In the context of

healthcare in the United States Healthcare in the United States is largely provided by private sector healthcare facilities, and paid for by a combination of public programs, private insurance, and out-of-pocket payments. The U.S. is the only developed country without a syste ...

, a pre-existing condition is a

medical condition A disease is a particular abnormal condition that adversely affects the structure or function (biology), function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical condi ...

that started before a person's

health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...

went into effect. Before 2014, some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with

adverse selection In economics, insurance, and risk management, adverse selection is a market situation where Information asymmetry, asymmetric information results in a party taking advantage of undisclosed information to benefit more from a contract or trade. In ...

by potential customers. Such exclusions have been prohibited since January 1, 2014, by the Patient Protection and Affordable Care Act. According to the

Kaiser Family Foundation KFF, which was formerly known as The Kaiser Family Foundation or The Henry J. Kaiser Family Foundation, is an American non-profit organization, non-profit organization, headquartered in San Francisco, San Francisco, California. It prefers KFF, w ...

, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.

Definitions

The

University of Pittsburgh Medical Center UPMC is an American integrated delivery system, integrated global nonprofit health enterprise that has 100,000 employees, 40 hospitals with more than 8,000 licensed beds, 800 clinical locations including outpatient sites and doctors' offices, a ...

defines a pre-existing condition as a "medical condition that occurred before a program of health benefits went into effect". J. James Rohack, president of the

American Medical Association The American Medical Association (AMA) is an American professional association and lobbying group of physicians and medical students. This medical association was founded in 1847 and is headquartered in Chicago, Illinois. Membership was 271,660 ...

, has stated on a '' Fox News Sunday'' interview that exclusions, based upon these conditions, function as a form of " rationing" of health care. Conditions can be broken down into two further categories, according to Lisa Smith of

Investopedia Investopedia is a global financial media website headquartered in New York City. Founded in 1999, Investopedia provides investment dictionaries, advice, reviews, ratings, and comparisons of financial products, such as securities accounts. It ...

: Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard. According to the Kaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.

Current U.S. federal regulation

; Patient Protection and Affordable Care Act (Pub.L. 111–148) enacted March 23, 2010 * Immediate reform: effective June 21, 2010 (90 days after enactment) ** National high-risk pool for individuals with a pre-existing condition who have been uninsured for the prior 6 months *** Premium to be set at a standard rate for a standard population *** Premium for older individuals allowed to be up to 4 times the premium for younger individuals *** Premium for tobacco users allowed to be up to 1.5 times the premium for non-tobacco users * Immediate reform: effective September 23, 2010 (6 months after enactment) ** Group health insurance plans and ''new (non- grandfathered)'' individual health insurance plans *** Pre-existing condition exclusions prohibited for children under age 19 * Reform delayed for 4 years: effective January 1, 2014 ** Individual ''and'' group health insurance plans *** Pre-existing condition exclusions prohibited in ''all'' health insurance plans *** Prohibit treating acts of domestic violence as a pre-existing condition *** Waiting period for enrollment in ''new'' health insurance plans limited to 90 days ** Grandfathered existing health insurance plans must prohibit pre-existing condition exclusions by January 1, 2014

Former regulation

Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in the

United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...

was left to individual U.S. states as a result of the McCarran–Ferguson Act of 1945 which delegated insurance regulation to the states and the

Employee Retirement Income Security Act The Employee Retirement Income Security Act of 1974 (ERISA) (, codified in part at ) is a U.S. federal tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax e ...

of 1974 (ERISA) which exempted self-insured large group health insurance plans from state regulation. After most states had by the early 1990s implemented some limits on pre-existing condition exclusions by small group (2 to 50 employees) health insurance plans, the

Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act of 1996 (HIPAA or the Ted Kennedy, Kennedy–Nancy Kassebaum, Kassebaum Act) is a United States Act of Congress enacted by the 104th United States Congress and signed into law by President ...

( Kassebaum- Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions for ''all'' group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation. ; Individual (non-group) health insurance plans * Maximum pre-existing condition exclusion period (states that permitted elimination riders permanently excluding pre-existing conditions noted by ''italics'' and asterisk*) ** 6 months:

Massachusetts Massachusetts ( ; ), officially the Commonwealth of Massachusetts, is a U.S. state, state in the New England region of the Northeastern United States. It borders the Atlantic Ocean and the Gulf of Maine to its east, Connecticut and Rhode ...

