Uncertainty, anxiety plague Iowans as the Marketplace enrollment deadline looms

ReShonda Young is not frivolous with her money.

“I’m not a big spender,” she said. “My monthly expenses are super low already. I don’t have the extra bells and whistles to life, I just don’t need all that.”

So now that Young has to budget for monthly health insurance premiums three times what she paid in 2025, it’s hard to know where the money will come from. She said she’s considering selling some of the rental properties she owns, but those were part of her retirement plan.

“The only thing that I look at is my food budget. That’s the only thing I can cut,” she said.

Young is one of the more than 136,000 Iowans who purchased their health insurance through the Affordable Care Act (ACA) marketplace this year. Premiums for many ACA plans are skyrocketing as enhanced premium tax credits expire and legislative efforts to extend them fail. These Iowans are weighing big decisions ahead of the Dec. 15 enrollment, decisions that will affect their physical and financial well-being throughout 2026.

High premiums coincide with other financial strains

Young has been purchasing her health insurance from the marketplace since 2016. She owns a small business, TNK Health Food Store in Waterloo. In addition to rising health care costs, Young is planning for price increases for the products she sells.

“We’ve been really just trying to buy up as much as we can before the end of the year so that we’ve got at least a few months after 2026 before we have to start paying those higher costs,” she said. “Obviously, if we’ve got to pay higher, we pass that on to our customers as well.”

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Young said many of her clients are older and don’t have much financial flexibility. They rely on her store for supplements, including some that doctors recommend they take. But when prices eventually rise, there could be consequences for her income.

“We know that people will also have to maybe make some tough decisions on which supplements that they’re able to continue to use, which potentially affects our bottom line,” she said.

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Matt Russell, interim executive director of the Iowa Farmer’s Union, says farmers in the state are facing similar struggles.

“With this health care thing, it's creating this huge expense at a time when their cash flows are really challenging right now in Iowa,” he said. “Prices are low for what we're selling and what we grew, and prices are high for what we have to buy to put a crop in”

Russell helps his husband run a small family farm near Lacona. They purchased their health insurance from the marketplace last year. Between the enhanced premium tax credits expiring and rising insurance costs, Russell estimated the $6,605 premium he paid in 2025 will grow to $9,133 in the coming year.

“That’s $3,000 that we’re not going to spend on our farm, we’re not going to spend on … taking our kids out for dinner, buying a couple things for the grandkids,” Russell said. “Instead, that $3,000 is just going to help to make sure that we have health insurance.”

Staying eligible for premium tax credits adds another layer of difficulty

Russell also carefully monitors his household’s income so that it doesn’t rise above 400 percent of the federal poverty level. Premium tax credits were introduced in 2014 to help families in certain tax brackets save extra on health insurance. The temporary enhanced premium tax credits available through the American Rescue Plan Act and Inflation Reduction Act added additional savings on top of the existing premium tax credits.

With the premium tax credit, Russell and his husband don’t pay the full cost of their premiums as long as they make less than 400 percent of the federal poverty level. But if they exceed that threshold, sometimes called the subsidy cliff, they’d lose the credit. If Russell and his husband make an additional $1,000 on their current plan, they’d pay the full $23,437 their plan premium costs, more than a quarter of their annual income.

This strategy of keeping yearly profits down isn’t compatible with the agriculture industry.

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“The way farming works is it's cyclical,” Russell said. “So even the best farmers don't make money every year or make a lot of money every year. They are managing the cycles.”

When farmers have a bad year, Russell said, they rely on credit to stay afloat. Then, when they have a good year, they use the extra cash to make investments in their farm and pay off some of the debt they accrued. If all additional income needs to be spent to avoid tax liability, it disrupts that cyclical planning without adding a comparable benefit.

“Those costs are just cost. They're not an investment other than in your health,” he said. “It is an investment in yourself, and it's risk management and all of that, but those additional costs don't deliver additional benefits.”

Tough choices: Going without or avoiding expensive care

Young said she never considered going without health coverage. She was diagnosed with breast cancer last year and said she doesn’t want to take any risks.

