESSENTIAL HEALTH BENEFITS: Requirements that insurance companies cover essential health benefits, such as prescription drugs and maternity care.
  • LIFETIME CAPS: Ban on insurance companies having lifetime caps on coverage.

The ACA Prevents Insurance Companies From Charging Americans With A Pre-Existing Condition More, Or Denying Them Coverage Altogether. Prior to the ACA, insurance companies were allowed to charge people more or deny coverage simply because they had a pre-existing condition. The ACA banned this practice, requiring that insurance companies offer people coverage regardless of their health status. Without the ACA, premium surcharges could once again be in the six figures for some conditions. 

The ACA Guarantees Comprehensive Coverage. Because of the ACA, insurers have to cover what are known as “essential health benefits,” such as maternity care, prescription drugs, and substance and mental health. Importantly, ACA-compliant plans must cover COVID-19 testing, treatment, and hospitalization. Before the ACA, individual market plans often failed to cover these basic health services.  

The ACA Ended Annual And Lifetime Limits, Including For People With Employer-Based Coverage. Because of the ACA, insurers can no longer put annual or lifetime limits on the care you receive. At the time the ACA was passed, 91 million Americans had health care through their employers that imposed lifetime limits. Many such plans capped benefits at $1 million, functionally locking people with complex medical needs out of coverage. 

A Closer Look At Who Has Pre-Existing Conditions In The U.S.

Before the Affordable Care Act, insurance companies routinely denied people coverage because of a pre-existing condition or canceled coverage when a person got sick. According to an analysis by the Center for American Progress, roughly half of nonelderly Americans, or as many as 135 million people, have a pre-existing condition. This includes:

  • 44 million people who have high blood pressure
  • 45 million people who have behavioral health disorders
  • 44 million people who have high cholesterol
  • 34 million people who have asthma and chronic lung disease
  • 34 million people who have osteoarthritis and other joint disorders

More than 17 million children, 68 million women, and 32 million people aged 55-64 have a pre-existing condition.

The Kaiser Family Foundation estimates that 54 million people, or 27 percent of adults aged 18 to 64, have a condition that would have been grounds for coverage denial in the pre-ACA marketplace. Recent survey data found that six in 10 say they or someone in their household suffers from a pre-existing condition, such as asthma, diabetes, or high blood pressure.