Oregon Oregon ( , ) is a U.S. state, state in the Pacific Northwest region of the United States. It is a part of the Western U.S., with the Columbia River delineating much of Oregon's northern boundary with Washington (state), Washington, while t ...

; ''

New Mexico New Mexico is a state in the Southwestern United States, Southwestern region of the United States. It is one of the Mountain States of the southern Rocky Mountains, sharing the Four Corners region with Utah, Colorado, and Arizona. It also ...

*'' ** 9 months: Washington; ''

New Hampshire New Hampshire ( ) is a U.S. state, state in the New England region of the Northeastern United States. It borders Massachusetts to the south, Vermont to the west, Maine and the Gulf of Maine to the east, and the Canadian province of Quebec t ...

*'' ** 12 months:

California California () is a U.S. state, state in the Western United States that lies on the West Coast of the United States, Pacific Coast. It borders Oregon to the north, Nevada and Arizona to the east, and shares Mexico–United States border, an ...

Idaho Idaho ( ) is a landlocked U.S. state, state in the Pacific Northwest and Mountain states, Mountain West subregions of the Western United States. It borders Montana and Wyoming to the east, Nevada and Utah to the south, and Washington (state), ...

Kentucky Kentucky (, ), officially the Commonwealth of Kentucky, is a landlocked U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders Illinois, Indiana, and Ohio to the north, West Virginia to the ...

Maine Maine ( ) is a U.S. state, state in the New England region of the United States, and the northeasternmost state in the Contiguous United States. It borders New Hampshire to the west, the Gulf of Maine to the southeast, and the Provinces and ...

Michigan Michigan ( ) is a peninsular U.S. state, state in the Great Lakes region, Great Lakes region of the Upper Midwest, Upper Midwestern United States. It shares water and land boundaries with Minnesota to the northwest, Wisconsin to the west, ...

New Jersey New Jersey is a U.S. state, state located in both the Mid-Atlantic States, Mid-Atlantic and Northeastern United States, Northeastern regions of the United States. Located at the geographic hub of the urban area, heavily urbanized Northeas ...

, New York,

Vermont Vermont () is a U.S. state, state in the New England region of the Northeastern United States. It borders Massachusetts to the south, New Hampshire to the east, New York (state), New York to the west, and the Provinces and territories of Ca ...

; ''

Colorado Colorado is a U.S. state, state in the Western United States. It is one of the Mountain states, sharing the Four Corners region with Arizona, New Mexico, and Utah. It is also bordered by Wyoming to the north, Nebraska to the northeast, Kansas ...

Connecticut Connecticut ( ) is a U.S. state, state in the New England region of the Northeastern United States. It borders Rhode Island to the east, Massachusetts to the north, New York (state), New York to the west, and Long Island Sound to the south. ...

Maryland Maryland ( ) is a U.S. state, state in the Mid-Atlantic (United States), Mid-Atlantic region of the United States. It borders the states of Virginia to its south, West Virginia to its west, Pennsylvania to its north, and Delaware to its east ...

Mississippi Mississippi ( ) is a U.S. state, state in the Southeastern United States, Southeastern and Deep South regions of the United States. It borders Tennessee to the north, Alabama to the east, the Gulf of Mexico to the south, Louisiana to the s ...

Montana Montana ( ) is a landlocked U.S. state, state in the Mountain states, Mountain West subregion of the Western United States. It is bordered by Idaho to the west, North Dakota to the east, South Dakota to the southeast, Wyoming to the south, an ...

North Carolina North Carolina ( ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It is bordered by Virginia to the north, the Atlantic Ocean to the east, South Carolina to the south, Georgia (U.S. stat ...

North Dakota North Dakota ( ) is a U.S. state in the Upper Midwest, named after the indigenous Dakota people, Dakota and Sioux peoples. It is bordered by the Canadian provinces of Saskatchewan and Manitoba to the north and by the U.S. states of Minneso ...

Ohio Ohio ( ) is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders Lake Erie to the north, Pennsylvania to the east, West Virginia to the southeast, Kentucky to the southwest, Indiana to the ...

Pennsylvania Pennsylvania, officially the Commonwealth of Pennsylvania, is a U.S. state, state spanning the Mid-Atlantic (United States), Mid-Atlantic, Northeastern United States, Northeastern, Appalachian, and Great Lakes region, Great Lakes regions o ...

