We used data from the National Health Interview Survey (NHIS) to estimate that 27% of nonelderly adults had a declinable health condition in 2018, the same percentage that we found in our earlier analysis for 2015. The NHIS has a number of questions about whether the respondent has ever been diagnosed with a number of the health conditions that would have been declinable in the pre-ACA non-group market. While we cannot duplicate the underwriting processes carried out by insurers, we feel that our approach is reasonable and may be conservative because the NHIS does not contain information about all of the conditions (e.g., AIDS/HIV) used by insurers and does not provide information on prescriptions that insurers also used to decline applicants for coverage.
Although each family member would have been separately underwritten in the pre-ACA non-group market, the economic consequences of having a member of the family denied coverage or surcharged due to their health would likely be felt by all members of the family. To look at the number of people that might be affected, we extended our previous methods and estimate that, in 2018, 45% of non-elderly families included a non-elderly adult with a declinable condition. Individuals living in households without a relative are considered to be a family of one person for this analysis.
A larger share of non-elderly adult women (30%) than men (24%) have declinable pre-existing conditions in 2018, unchanged from 2015. We estimate that 23.7 million men have a pre-existing condition that would have left them uninsurable in the individual market pre-ACA, compared to 30.1 million women. Pregnancy explains part (about 2 million women) but not all of this difference.
The prevalence of declinable conditions also increases with age among non-elderly adults: ranging from 18% of those in the 18-34 age group to 44% for those in the 55-64 age group.
Table 2 Share of Non-Elderly People with Declinable Condition | |
Age Group | Share with Declinable Condition |
18-34 | 18% |
35-44 | 24% |
45-54 | 29% |
55-64 | 44% |
The rates of declinable pre-existing conditions continue to vary from state to state. On the low end, in Colorado, at least 22% of non-elderly adults have conditions that would likely be declinable if they were to seek coverage in the individual market under pre-ACA underwriting practices. Rates are higher in other states – particularly in the South – such as Arkansas (34%), Kentucky (34%), Mississippi (34%), and West Virginia (37%), where at least a third of the non-elderly population would have declinable conditions.
Table 3: Estimated Number and Percent of Non-Elderly People with Declinable Pre-Existing Conditions Under Pre-ACA Practices, 2018 | ||
State | Percent of Non-Elderly Population | Number of Non-Elderly Adults |
Alabama | 33% | 957,000 |
Alaska | 26% | 119,000 |
Arizona | 28% | 1,145,000 |
Arkansas | 34% | 597,000 |
California | 25% | 6,093,000 |
Colorado | 22% | 789,000 |
Connecticut | 24% | 529,000 |
Delaware | 28% | 160,000 |
District of Columbia | 23% | 113,000 |
Florida | 28% | 3,526,000 |
Georgia | 28% | 1,805,000 |
Hawaii | 25% | 212,000 |
Idaho | 26% | 259,000 |
Illinois | 26% | 2,045,000 |
Indiana | 30% | 1,210,000 |
Iowa | 25% | 466,000 |
Kansas | 27% | 465,000 |
Kentucky | 34% | 890,000 |
Louisiana | 33% | 932,000 |
Maine | 28% | 225,000 |
Maryland | 27% | 1,019,000 |
Massachusetts | 23% | 975,000 |
Michigan | 29% | 1,753,000 |
Minnesota | 23% | 790,000 |
Mississippi | 34% | 593,000 |
Missouri | 30% | 1,079,000 |
Montana | 24% | 152,000 |
Nebraska | 26% | 295,000 |
Nevada | 26% | 487,000 |
New Hampshire | 28% | 233,000 |
New Jersey | 25% | 1,359,000 |
New Mexico | 28% | 337,000 |
New York | 26% | 3,200,000 |
North Carolina | 28% | 1,762,000 |
North Dakota | 25% | 113,000 |
Ohio | 29% | 1,983,000 |
Oklahoma | 31% | 718,000 |
Oregon | 28% | 701,000 |
Pennsylvania | 27% | 2,105,000 |
Rhode Island | 27% | 175,000 |
South Carolina | 30% | 914,000 |
South Dakota | 24% | 123,000 |
Tennessee | 32% | 1,302,000 |
Texas | 28% | 4,794,000 |
Utah | 24% | 438,000 |
Vermont | 24% | 92,000 |
Virginia | 26% | 1,349,000 |
Washington | 25% | 1,154,000 |
West Virginia | 37% | 382,000 |
Wisconsin | 25% | 883,000 |
Wyoming | 25% | 86,000 |
US | 27% | 53,884,000 |
SOURCE: Kaiser Family Foundation analysis of data from National Health Interview Survey and the Behavioral Risk Factor Surveillance System.
NOTE: Five states (MA, ME, NJ, NY, VT) had broadly applicable guaranteed access to insurance before the ACA. What protections might exist in these or other states under a repeal and replace scenario is unclear. |
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