Gov. Reynolds signs temporary tax hike to address Iowa Medicaid shortfall

DES MOINES — Iowa Gov. Kim Reynolds on Thursday signed into law a measure temporarily increasing taxes on certain private health insurers to help close a growing Medicaid budget shortfall, setting up a debate over whether the move will stabilize care or drive up costs for Iowans.

The legislation, House File 2739, raises the tax on health maintenance organizations (HMOs) from about 0.9% to 3.5% for part of the year before dropping back below 1% later in 2026.

Supporters say the change is designed to draw down additional federal funding and shore up the state's Medicaid system. Critics argue it will ultimately be passed on to consumers through higher premiums and out-of-pocket costs.

Reynolds defended the policy as a temporary and necessary response to mounting fiscal pressure on Medicaid.

"This is a temporary increase, first of all. It reverts back to 0.95% in September," Reynolds told reporters Wednesday. "We have one of the lowest premium tax rates in the country. … But the fact of the matter is, it helps cover the Medicaid shortfall from COVID. We've been watching it all along. We knew that this was going to hit at some point. The bill has come due."

She pointed to national trends, arguing Iowa is not alone in facing rising Medicaid costs tied to the end of pandemic-era federal support and increased health care needs.

"You can look at every single red and blue state … everybody is experiencing the same thing," Reynolds said. "It's the outlay from COVID. But we're seeing a higher acuity. We're seeing higher needs post-COVID."

A temporary fix — or a cost shift?

The bill has put Reynolds and Republican lawmakers at odds with health insurers and drawn strong criticism from Democrats.

Republicans frame the measure as a targeted, short-term fix to a real and growing problem. State projections show a $90.6 million shortfall in the current fiscal year, growing to $167.6 million by fiscal 2027, driven largely by the expiration of enhanced federal funding and a higher post-pandemic demand for care.

Over the next five to seven years, the gap could reach roughly $600 million, according to Rep. Gary Mohr, R-Bettendorf, who chairs the House budget committee.

By increasing the HMO tax, Iowa can draw down an estimated $124 million in additional federal funds, boosting total Medicaid resources by roughly $170 million and helping avoid cuts to services for vulnerable residents.

Sen. Mark Costello, R-Imogene, said the approach uses a financing mechanism common in other states while preserving Iowa's relatively low tax structure.

But the policy puts Reynolds — who has built her reputation on aggressive tax cuts — in the position of backing what is functionally a tax increase. She has sought to reconcile that by emphasizing the measure's temporary nature and arguing insurers can absorb the cost.

"They do not have to pass that one-time cost along to individual policy owners," Reynolds said. "We didn't see them reduce their premiums when we cut the tax, and they're sitting on significant profits."

In 2023, Iowa lawmakers approved a phased reduction of the state's insurance premium tax. Despite the cuts to insurers, premiums increased, Reynolds said.

She pointed specifically to Wellmark Blue Cross and Blue Shield, saying the company reported about $357 million in profit over a recent two-year period. Wellmark has opposed the legislation, warning lawmakers the increased tax burden would likely lead to higher costs for policyholders.

The bill also transfers nearly $350 million from the state's Taxpayer Relief Fund to account for state revenue declines caused by tax policy changes made through the federal One Big Beautiful Bill Act. Another $89 million would transfer from the state's general fund to the Iowa Department of Health and Human Services for the state's Medicaid program.

Democrats, insurers warn of higher costs

Democrats and industry representatives strongly dispute the governor's assertion that the costs won't reach consumers.

"This bill is a tax increase on Iowans, full stop," said Sen. Molly Donahue, D-Marion, who described the policy as a "hidden tax increase" that will raise premiums, deductibles and other out-of-pocket expenses.

Insurance officials have echoed that concern, estimating the change could increase costs by roughly $115 per person this year, or nearly $500 for a family of four, based on the added tax burden.

Democrats argue the measure shifts the cost of state budget decisions onto families and small businesses already facing high health care expenses.

"This is a marked increase in cost for Iowans with no change in services or coverage," said Sen. Catelin Drey, D-Sioux City.

Broader budget pressures

The debate reflects deeper tensions in Iowa's fiscal policy.

Reynolds and Republican lawmakers have enacted sweeping tax cuts in recent years — totaling billions of dollars — while maintaining strong reserve funds. But those same policies have contributed to tighter ongoing revenues, increasing reliance on one-time solutions and transfers out of reserve funds to balance the budget.

The state is projected to spend more than $1 billion above annual revenues for the second consecutive year, with lawmakers planning to use funds from the state's $4 billion Taxpayer Relief Fund to close the gap.

Against that backdrop, the Medicaid funding gap has become one of the most immediate pressures.

Republicans argue the insurer tax increase is the least disruptive option available, allowing the state to stabilize the program without cutting benefits.

Critics counter that it highlights a structural imbalance that will require more difficult decisions ahead.

What comes next

The HMO tax increase takes effect, pending federal approval, and applies retroactively to Jan. 1, with the higher tax rate in place for most of 2026 before dropping back in October.