Rhode Island Rhode Island ( ) is a state in the New England region of the Northeastern United States. It borders Connecticut to its west; Massachusetts to its north and east; and the Atlantic Ocean to its south via Rhode Island Sound and Block Is ...

South Dakota South Dakota (; Sioux language, Sioux: , ) is a U.S. state, state in the West North Central states, North Central region of the United States. It is also part of the Great Plains. South Dakota is named after the Dakota people, Dakota Sioux ...

Utah Utah is a landlocked state in the Mountain states, Mountain West subregion of the Western United States. It is one of the Four Corners states, sharing a border with Arizona, Colorado, and New Mexico. It also borders Wyoming to the northea ...

Virginia Virginia, officially the Commonwealth of Virginia, is a U.S. state, state in the Southeastern United States, Southeastern and Mid-Atlantic (United States), Mid-Atlantic regions of the United States between the East Coast of the United States ...

West Virginia West Virginia is a mountainous U.S. state, state in the Southern United States, Southern and Mid-Atlantic (United States), Mid-Atlantic regions of the United States.The United States Census Bureau, Census Bureau and the Association of American ...

Wyoming Wyoming ( ) is a landlocked U.S. state, state in the Mountain states, Mountain West subregion of the Western United States, Western United States. It borders Montana to the north and northwest, South Dakota and Nebraska to the east, Idaho t ...

*'' ** 18 months:

Minnesota Minnesota ( ) is a U.S. state, state in the Upper Midwestern region of the United States. It is bordered by the Canadian provinces of Manitoba and Ontario to the north and east and by the U.S. states of Wisconsin to the east, Iowa to the so ...

** 2 years: ''

Alabama Alabama ( ) is a U.S. state, state in the Southeastern United States, Southeastern and Deep South, Deep Southern regions of the United States. It borders Tennessee to the north, Georgia (U.S. state), Georgia to the east, Florida and the Gu ...

Florida Florida ( ; ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders the Gulf of Mexico to the west, Alabama to the northwest, Georgia (U.S. state), Georgia to the north, the Atlantic ...

Georgia Georgia most commonly refers to: * Georgia (country), a country in the South Caucasus * Georgia (U.S. state), a state in the southeastern United States Georgia may also refer to: People and fictional characters * Georgia (name), a list of pe ...

Illinois Illinois ( ) is a U.S. state, state in the Midwestern United States, Midwestern United States. It borders on Lake Michigan to its northeast, the Mississippi River to its west, and the Wabash River, Wabash and Ohio River, Ohio rivers to its ...

Iowa Iowa ( ) is a U.S. state, state in the upper Midwestern United States, Midwestern region of the United States. It borders the Mississippi River to the east and the Missouri River and Big Sioux River to the west; Wisconsin to the northeast, Ill ...

Kansas Kansas ( ) is a landlocked U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders Nebraska to the north; Missouri to the east; Oklahoma to the south; and Colorado to the west. Kansas is named a ...

South Carolina South Carolina ( ) is a U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders North Carolina to the north and northeast, the Atlantic Ocean to the southeast, and Georgia (U.S. state), Georg ...

Tennessee Tennessee (, ), officially the State of Tennessee, is a landlocked U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders Kentucky to the north, Virginia to the northeast, North Carolina t ...

Texas Texas ( , ; or ) is the most populous U.S. state, state in the South Central United States, South Central region of the United States. It borders Louisiana to the east, Arkansas to the northeast, Oklahoma to the north, New Mexico to the we ...

Wisconsin Wisconsin ( ) is a U.S. state, state in the Great Lakes region, Great Lakes region of the Upper Midwest of the United States. It borders Minnesota to the west, Iowa to the southwest, Illinois to the south, Lake Michigan to the east, Michig ...

*'' ** 3 years: ''

Hawaii Hawaii ( ; ) is an island U.S. state, state of the United States, in the Pacific Ocean about southwest of the U.S. mainland. One of the two Non-contiguous United States, non-contiguous U.S. states (along with Alaska), it is the only sta ...

*'' ** 10 years:

Indiana Indiana ( ) is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders Lake Michigan to the northwest, Michigan to the north and northeast, Ohio to the east, the Ohio River and Kentucky to the s ...

