21,000 Iowans have dropped health insurance since expiration of ACA subsidies

A popular tax credit that helped 22 million Americans afford premiums for health insurance plans purchased on Affordable Care Act marketplaces expired at the end of 2025. Since Congress failed to renew the expanded credit, tens of thousands of Iowans have dropped their insurance plans.

Karl Vilums, a retired hospital finance executive in Urbandale, said the premium for his bronze-level insurance plan a year ago was about $150 a month. 

“When they decided not to extend the credit tax credit, it went to about $1,500 a month,” Vilums told the Iowa Independent. “And I was notified by Wellmark, it’s going to go up another I think 5%, 5.5%, something like that, for a bronze.” The plan includes a $7,500 annual deductible before the company starts paying for most of his health care services.

He’s not the only one facing the difficult decision to either pay skyrocketing premiums or go without health insurance: According to a July 2026 AP analysis of Centers for Medicare and Medicaid Services data, 124,311 Iowans were enrolled in an Affordable Care Act marketplace plan as of February 2025. By February 2026, that number had dropped by 21,058, to 103,253.

In 2021, Congress passed and President Joe Biden signed a law that temporarily expanded eligibility for subsidies for ACA marketplace insurance policies and increased the size of the benefit for those who were already eligible. A year later, the enhanced tax credits were renewed through 2025. With the expanded credits, enrollment in marketplace insurance plans more than doubled nationwide between 2021 and 2025. 

The GOP-led Congress in 2025 allowed the subsidies to expire; President Donald Trump had said he was against renewal. In Iowa, out-of-pocket costs for ACA marketplace policy premiums increased by 67%, from an average of $141 a month in 2025 to $235 in 2026.

“It creates a crunch on our budget, but we can make it happen,” Vilums said. “But I know people that simply cannot afford that. I mean, most people probably can’t afford $1,500 a month, and then a plan that has a $7,500 deductible for an individual — I mean, it’s pretty wild. So most people, probably in my position, probably would drop their insurance.”

A bill on extending the tax credits through 2028 passed in the House in January by a 230-196 vote, but it has not received a vote in the Senate. A similar three-year extension bill fell short of the required three-fifths supermajority in that chamber in December 2025, receiving 51 votes for and 48 against.

Iowa Republican Sens. Joni Ernst and Chuck Grassley voted against the three-year extension, as did Republican Reps. Randy Feenstra, Ashley Hinson, and Miller-Meeks. Republican Rep. Zach Nunn voted against bringing the bill to the floor for a vote, but then voted in favor of final passage, saying, “I want the ACA gone as much as any of you, but I’m not going to leave 126,000 Iowans to wait for Congress to get its job done.” 

“I will not support the status quo of health care in America today, it’s a disaster,” Hinson said in a Jan. 8 press release. “I hope my colleagues will join me in reaching a bipartisan consensus to give working families certainty while we address the root causes of out-of-control health care costs. I’m committed to taking on shady middlemen to lower prescription drug costs, and to directing health care dollars to families through HSAs rather than sending them to big insurance companies.”

Vilums recently shared his story at an Iowa Democratic Party press conference highlighting Hinson’s vote.

At the same event, Amber Gustafson, an Ankeny small-business owner who has gotten coverage through the ACA marketplace since its creation, shared her own insurance story. 

“As our family is getting ready to send our kids back to school, we are watching the price of everything go up: clothes, food, tuition, gas,” Gustafson told reporters. “And now for the second year in a row, our health insurance costs are increasing. Last year, our costs went up 17%. This year they are going up an additional 5.5%. And that’s a nearly 25% increase in just two years. Our family will budget in other areas to be able to make this work because it is our only option for now. But it is not sustainable.”

A Hinson spokesperson did not immediately respond to a request for comment for this story.

Vilums predicts that things will get worse for many Iowans. “What’ll happen is folks that are on the ACA won’t be able to afford it. They’ll drop their coverage. Folks that are on Medicaid that lose their coverage based on the new criteria or whatever in the Big Beautiful Bill, they’ll lose their coverage because they won’t qualify for Medicaid anymore. They’ll try to go to the marketplace. Then the marketplace will be unaffordable. So they just will go without insurance.” 

When that happens, he says, people will delay care and end up in the emergency room: “It’ll force hospitals to increase their prices, renegotiate contracts with payers. Payers will then increase premiums to everybody. I don’t care if it’s Medicaid, Medicare, I mean, commercial insurance will have to go up because if you want to keep the health system intact, without it completely falling apart from an economic standpoint, you’ll have to increase rates. There’s no way around it.”