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Before the Affordable Care Act, health insurance companies could use a person’s medical history  — or what they called "pre-existing conditions" — as a way to charge that person more for coverage or deny them coverage altogether.

Imagine you’re trying to enroll in a new health insurance plan. Maybe you no longer have insurance through your employer or you’re joining your partner’s plan. But you’re denied coverage. Why? Because you’ve received medical treatment for a certain health condition in the past, or you have a family history of a health condition. You may have what health insurance companies refer to as a “pre-existing condition.”

About 130 million nonelderly people have pre-existing conditions. Insurers have long used a person’s medical history as a way to charge them more for coverage or deny them coverage.

Before the Affordable Care Act (ACA), also known as Obamacare, was passed in 2010, patients with pre-existing conditions were forced to:

  • Pay significantly more for health insurance

  • Go without health insurance

Insurance companies included a broad range of health problems under the pre-existing conditions label — not just chronic illnesses or injuries, but also common health problems like asthma, high blood pressure, and allergies. Pre-existing conditions also applied to a person’s family health history. For example, if your father had diabetes, you might not be eligible for coverage or could face higher premiums.

How “Being a Woman” Was a Pre-Existing Condition Before the ACA

Women, in particular, were especially affected because health conditions women frequently experienced were considered pre-existing conditions. Prior to the ACA, about 29.4 million women under age 65 had a pre-existing condition, compared to 22.8 million men under age 65.

Millions of women were denied coverage because of a range of health issues labeled as pre-existing conditions, including pregnancy, breast cancer, and irregular periods. Black and Latino women face higher rates of many chronic illnesses. As a result, higher premiums or denial of coverage for pre-existing conditions threaten the health and financial security of women of color the most.

Here are some ways health insurance companies used pre-existing conditions as a way to deny women coverage or price them out altogether: 

  • If you had been or were considering becoming pregnant. For example, one health insurance company denied coverage to any woman who had been pregnant or received infertility treatment within the past five years.
  • If you had a Cesarean, or C-section. Some insurance plans didn’t cover C-sections and other charged women who underwent the procedure 25% higher premiums.

  • If you had breast cancer. One in eight women will develop invasive breast cancer in the United States, but certain health insurance companies still considered it a pre-existing condition. The ability to charge women with breast cancer more for coverage impacts African-American women the most. African-American women under age 45 are more likely to develop breast cancer compared to white women, and African-American women, overall, are most likely to die from the disease.

  • If you had mental health needs. Women are 40% more likely than men to develop mental health needs. For example, 7.3 million women (compared to 2.8 million men) annually experience major depression. Without the ACA protections, women who need mental health treatment could pay as much as $8,490 more per year.

  • If you were a woman with HIV. African-American and trans women are the women most likely to have HIV. People living with HIV have historically experienced barriers to accessing care in part due to stigma in the medical industry, including health insurance plans. Without protections, people living with HIV could face exorbitant premium costs and be priced out of health care.

Efforts by health insurance companies and anti-women’s health politicians to classify people as having pre-existing conditions caused the number of uninsured and underinsured people in the country to swell. Some died or went bankrupt trying to manage their medical conditions.

By the 1980s, pre-existing conditions caused so many Americans to suffer without health care coverage that the federal government couldn’t ignore it anymore. The government started to implement limited protections for people with pre-existing conditions, but they weren’t enough. By 2013, millions of Americans — one-fourth of those aged 18-65 — were denied health insurance coverage because of their pre-existing conditions.

The Affordable Care Act changed all that.

How Does the Affordable Care Act Help People with Pre-Existing Conditions?

President Barack Obama signed the Affordable Care Act into law in 2010. The law, which was fully enacted in 2014, provides critical protections for patients with health problems, including making it illegal for health insurance companies to discriminate against people with pre-existing conditions. These protections ensured that insurers can no longer deny people coverage for having a pre-existing condition or charge you more for just being a woman.

Thanks to Protections Under the ACA, Health Insurance Companies:

  • Can’t refuse to provide health insurance coverage for people with pre-existing conditions;

  • Can’t charge people with pre-existing conditions more for health coverage;

  • Can’t engage in gender rating which costs women over $1 billion annually; and

  • Can’t refuse to pay for "essential health benefits" for any pre-existing condition, including pregnancy and childbirth.

What Do Americans Think About Providing Protections for People with Pre-existing Conditions?

Before the Affordable Care Act, overwhelming majority of Americans — including strong majorities of Republicans, Independents, and Democrats — wanted to require insurance companies to cover people with pre-existing conditions. 

That hasn’t changed. Today, 72% of Americans across political parties want to keep the ACA's protections for pre-existing conditions, which remain one of the law’s most popular features.

Americans know that protections for people with pre-existing conditions have saved lives and livelihoods. Four in 10 Americans — or 41% — say they're “very worried” that they or a family member will lose coverage if the Supreme Court overturns the ACA’s pre-existing condition protections. More than half of Americans — or 52% — are “very worried” they or a family member will have to pay more for coverage.

Republican Attacks on the ACA’s Protections for People with Pre-existing Conditions

While he was president, Donald Trump worked tirelessly with administration officials and anti-reproductive health members of Congress to repeal the ACA and gut its protections for people with pre-existing conditions. We’ve fought back against the various iterations of Trumpcare — and we’ve won every time.

In 2017, the House passed the American Health Care Act (AHCA), which would have let insurance companies charge people with pre-existing conditions exorbitant rates. The Senate introduced their own version of the Better Care Reconciliation (BCRA). The bill died, but Republicans didn’t give up. They tried to pass the Graham-Cassidy-Heller health care bill and the Skinny Repeal bill — both of which tried to gut protections for pre-existing conditions and strip health care from millions of Americans.

The Graham-Cassidy-Heller bill was the worst bill for women in a generation. If Republicans had their way, insurance companies would have been able to charge a person who had been pregnant about $17,320 more per year for health coverage. Breast cancer survivors could have been charged $28,660 more per year for coverage.

Another version of Trumpcare, called the Cruz amendment, put health care completely out of reach for many people, especially women. Under the proposal, any person who had a C-section could have been forced to pay exorbitant monthly premiums for health insurance.

Today, some Republican members of Congress are introducing bills that mimic the ACA’s language. But don’t be fooled. Giant loopholes in these plans would let insurers refuse to cover chronic, or even life-threatening, "pre-existing" conditions that affect over 130 million Americans.

How Were 2018 Candidates Talking About Pre-existing Conditions?

Surveys about midterm elections show that voters care about health care more than any other midterm-election issue. So Republican candidates on the 2018 campaign trail did everything they could to cover up their records of attacking protections for people with pre-existing conditions.

 READ MORE: Fact-Checking Republican Claims on Pre-existing Conditions

Most of these candidates supported the Graham-Cassidy-Heller bill or its other harmful versions of it. But on the 2018 campaign trail, they sang a different tune. They knew that repealing the ACA was unpopular with voters, so they deceived voters and misrepresented their harmful records.

At the time, Vice President Mike Pence, Senate Majority Leader Mitch McConnell, and House Majority Whip Steve Scalise (R-La.) made clear that Republicans would try to repeal the Affordable Care Act if they came out of the 2018 midterm election with enough seats to keep control of the Senate — which they did. As Pence told reporters then: “We made an effort to fully repeal and replace Obamacare, and … we’ll continue to go back to that.”