** unlimited: ''

Alaska Alaska ( ) is a non-contiguous U.S. state on the northwest extremity of North America. Part of the Western United States region, it is one of the two non-contiguous U.S. states, alongside Hawaii. Alaska is also considered to be the north ...

Arizona Arizona is a U.S. state, state in the Southwestern United States, Southwestern region of the United States, sharing the Four Corners region of the western United States with Colorado, New Mexico, and Utah. It also borders Nevada to the nort ...

Arkansas Arkansas ( ) is a landlocked state in the West South Central region of the Southern United States. It borders Missouri to the north, Tennessee and Mississippi to the east, Louisiana to the south, Texas to the southwest, and Oklahoma ...

Delaware Delaware ( ) is a U.S. state, state in the Mid-Atlantic (United States), Mid-Atlantic and South Atlantic states, South Atlantic regions of the United States. It borders Maryland to its south and west, Pennsylvania to its north, New Jersey ...

District of Columbia Washington, D.C., formally the District of Columbia and commonly known as Washington or D.C., is the capital city and Federal district of the United States, federal district of the United States. The city is on the Potomac River, across from ...

Louisiana Louisiana ( ; ; ) is a state in the Deep South and South Central regions of the United States. It borders Texas to the west, Arkansas to the north, and Mississippi to the east. Of the 50 U.S. states, it ranks 31st in area and 25 ...

Missouri Missouri (''see #Etymology and pronunciation, pronunciation'') is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. Ranking List of U.S. states and territories by area, 21st in land area, it border ...

Nebraska Nebraska ( ) is a landlocked U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders South Dakota to the north; Iowa to the east and Missouri to the southeast, both across the Missouri River; Ka ...

Nevada Nevada ( ; ) is a landlocked state in the Western United States. It borders Oregon to the northwest, Idaho to the northeast, California to the west, Arizona to the southeast, and Utah to the east. Nevada is the seventh-most extensive, th ...

Oklahoma Oklahoma ( ; Choctaw language, Choctaw: , ) is a landlocked U.S. state, state in the South Central United States, South Central region of the United States. It borders Texas to the south and west, Kansas to the north, Missouri to the northea ...

*'' ** Elimination riders permanently excluding pre-existing conditions *** prohibited:

, New York,

, Washington *** ''permitted*: 37 other states and DC'' * Maximum look-back period for pre-existing conditions ** 3 months:

** 6 months:

, New York,

, Washington,

** 12 months:

** 2 years:

** 3 years:

, ** 5 years:

** unlimited:

; Small group (2 to 50 employees) health insurance plans * Maximum pre-existing condition exclusion period ** 0 months:

** 3 months:

** 6 months:

** 9 months:

, Washington ** 12 months: 36 other states + DC * Maximum look-back period for pre-existing conditions ** 0 months:

** 3 months:

** 6 months: 45 other states + DC ; Large group (self-insured) health insurance plans * Maximum pre-existing condition exclusion period ** 12 months: 50 states + DC * Maximum look-back period for pre-existing conditions ** 6 months: 50 states + DC Pre-existing condition exclusions were prohibited for HIPAA-eligible individuals (those with 18 months continuous coverage unbroken for no more than 63 days and coming from a group health insurance plan). Individual (non-group) health insurance plans could exclude maternity coverage for a pre-existing condition of pregnancy. Group health insurance plans sponsored by employers with 15 or more employees were prohibited by the Pregnancy Discrimination Act of 1978 from excluding maternity coverage for a pre-existing condition of pregnancy; this prohibition was extended to all group health insurance plans by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Practice and effect

Advocates against pre-existing condition rules argue that they cruelly deny people in need of treatment.

State Farm State Farm Insurance is a group of mutual insurance companies throughout the United States with corporate headquarters in Bloomington, Illinois. Founded in 1922, it is the largest property and casualty insurance, property, casualty and auto i ...

spokeswoman K.C. Eynatten has said, "We realized our position was based on gut feelings, not hard numbers... we became aware that we were part of the reason a woman and her children might not leave an abuser. They were afraid they'd lose their insurance. And we wanted no part of that." Jerry Flanagan, health-care policy director of Consumer Watchdog, has stated that "insurance companies want premiums without any risk" and go to extreme "lengths... to go to make a profit". InsureMe, an insurance quote provider website, has argued that even though health insurance is basically to protect people from very high costs of health care, the commercial health insurance system is not playing fair and are always trying to avoid risk in order to boost their profits. Some practices by some

companies, such as determining domestic violence to be an excludable pre-existing condition, have been called abuses by Maria Tchijov, a Service Employees International Union new media coordinator, and by an Office of Rural Health Policy report. The rationale behind pre-existing condition clauses, according to those who defend the policies, is that they reduce the cost of health insurance coverage for those who still receive it, thus giving more people an opportunity to afford insurance in the first place. The ''

