Prior to the ACA, Where You Lived Determined How Accessible and Affordable Coverage Would Be

Before the Affordable Care Act (ACA), what state you lived in determined how easily you could purchase a health plan, the price, and what the plan would cover in the individual market. Rules varied by state, but one common fact was that insurers could use your health status to deny coverage, to exclude coverage or to charge you more in premiums. In particular, if you had a pre-existing condition, it was much harder to get covered. Based on the extensive list that insurers used to define a pre-existing condition, less than perfect health put you at risk of being uninsurable. The ACA was enacted to address these problems to accessing coverage. The ACA requires all insurers to offer you a health plan, regardless of your health status or any other factors, and prohibits insurers from excluding coverage for any pre-existing conditions or charging a higher premium based on health status.

As Congress debates repeal of the Affordable Care Act (ACA) and the protections it established for people, particularly with pre-existing conditions, many policymakers have called for greater state flexibility in insurance regulation than currently exists under the ACA. An understanding of how states approached protections for people with pre-existing conditions in the past can help inform what we may go back to without a national standard.

In a new primer, we provide a 50-state review of access and affordability requirements, before the ACA set a federal floor. Funded by the Robert Wood Johnson Foundation, the brief summarizes the laws of 50 states and the District of Columbia regarding guaranteed issue, pre-existing condition exclusions, and health status rating in the individual market on the eve of the ACA.

You can read the primer and review the 50-state chart here.

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