“Probably without having the diagnosis I’d say I may chance it.,” Young said. “Not now.”

Seth Watkins, however, might.

Watkins runs Pinhook Farm near Clarinda. His wife is a former teacher who retired to take care of their son, who has special needs and is aging out of school supports. Their daughter is in college at Grinnell. Watkins said he wants to be sure his wife and daughter are covered, but he’s considering going without. So, he said, he’s been researching care he can get in Mexico.

“I think that’s horrible and I don’t want that to be my option, but I want to take care of my wife and my daughter first, and that might be an option we have to consider,” Watkins said. “I never thought I’d have to do things like that in this country with a representative government.”

Decorah small business owner Cheryl Wieseler, speaking at a press conference held last week by Protect Our Care Iowa, a nonprofit advocating for lower health care costs and expanded health care access, described her thought process after a recent injury.

“As I was laying on the floor after I fell, my first thought was, I just broke my arm. My second thought was, I don’t know how I’m going to pay for this,” Wieseler said. “That should not have been my second thought.”

At the same press conference, Iowa House representative for District 30 and physician Megan Srinivas said this increased risk-taking is a consequence of higher health insurance costs.

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“When we don’t extend these ACA tax credits, what we see is people not only delaying their care, but when they come into the hospital, they’re in far more dangerous states of health,” Srinivas said. "I've seen far too many patients who've come in with that delayed cancer diagnosis and because of that, all we could do was palliative care.“

Srinivas shared a story about a diabetic patient she saw who rationed his insulin to save money. He eventually landed in the emergency room, spent six days in the ICU and has permanent bodily damage as a result.

"When the ACA tax credits became available, he was able to get that insurance,“ Srinivas said. ”He understood the importance it was for his own life, but he's revisiting that now.“

Meeting the deadline matters

Data from the Centers for Medicare and Medicaid Services indicate so far, 31,888 Iowans have renewed their plans or opted for new ones, less than one-fourth of the state’s currently enrolled population. That number will likely increase after the Dec. 15 deadline, when plans automatically renew for those who don’t opt out.

Although enrollment for ACA marketplace insurance runs until Jan. 15, the December deadline is the cutoff for coverage that will start on the first day of 2026.

Meeting the December deadline is important, Srinivas said.

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“January is actually one of the most expensive medical coverage months of the entire year because that’s when we see high rates of flu, COVID, RSV especially for babies, we see more emergency room visits because of weather related issues,” she said. “If they’re missing the month of January, we’re putting people at a large risk of creating medical debt that they might not ever be able to come out of.”

Young said she recently reacquainted herself with a column she wrote in 2017, called “Keep and repair the Affordable Care Act.” It was published by The Gazette.

“Same president, same message, just different year,” Young said.“ I thought, wow. Almost nine years later, same thing, but a worse outcome.”

Help is available

Whether you’re still trying to find an affordable plan before Dec. 15 or Jan. 15, help is available in a format that works best for you.

• The Iowa Navigator program is a federally-funded program that provides digital assistance for people searching for plans on the Marketplace. Reach out to a representative or follow the step-by-step instructions on the website at iowanavigator.com/how-to-enroll.
• Iowa Health and Human Services can help Iowans find a plan. Work with someone in person at a local public health department or other location listed at hhs.iowa.gov/hhs-office-locations.
• Find in-person help at one of Iowa’s 14 federally qualified health centers. Find a location at findahealthcenter.hrsa.gov/?hmpgtile=hmpg-hlth-srvcs.
• Some insurance brokers can help navigate the health care marketplace, but they may have a financial motive to sell certain plans.

The tools below can calculate the cost of plans on the marketplace:

• Use the premium explorer on the state’s open data page to compare premiums based on age, location and plan type. Visit data.iowa.gov/stories/s/7rtq-dygq
• KFF’s ACA Enhanced Premium Tax Credit calculator provides a look at the price of a plan with and without the expiring enhanced subsidies. Find it at kff.org/interactive/calculator-aca-enhanced-premium-tax-credit/.

Comments: fern.alling@thegazette.com