Open enrollment for ACA health coverage starts Nov. 1. Here is what’s changing for Iowans

From a small-business owner in Decorah, to a laid off worker in Des Moines, thousands of Iowans are facing hard choices this fall: pay more for health insurance, drop coverage entirely or gamble on cheaper plans with fewer protections.

As open enrollment for 2026 health care coverage through the Affordable Care Act marketplace begins Saturday, advocates warn that the expiration of enhanced federal tax credits could double premiums for many middle-income families and threaten care access in rural communities.

Insurance Commissioner Doug Ommen urged Iowans to plan early and pay close attention to federal subsidy changes that could sharply affect affordability.

Enhanced premium tax credits, enacted under the American Rescue Plan Act in 2021 and extended through 2025 by the Inflation Reduction Act, have lowered costs for tens of thousands of Iowans. Without congressional action, premiums could spike for families in January, advocates said.

"Now is the time for Iowans to be thinking about health insurance coverage for next year … especially given the changes at the federal level in the amounts of federal subsidies provided and who can receive them," Ommen said in a news release.

"The enhanced subsidies in the American Rescue Plan Act and the Inflation Reduction Act that Congress used to mask these problems are expiring at the end of 2025, and the true cost of the ACA coverage will once again be exposed," he said.

Rising premiums and expiring subsidies

Insurers have filed 2026 rate increases of 12-25%, citing higher medical costs, greater utilization and the rollback of enhanced subsidies.

When expanded premium tax credits expire at year's end, assistance will revert to the ACA's original structure — raising premiums for those currently eligible and eliminating help for middle-income households at or above 400% of the federal poverty level.

The Iowa Insurance Division has provided examples of how costs will change for some enrollees:

A family of four with an income of 199% of the federal poverty level ($63,979), will see their monthly cost increase from $101 to $345.

A couple, both age 55, making 450% of the federal poverty level ($95,175), will see their monthly rate increase from $652 to $1,659.

A 60-year-old couple making $82,000 would see their monthly benchmark premium jump from about $581 to about $1,800, and 40-year-old making $31,000 would see their monthly cost rise from $58 to $153, according to an analysis by health policy organization KFF.

Consumers can preview 2026 premiums on the Iowa Individual ACA Premiums Explorer, with final rates live on HealthCare.gov beginning Nov. 1.

Expert's advice: Start early, seek guidance

Natasha Murphy, health policy director at the Center for American Progress, urges consumers to log on early, compare plans carefully and weigh total costs — including co-pays and deductibles — rather than focusing solely on premiums.

She advises consumers to actively choose a plan instead of allowing auto-reenrollment, confirm provider and drug coverage, and seek help from licensed brokers or navigators.

Murphy said using navigators, brokers or licensed insurance agents is more important than ever this year, given the uncertainty surrounding federal subsidies and changes to marketplace options. These professionals can help consumers understand the finer details of each plan — including deductibles, maximum out-of-pocket costs, covered services and provider networks — helping individuals and families identify the plan that best fits their specific health and financial situations.

Murphy said expert guidance can make the enrollment process clearer and less overwhelming — and help prevent costly mistakes, such as choosing a plan that fails to cover necessary treatments or essential services.

If Congress delays renewing subsidies until after enrollment begins, she warned, some consumers could drop coverage due to high prices and fail to reenroll even if premiums are later reduced.

Navigator funding cuts shrink in-person help

The nonprofit IA Navigator announced in September that federal funding reductions will sharply limit enrollment assistance. The group, which has helped more than 10,000 Iowans since 2015, will close offices in Des Moines, Cedar Rapids and Sioux City but continue statewide service via phone and online appointments at iowanavigator.com and by calling 515-978-9570, though callers may experience longer wait times or may have to leave a voicemail.

"Our main office will remain open, and we will continue assisting people across the state by phone through scheduled appointments," the organization said in a social media post. "… Even with fewer staff and fewer physical locations, IA Navigator is not going away."

Advocates warn of coverage losses, higher costs

Iowa physicians, patients and small-business owners warned in a press call last week that letting the enhanced credits lapse would drive up premiums, force families to drop coverage, threaten preventive care and strain rural hospitals.

The call was hosted by Protect Our Care, a group that advocates for affordable and equitable health care for all.

Physician anesthesiologist Dr. Jake Thomas said premiums could "skyrocket" for 24 million Americans if the credits lapse, with 5 million losing coverage entirely. He and Dr. Cecilia Norris, of the Iowa City Free Medical Clinic, warned of hospital closures and surges in emergency-room visits as patients forgo care.

Thomas also warned of ripple effects on rural hospitals in places like Newton and Manning that he said are at "imminent risk of shutting down" as fewer people can afford care.

Lori Hunt, a Des Moines resident and breast-cancer survivor who receives ACA subsidies, said the credits make her insurance affordable enough to keep up with mammograms and medication. Without them, she said, her premiums would exceed her mortgage.

