IStock Photo 10855846 © Nicole S. Young

The debate over excluding people from health insurance plans due to “pre-existing conditions” is one of the underlying issues in the national health care conversation. One of the more troubling examples of the policy’s application: excluding women who have been abused.

Since the Violence Against Women Act was first signed into law in 1994, it has awarded more than $3 billion to organizations and programs that work to end abuse against women. By 2003, domestic violence prevention programming was supported by 80% of the population, according to a study in the American Journal of Public Health. That makes it surprising that in certain parts of the country, health insurance companies are not legally prohibited from denying coverage to survivors of domestic violence. In other words, when it comes to accepting someone into a health plan, intimate partner violence, or IPV, is a pre-existing condition.

IPV includes threats as well as physical, sexual, and emotional abuse. Between 1993 and 2008, the rate of IPV against women declined 53%. Nevertheless, today the odds a female 12 or older will be the victim of a violent crime committed by someone she considers a friend or acquaintance in a year are 1 in 175. The odds she will be victimized by an intimate partner in a year are 1 in 234.2. Of those victims, 1 in 15.46 will be raped.

The cost of IPV is estimated at more than $8.3 billion, which includes medical care, mental health services, and lost productivity (i.e., victims who are unable to go to work). That cost is driven by two key factors.

First, victims often need health care several times for a single incident. Victims of both rape and physical assault average 1.9 emergency department visits per victimization. Of the one third of victims of intimate partner rape who visit a mental health care professional, the average number of visits is 12.4.

Second, victims are likely to be assaulted more than once. Data published in 2006 suggests that female rape victims average 2.9 rapes, and female victims of physical assault average 3.1 assaults. That suggests that the average female IPV victim is actually victimized three times.

Denying these women coverage can create a situation in which women have incentive to stay in an abusive relationship. In 2007, nearly two-thirds of nonelderly women aged 18-64 received health benefits through their own or their spouse’s employer. If it’s the latter, and that partner is violent, then she has a trade-off: leave the abuse or lose her insurance. In a case where a woman has other medical conditions, that can be strong incentive to stay.

Between 1994, when the legality of using domestic violence as insurance underwriting criteria was first recognized, and 2008, 42 states passed legislation that specifically prohibits the practice. And a 2008 report by the National Women’s Law Center pointing out that 9 states and the District of Columbia still didn’t have such legislation spurred several state insurance commissioners to respond with surprise and, even more importantly, with action. Arkansas passed a law in April 2009, and, as of October 2009, 4 more states have taken up the issue in their state legislatures: North Carolina, Oklahoma, North Dakota, and Mississippi. Still, that leaves some stragglers: in Idaho, South Carolina, South Dakota, Wyoming, and the District of Columbia, it’s not illegal to call domestic violence a pre-existing condition.