How many people would be screwed over by repealing the ACA? 23 Million? 30 Million? Try 52 Million.

UPDATE 12/31: A few folks in the comments have noted that a) pre-existing condition denials aren't an issue for most group policies even without the ACA and b) some of the professions listed below don't appear to belong on the list since those groups should be guaranteed coverage anyway (ie, the VA/TriCare for those in the military; members of police/firefighter unions and so on). Both KFF and I have already addressed the first point (yes, they're covered now but if they lose their job for any reason they'd likely be screwed; thus, the "...if they were to lose their current coverage" caveat). As for the second one, I've asked Larry Levitt & Cynthia Cox of the KFF to clarify.

Update 12/31: I've received clarification from Larry Levitt re. the 2nd criticism: "I suspect insurers were mostly being overly cautious just in case. Active duty military would be covered otherwise. Police and fire generally would, but possibly not in small towns or volunteer firefighters."

OK, I'm a bit late to the party on this one.

I've crunched the numbers up and down to come up with an estimate of how many people would likely lose their healthcare coverage entirely if the Republican Party does indeed repeal the Affordable Care Act, as they've been vowing to do for years now. My best estimate comes in at around 23 million people for a full repeal with immediate effect and no reasonable alternative in place to pick up the pieces. Meanwhile, the Urban Institute ran their own projections and concluded that nearly 30 million people would lose coverage from a partial repeal (which would actually have an even bigger negative impact than a full repeal since it would pretty much wipe out the off-exchange individual market as well via a "death spiral" domino effect).

However, there's another way of looking at this: Let's suppose that a full repeal does go through...including the much-debated requirement that insurance carriers have to accept people with pre-existing conditions into the same policies as everyone else, and that they can't be charged more for the same policies due to their medical condition. Just how many people are we talking about here?

Well, according to a Kaiser Family Foundation study published a few weeks back, the answer is "a lot":

Before private insurance market rules in the Affordable Care Act (ACA) took effect in 2014, health insurance sold in the individual market in most states was medically underwritten.1 That means insurers evaluated the health status, health history, and other risk factors of applicants to determine whether and under what terms to issue coverage. To what extent people with pre-existing health conditions are protected is likely to be a central issue in the debate over repealing and replacing the ACA.

...We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C). Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll, most people (53%) report that they or someone in their household has a pre-existing condition.

They go on to present a table which breaks out the numbers (by both percentage and raw population) of people in each state who would be effectively uninsurable if they were to lose their current coverage: 27% of the under-65 population, or a whopping 52.2 million Americans.

They also include a handy, but by no means comprehensive list of the types of conditions which would likely get you kicked to the curb by most insurance carriers if the ACA is repealed and the accompanying pre-existing condition clause is scratched out:

  • Lupus
  • Alcohol abuse/ Drug abuse with recent treatment
  • Mental disorders (severe, e.g. bipolar, eating disorder)
  • Alzheimer’s/dementia
  • Multiple sclerosis
  • Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease
  • Muscular dystrophy
  • Cancer within some period of time (e.g. 10 years, often other than basal skin cancer)
  • Obesity, severe
  • Cerebral palsy
  • Organ transplant
  • Congestive heart failure
  • Paraplegia
  • Coronary artery/heart disease, bypass surgery
  • Paralysis
  • Crohn’s disease/ ulcerative colitis
  • Parkinson’s disease
  • Chronic obstructive pulmonary disease (COPD)/emphysema
  • Pending surgery or hospitalization
  • Diabetes mellitus
  • Pneumocystic pneumonia
  • Epilepsy
  • Pregnancy or expectant parent
  • Hemophilia
  • Sleep apnea
  • Hepatitis (Hep C)
  • Stroke
  • Kidney disease, renal failure
  • Transsexualism

They also list some common prescription medications which you'd have to pay full price for:

  • Adalimumab/Humira
  • Cyclosporine/Sandimmune
  • Methotrexate/Trexall
  • Ustekinumab/Stelara
  • Anastrozole/Arimidex
  • Nolvadex/Tamoxifen
  • Femara
  • Avandia/Rosiglitazone
  • Glucagon
  • Humalog/Insulin products
  • Metformin HCL
  • Abilify/Ariprazole
  • Aricept/Donepezil
  • Clozapine/Clozaril
  • Haldol/Haldoperidol
  • Lithium
  • Requip/Ropinerole
  • Risperdal/Risperidone
  • Zyprexa
  • Abacavir/Ziagen
  • Efavirenz/Atripla
  • Interferon
  • Lamivudine/Epivir
  • Ribavirin
  • Zidovudine/Retrovir
  • Anginine (angina)
  • Clomid (fertility)
  • Epoetin/Epogen (anemia)
  • Genotropin (growth hormone)
  • Remicade (arthritis, ulcerative colitis)
  • Xyrem (narcolepsy)


Even if you don't have any of the above conditions or require any of the above medications (and remember, neither list is comprehensive by any means), simply having the wrong job could mean "NO COVERAGE FOR YOU!!" (shouted in my best 'Soup Nazi' voice, which certainly seems appropriate here):

  • Active military personnel
  • Iron workers
  • Professional athletes
  • Air traffic controller
  • Law enforcement/detectives
  • Sawmill operators
  • Aviation and air transportation
  • Loggers
  • Scuba divers
  • Blasters or explosive handlers
  • Meat packers/processors
  • Security guards
  • Bodyguards
  • Mining
  • Steel metal workers
  • Crop dusters
  • Nuclear industry workers
  • Steeplejacks
  • Firefighters/EMTs
  • Offshore drillers/workers
  • Strong man competitors
  • Hang gliding
  • Oil and gas exploration and drilling
  • Taxi cab drivers
  • Hazardous material handlers
  • Pilots
  • Window washers

Even if you manage to dodge these bullets (admittedly, I don't imagine that "strong man competitors" are a very large segment of the workforce), there's still more surprises in store for you if you manage to get the carrier to accept you at all:

...underwriters also examined individual applications and medical records for other conditions that could generate significant “losses” (claims expenses.) Among such conditions were: acne, allergies, anxiety, asthma, basal cell skin cancer, depression, ear infections, fractures, high cholesterol, hypertension, incontinence, joint injuries, kidney stones, menstrual irregularities, migraine headaches, overweight, restless leg syndrome, tonsillitis, urinary tract infections, varicose veins, and vertigo.

In short, a full 27% of the non-elderly population would be at the mercy of insurance carriers to decide whether or not they happen to feel like granting them coverage...or how much they feel like charging them based on whatever criteria the carrier happens to feel like imposing.

One might even call the committees which decide such things "death panels".