Small-business owners Cheryl Wieseler of Decorah and Abbey Paxton of Des Moines said rising premiums threaten their livelihoods. Wieseler said her estimated 2026 premiums would "almost eat up all of my profits," while Paxton said the increase would wipe out any tax relief Republicans have touted.

Dr. Cecilia Norris, medical director of the Iowa City Free Medical Clinic, predicted a surge in emergency room visits if people forgo coverage. Before the ACA, Norris said she saw people nurse along diabetic foot ulcers until they needed amputations and skip mammograms.

"I suspect that the demand on services through the whole gamut of primary care to specialty care is going to skyrocket and be more expensive," she said.

Stopping the tax credits before there's any substitute would be "a total disaster," Norris said.

GOP lawmakers push back

Iowa's Republican U.S. House members have criticized Democrats for linking subsidy renewal to reopening the federal government.

U.S. Rep. Mariannette Miller-Meeks, the Republican representative for Iowa's 1st Congressional District, called Democrats' approach "an unreasonable demand."

"I don't like Democrats shutting down the government over something they could not get done when they had the House, Senate and White House," she said at her annual tailgate fundraiser last week.

She argued the subsidies reward insurers.

"The money goes to the insurance company, not the individual," she told conservative radio host Simon Conway. "There's no incentive to lower premiums, and this will continue to make the ACA even more unaffordable."

U.S. Rep. Ashley Hinson, R-Marion, said Democrats are "using the shutdown as leverage."

"The reason the subsidies exist in the first place is because it's the unaffordable Care Act," Hinson said on a press call. She added: "If my colleagues on the other side of the aisle actually cared about health care, they would … reopen the government so we can have the conversations about ways we can work together to (keep coverage affordable). It's impossible to have those conversations when the government's closed."

President Donald Trump and GOP leaders have said they'll consider extending the credits — but only after Democrats vote to reopen the government.

"Health care is not a partisan issue," said Amy Adams, Iowa state director of Protect Our Care. "It's a human issue. Iowans deserve representatives who stand with them, not against them."

Avoid scams and under-coverage

The Insurance Division is warning Iowans to be cautious of fraudulent or misleading "free-plan" offers.

"Scammers often attempt to take advantage of folks when there are changes in law or how consumers can purchase insurance coverage," Ommen said. "It's important … to talk with a licensed insurance agent to make sure the coverage fits the individual needs of that consumer and their family."

Beyond ACA-compliant plans, Iowans purchasing their own health coverage also have several non-traditional or limited coverage alternatives, though regulators caution that these options differ significantly from standard insurance.

Recent federal changes now allow short-term limited duration plans to be sold for up to three years, consistent with Iowa regulations. These policies can provide temporary coverage but often exclude many of the ACA's essential health benefits, such as maternity care or mental health services.

Similarly, Limited Benefits Plans only reimburse for specific medical conditions or procedures and cover a limited dollar amount. A health benefit plan sponsored by a nonprofit agricultural organization such as the Farm Bureau Health Plan operates outside ACA rules, and Direct Primary Care provides access to certain medical services in exchange for a flat monthly or annual fee paid directly to a provider.

State officials and consumer advocates urge Iowans to review these options carefully, noting that coverage levels, exclusions and financial protections can vary widely from traditional insurance, potentially leaving families exposed to large, unexpected bills.

Calls for reform

Ommen said federal taxpayers will spend about $630 million in 2025 on premium tax credits for roughly 110,000 Iowans — evidence, he argues, of a system masking deep structural flaws.

He cited two long-standing ACA design problems. One is the subsidy cliff. If a person or family crosses the income threshold by even one dollar, all assistance can be eliminated.

"This not only creates a disincentive for families to earn more during the upcoming year but can also force them to repay thousands of dollars in premium tax credits if their income unexpectedly increases," Ommen said.

The other issue Ommen cited is age-banding limits. Insurers can charge older adults only three times what younger people pay. Enhanced subsidies have flattened real differences, he said, driving younger, healthier Iowans out of the market and worsening the risk pool.

Murphy said the 400% federal poverty level subsidy cliff should be eliminated so that middle-income Americans are not excluded from financial assistance, given the high cost of coverage. She also supports closing the Medicaid coverage gap by expanding eligibility in the 10 remaining states that have not yet done so — a step that would reduce the uninsured rate and strengthen the ACA marketplace overall.

To curb costs, she urged tackling hospital fees, provider consolidation and private-equity ownership that inflate prices. She also said supporting state-level cost commissions and similar initiatives designed to monitor and reduce health care spending could help lower premiums and ensure the ACA remains both affordable and sustainable for consumers in Iowa and nationwide.

Bottom line

With rising premiums, expiring subsidies and reduced navigator capacity, Iowans are urged to start early, compare carefully and seek expert help to secure affordable, comprehensive coverage for 2026.