San Francisco Chronicle The ''San Francisco Chronicle'' is a newspaper serving primarily the San Francisco Bay Area of Northern California. It was founded in 1865 as ''The Daily Dramatic Chronicle'' by teenage brothers Charles de Young and M. H. de Young, Michael H. ...

'' has reported that " sts for those with coverage could go up because people in poor health who'd been shut out of the insurance pool would now be included... they would get medical care they could not access before."

Senator A senate is a deliberative assembly, often the upper house or Legislative chamber, chamber of a bicameral legislature. The name comes from the Ancient Rome, ancient Roman Senate (Latin: ''Senatus''), so-called as an assembly of the senior ...

Mike Enzi Michael Bradley Enzi ( ; February 1, 1944 – July 26, 2021) was an American politician who served in the United States Senate from Wyoming as a member of the Republican Party (United States), Republican Party from 1997 to 2021. Prior to his te ...

, a Republican from

, has voted to allow insurance companies to consider domestic violence as a pre-existing condition and supported his vote by saying that covering such people could raise insurance premiums to the point where it would preclude others from buying it. He has remarked that "If you have no insurance, it doesn't matter what services are mandated by the state". According to the California-based advocacy group Consumer Watchdog, other possible situations falling under pre-existing condition clauses are chronic conditions as

acne Acne ( ), also known as ''acne vulgaris'', is a long-term Cutaneous condition, skin condition that occurs when Keratinocyte, dead skin cells and Sebum, oil from the skin clog hair follicles. Typical features of the condition include comedo, ...

, hemorrhoids, toenail fungus,

allergies Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include Allergic rhinitis, hay fever, Food allergy, food al ...

tonsillitis Tonsillitis is inflammation of the tonsils in the upper part of the throat. It can be acute or chronic. Acute tonsillitis typically has a rapid onset. Symptoms may include sore throat, fever, enlargement of the tonsils, trouble swallowing, and en ...

, and

bunion A bunion, also known as hallux valgus, is a deformity of the metatarsophalangeal joint, MTP joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is ...

s, hazardous occupations such as

police officer A police officer (also called policeman or policewoman, cop, officer or constable) is a Warrant (law), warranted law employee of a police, police force. In most countries, ''police officer'' is a generic term not specifying a particular rank. ...

, stunt person,

test pilot A test pilot is an aircraft pilot with additional training to fly and evaluate experimental, newly produced and modified aircraft with specific maneuvers, known as flight test techniques.Stinton, Darrol. ''Flying Qualities and Flight Testin ...

, circus worker, and firefighter, and

pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...

and/or the intention to adopt.

Commentary by lawmakers

According to a Reason.com libertarian opinion blog by Peter Suderman, the ' Pledge to America' issued by the Republican Party in September 2010 stated, "Health care should be accessible for all, regardless of pre-existing conditions or past illnesses.... We will make it illegal for an insurance company to deny coverage to someone with prior coverage on the basis of a pre-existing condition." In a March 3, 2010, address, President

Barack Obama Barack Hussein Obama II (born August 4, 1961) is an American politician who was the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, he was the first African American president in American history. O ...

said that coverage denied to those with pre-existing conditions is a serious problem that would only grow worse without major reforms. In a September 2010 visit with Falls Church, Virginia, residents, Obama referred to a woman with an eye condition and a woman with non-Hodgkin's lymphoma as personal examples in the audience of those benefiting from changing pre-existing condition rules.

Public opinion

A ''

Time Time is the continuous progression of existence that occurs in an apparently irreversible process, irreversible succession from the past, through the present, and into the future. It is a component quantity of various measurements used to sequ ...

''-Abt SRBI poll in late July 2009 found that a large majority of Americans (80%) favored a requirement that insurance companies insure people even if they have pre-existing conditions. In September 2009, the monthly Kaiser Health Tracking Poll report said:

Definitions

Current U.S. federal regulation

Former regulation

Practice and effect

Commentary by lawmakers

Public opinion

See also

References

Further reading