ASPE Issue Brief Page 4
ASPE Office of Health Policy January 5, 2017
A few states sought to require that people with pre-existing conditions be offered
coverage at the same price as other Americans. But without accompanying measures to
ensure that healthy residents also continued to buy insurance, these states saw escalating
premiums that made health insurance unaffordable for sick and healthy residents alike.
In contrast, the ACA implemented a nationwide set of reforms in the individual health insurance
market. The law requires individual market insurers to offer comprehensive coverage to all
enrollees, on common terms, regardless of medical history. Meanwhile, the ACA also includes
measures to ensure a balanced risk pool that keeps coverage affordable. To directly improve
affordability while encouraging individuals to buy coverage, the ACA offers financial assistance
for eligible taxpayers with household incomes up to 400 percent of the federal poverty level to
reduce their monthly premium payments.
The law also includes an individual shared
responsibility provision that requires people who can afford coverage to make a payment if they
instead elect to go without it.
Prevalence of Pre-Existing Conditions
Estimating the Number of Americans with Pre-Existing Conditions
This analysis updates earlier ASPE estimates of the number of non-elderly Americans potentially
benefitting from the ACA’s pre-existing conditions protections. As in the earlier study, we
consider two definitions of pre-existing conditions. The narrower measure includes only
conditions identified using eligibility guidelines from state-run high-risk pools that pre-dated the
ACA. These programs were generally intended to cover individuals who would be outright
rejected for coverage by private insurers. The broader measure includes additional common
health conditions (for example, arthritis, asthma, high cholesterol, hypertension, and obesity) and
behavioral health disorders (including alcohol and substance use disorders, depression, and
Alzheimer’s) that could have resulted in denial of coverage, exclusion of the condition, or higher
premiums for individuals seeking individual market coverage before the ACA protections
applied.
Former insurance commissioners in Rhode Island and Washington described the problems created by partial
reforms in their states. See, for example, Christopher Koller, “Why Republican Health Insurance Reform Ideas Are
Likely to Fail,” Politico, December 7, 2016, http://www.politico.com/agenda/story/2016/12/republican-health-
reform-ideas-obamacare-unlikely-work-000252, and Harris Meyer, “What It Will Take to Stop Insurers From
Fleeing After ACA Repeal,” Modern Health Care, December 5, 2016,
http://www.modernhealthcare.com/article/20161205/NEWS/161209962. The exception was Massachusetts, which
enacted its own version of the ACA’s insurance market reforms, subsidies, and individual responsibility provision in
2006.
Office of the Assistant Secretary for Planning and Evaluation, Health Plan Choice and Premiums
in the 2017 Health Insurance Marketplace, October 24, 2016, available at
https://aspe.hhs.gov/sites/default/files/pdf/212721/2017MarketplaceLandscapeBrief.pdf.
For an extended discussion of the ACA’s insurance market reforms, see
https://www.whitehouse.gov/sites/default/files/page/files/20161213_cea_record_healh_care_reform.pdf.
These conditions were selected based on underwriting guidelines identified using internet searches in the pre-
ACA period.