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The Road Not Traveled

How Policy, Business Decisions in Iowa Led to Higher Premiums
Map of Iowa where premiums are higher due to policy decisions
  • Sabrina Corlette
    Sabrina Corlette

    Research Professor and Project Director, Center on Health Insurance Reforms, Health Policy Institute, McCourt School of Public Policy, Georgetown University

  • Kevin Lucia

    Research Professor, Center on Health Insurance Reforms, Health Policy Institute, McCourt School of Public Policy, Georgetown University

  • Sabrina Corlette
    Sabrina Corlette

    Research Professor and Project Director, Center on Health Insurance Reforms, Health Policy Institute, McCourt School of Public Policy, Georgetown University

  • Kevin Lucia

    Research Professor, Center on Health Insurance Reforms, Health Policy Institute, McCourt School of Public Policy, Georgetown University

  • Iowa’s segmentation of the individual health insurance market between healthy and less-healthy consumers offers important lessons for other states

  • Iowa’s new law exempting certain health plans from state and federal regulation will make a bad situation worse for the state’s individual insurance market

This year, Iowa’s legislature took the extraordinary step of abdicating the state’s authority to regulate health insurance products. The bill, enacted in April, exempts health plans offered by the state’s Farm Bureau from state and federal insurance regulation, including Affordable Care Act (ACA) provisions designed to protect people with preexisting conditions and provide a minimum standard of benefits.

Proponents argue that such a law is needed to provide individual market consumers with cheaper health plan options than available under the ACA. Critics point out that younger, healthier consumers are most likely to benefit from these plans. And while details haven’t been provided yet, the Farm Bureau plans are expected to be medically underwritten, and not cover the ACA’s minimum set of benefits. As a result, older Iowans, those with preexisting conditions, and those who need comprehensive coverage are unlikely to find these plans affordable or attractive. And many could be denied enrollment outright. As enrollment in the ACA-compliant individual market becomes older and sicker, marketplace consumers who do not qualify for the ACA’s income-related premium subsidies will face increasingly higher premiums.

Iowa’s Farm Bureau statute is making a bad situation worse for the state’s individual market. Thanks to a number of decisions by state policymakers and the dominant insurance company – Wellmark Blue Cross Blue Shield – premiums in the state’s individual market are already among the highest in the country, with an average annual marketplace plan premium in excess of $10,000 in 2018.

A Study of Market Failure: Iowa’s Individual Health Insurance Market

The current dismal state of the ACA individual market in Iowa was not a foregone conclusion. In 2014, when the marketplaces launched, Iowa had four insurers competing in the ACA’s marketplace. In 2018, only one insurer is selling ACA-compliant health plans; it agreed to do so only after implementing an average 50 percent increase to unsubsidized premiums.

Iowa’s marketplace enrollment has also lagged that of other states. As of 2016, only 20 percent of eligible Iowans had enrolled (by comparison, that number was 40 percent in Illinois, 43 percent in Missouri, and 57 percent in Maine). Iowa is an outlier for a critical reason. Wellmark BlueCross BlueShield declined to participate in the marketplace for the first three years, entered only briefly in 2017 and then declined to participate in 2018, but is returning to the market in 2019. The insurer also maintained a large block of pre-ACA grandfathered and transitional, or “grandmothered,” health plans (see table).

Because the enrollees in these plans must pass a health screen before being allowed to enroll, they are relatively healthy. Because Wellmark was able to hang on to these healthy enrollees, the pool of people available for the ACA-compliant market was much smaller and sicker than it otherwise would have been.

Affordable Care Act Grandfathered and Grandmothered Health Plans

Grandfathered health plans

Policies in effect before the March 2010  enactment of the ACA;  not subject to ACA standards and protections. Although these policies can be renewed indefinitely as long as they do not undergo substantial changes, they can’t be newly issued.  

Grandmothered (transitional) health plans

Policies issued after the ACA’s 2010 enactment but before 2014. Policies are not required to meet critical ACA protections.

Grandfathered and Grandmothered Policies: Policy and Business Choices with Long-Term Consequences

Due to the transitional nature of the individual market and the high administrative costs of maintaining grandfathered health plans, many insurers — other than Wellmark — discontinued these products over time. And unlike several states that prohibited these policies in order to ensure a healthier, more stable individual market, Iowa’s leadership embraced the Obama administration’s decision to allow the renewal of grandmothered health plans. Iowa stands out even among states that did not ban such plans:  an estimated 38,000 people remained in grandmothered policies as late as 2018. Indeed, approximately 60 percent of Iowans buying insurance on their own stayed with pre-ACA grandfathered or grandmothered health plans.

Left with a smaller and sicker pool of enrollees than they had projected, it is therefore not surprising that the insurers remaining in the market needed significant premium increases. The premium hike implemented in 2018 likely drove as many as 26,000 Iowans to drop their coverage this year.

Enrollment and Premiums Had Iowa Taken a Different Path

What if Iowa had taken a different path? If Wellmark had, like many other insurers, discontinued its grandfathered policies, and if the state had prohibited grandmothered plans, the individual market would be a lot healthier than it is today. In fact, doing so would have added up to 85,000 people to Iowa’s ACA-compliant market, according to a new estimate by Wakely Consulting Group. Those added enrollees, because they are relatively healthy, would have reduced average premiums for ACA-compliant plans by up to 18 percent (see table).1

Enrollment and Premiums in ACA-Compliant Market Due to Improved Risk Pool


Without Grandfathered Plans

Without Grandmothered Plans

Without Grandfathered or Grandmothered Plans

Total change in ACA-compliant enrollment

+25,000 to 40,000

+30,000 to 45,000

+55,000 to 85,000

Change in premiums

-5% to -12%

-5% to -12%

-8% to -18%

Analysis by Wakely Consulting Group. Numbers have been rounded.

Looking Ahead

Iowa’s experience offers important lessons. The more the individual market is segmented between healthy and the less-healthy consumers, the more likely unsubsidized enrollees are to face unaffordable premiums. Federal proposals such as those to expand the availability of short-term and association health plans, to the extent they are not limited by state policies, could result in more state individual markets resembling Iowa’s. The primary losers in such a scenario are the working middle-class consumers: entrepreneurs who run their own businesses, freelancers and consultants, farmers and ranchers, and early retirees who earn too much to qualify for the ACA’s premium subsidies.

State leaders can protect these families by adopting policies that will expand the risk pool and maintain a balance between healthy and less-healthy enrollees. A number of states have already done so, through state-level reinsurance programs, expanded annual enrollment opportunities, and limits on short-term and association health plans. It’s not too late for other states to follow their lead.


1 The report estimates total enrollment and potential effect of different scenarios. Both enrollment and premium effects are presented as a range because the number and types of people that would enroll under theoretical conditions is difficult and inherently uncertain. Please read the full report for a complete description of Wakely’s methodology, assumptions and the associated limitations. 

Publication Details



Sabrina Corlette and Kevin Lucia, "The Road Not Traveled: How Policy, Business Decisions in Iowa Led to Higher Premiums," To the Point (blog), Commonwealth Fund, June 27, 2018.