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How many people with pre-existing conditions would be affected by the big beautiful bill's changes to ACA?
Executive Summary
The available analyses disagree sharply: estimates range from about 5.3 million to over 130 million nonelderly Americans with pre‑existing conditions who could be affected by repeal or waiver provisions in various ACA‑replacement bills, and more recent 2025 analyses focus on roughly 15–17 million people projected to lose coverage under the “Big Beautiful Bill.” These differences reflect divergent methods, different bills or waiver pathways analyzed, and whether analysts count people who would face higher costs, lose coverage entirely, or live in states that might weaken protections [1] [2] [3] [4] [5].
1. Numbers All Over the Map — Why Estimates Diverge Sharply
Analysts use different definitions of “affected”: some count people who would face higher premiums or underwriting, others count those who would become uninsured, and still others count all nonelderly people with any diagnosed condition. That yields large numeric spread: a 2017 review of the AHCA waiver pathway estimated 6.3 million adults could face medical underwriting if coverage gaps occurred [1], while a 2024 policy analysis projected 5.3 million in the individual market living in states that waive essential benefits [2]. In contrast, advocacy and modeling pieces label over 130 million nonelderly Americans as having at least one pre‑existing condition who could see higher costs under wholesale repeal scenarios [6] [3]. Those latter tallies adopt the broadest definition — counting anyone with any prior diagnosis — and thereby produce the largest headline numbers [6] [3].
2. Recent 2025 Analyses Focus on Coverage Losses, Not Only Cost Increases
The most recent pieces from 2025 center on the “Big Beautiful Bill” and model net coverage losses over the coming decade. Independent and policy‑oriented estimates converge around 15–17 million people losing coverage by 2034 under current legislative proposals, with roughly 7–11 million of those losses tied to Medicaid cuts and marketplace changes [4] [7] [5]. Those reports do not all disaggregate how many of the newly uninsured have pre‑existing conditions, but they highlight that people reliant on Medicaid or marketplace plans — populations with higher prevalence of chronic conditions — would be disproportionately affected, implying a substantial share of the 15–17 million would have pre‑existing conditions [4] [5].
3. Where the Congressional Waiver Pathway Changes the Calculus
Several analyses emphasize the waiver mechanism as a fulcrum point. The Meadows‑MacArthur and similar amendments allow states to waive key ACA protections, enabling medical underwriting or higher cost‑sharing for people with a coverage gap; therefore, modeling that assumes broad state uptake finds larger affected populations. A 2017 CBPP-style review flagged that waivers would permit surcharges and narrowed benefits, shifting costs to people with prior conditions even if they remain insured [8]. The Graham‑Cassidy-era reporting stressed potential very large premium surcharges for specific illnesses and warned that CBO projections implied many people could end up in states that waive protections — a structural risk not captured in single‑number tallies [9].
4. The Stakes: Costs, Coverage, and Who Bears the Burden
Analyses present two principal harms: higher out‑of‑pocket costs for those who stay insured and loss of coverage for others. Studies modeling premium surcharges estimate thousands to tens of thousands in added annual costs for serious illnesses if community rating is weakened [3]. Conversely, the 2025 coverage‑loss estimates show millions could lose Medicaid or marketplace access entirely, translating into interruptions in care for people with chronic conditions. Which harm dominates depends on modeling assumptions about state policy choices, whether people can afford surcharges, and whether employer coverage or alternative programs absorb displaced patients [5] [3].
5. Interpreting the Sources — Motives and Method Limits
The set of analyses includes academic, advocacy, and journalistic models from 2017 through 2025. Older estimates addressed then‑active proposals like AHCA and Graham‑Cassidy and often emphasized premium surcharge mechanics [1] [9]. More recent 2025 reports analyze a different legislative package, focus on net uninsured impacts, and draw on updated microsimulation runs [4] [7]. Advocacy‑oriented pieces tend to present broader, population‑wide counts to underscore potential scale [6] [3], while targeted policy briefs report narrower counts tied to specific markets or waiver scenarios [1] [2]. These methodological choices explain most headline differences.
6. Bottom Line for Policymakers and the Public
There is no single consensus number because the result hinges on which policy levers are enacted, how many states seek waivers, and whether people can absorb higher premiums. If waivers and underwriting expand, tens of millions — potentially into double digits — of people with pre‑existing conditions could face higher costs or lost coverage; if waiver uptake is limited, the impacted subset could be measured in single‑digit millions concentrated in the individual market [2] [3] [5]. Evaluations must therefore present both coverage‑loss and cost‑burden scenarios, and policymakers should be explicit about which pathway they are modeling when quoting a single number [8] [4].