Iowa GOP delegation splits as U.S. House advances ACA subsidy extension

Iowa’s all-Republican U.S. House delegation split Thursday as the chamber passed legislation to extend expired health care subsidies, with three of the state’s four members opposing the measure and one breaking with GOP leadership to support it.

U.S. Reps. Mariannette Miller-Meeks, Ashley Hinson and Randy Feenstra voted against the three-year extension, while Zach Nunn, R-Bondurant, joined 16 other Republicans and all Democrats in backing the bill, which passed 230-196, that would revive the pandemic-era subsidies, which lowered insurance costs for roughly 22 million people nationwide.

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The vote came after a rare procedural maneuver that bypassed House Republican leadership and forced the legislation to the floor, reviving enhanced subsidies that expired late last year. The bill now heads to the Senate, where negotiations are underway on a potential bipartisan alternative that could include income limits and other changes sought by Republicans.

In a post on X, Nunn said his “number one priority is to bring down health care costs for all Iowans,” pointing to past bipartisan work to lower premiums, increase competition and hold big insurers accountable. He argued that Congress should not “leave 100,000 Iowans behind because of bad prior policies,” and said his vote reflects a commitment to expanding access to care while investing in patients and community-based providers.

Miller-Meeks, R-Ottumwa, on Thursday sharply criticized the Democrat-backed push to extend enhanced ACA subsidies, arguing the approach would increase federal spending without fixing underlying problems in the health care system.

“Today, Democrats are ramming through a 3-year extension of the COVID-era Obamacare subsidies with no reforms,” Miller-Meeks wrote in a Facebook post ahead of the vote. She argued the subsidies “go straight to profitable insurance companies,” are “riddled with fraud,” do not lower premiums and lack income caps.

In a statement following her vote, Miller-Meeks said she hears frequently from Iowans and employers facing rapidly rising premiums who do not qualify for exchange subsidies, noting that an estimated 130-160 million Americans are not enrolled through the ACA. She said she supported the Republican-backed Lower Health Care Premiums for All Americans Act, which she asserted would cut premiums for all Americans — including those on the ACA exchange — while expanding choice, increasing transparency, supporting small businesses and shifting decision-making back to doctors and patients.

The measure, introduced by Miller-Meeks and backed by Republican House Speaker Mike Johnson, aims to lower insurance costs nationwide and save taxpayers billions. Supporters say it would broaden plan choice, expand association health plans, clarify stop-loss insurance and increase prescription drug price transparency.

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A nonpartisan Congressional Budget Office analysis found the proposal would reduce the federal deficit by about $35.6 billion over the next decade and lower benchmark marketplace premiums by an average of 11 percent from 2027 to 2035, while also slightly increasing the number of uninsured Americans. CBO projected an average of 100,000 more people would be uninsured over that period.

Democrats counter that scaling back premium tax credits could steer consumers into skimpier plans with higher deductibles and cost-sharing and could weaken protections for people with preexisting conditions, a charge Republicans dispute.

Miller-Meeks criticized Democrats for unanimously opposing her bill, arguing that vote shows they are “not serious about lowering health care costs for the American people.”

Hinson, R-Marion, said she opposed extending Affordable Care Act enhanced premium subsidies without what she described as guardrails to prevent “waste, fraud and abuse,” but signaled openness to a temporary, bipartisan extension paired with changes to the program.

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In a statement after the House vote, Hinson said, “I will not support the status quo of health care in America today, it’s a disaster,” adding both parties share responsibility. She said she is working with House and Senate lawmakers on a bipartisan framework that could include income caps, monthly minimum premiums and an extension of open enrollment through March.

Hinson also said she supports efforts to lower prescription drug costs by targeting pharmacy benefit managers and shifting health care dollars toward health savings accounts rather than insurance companies, arguing the approach would provide families more certainty while Congress works to rein in rising costs.

Republicans have argued that expanding health savings accounts and increasing plan flexibility would lower premiums and improve access over time, while Democrats counter that allowing the enhanced subsidies to expire will raise costs immediately and leave more Americans uninsured or underinsured.

“It’s time to drop the partisan rhetoric and fighting and come together to pass a real bipartisan plan to improve health care access and affordability for all Americans,” Hinson said.

Iowans urge Congress to restore ACA tax credits

Rural health advocates, providers and Affordable Care Act enrollees urged Iowa’s Republican U.S. House members to restore expired enhanced premium tax credits, warning tens of thousands of Iowans face hundreds of dollars more per month in costs, with rural residents hit hardest, and said free clinics are already seeing an influx in uninsured patients. They argued the subsidies help keep families insured and rural hospitals afloat while Congress debates longer-term health care reforms, cautioning that proposals focused on health savings accounts do little to address short-term affordability.

At a Thursday press conference, Iowa Democratic Party Chair Rita Hart said Republicans “unleashed a health care crisis on rural Iowa” by allowing the pandemic-era credits to lapse last month, leading to premium increases of thousands of dollars for some families.

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Hart warned tens of thousand of Iowans face an average of $500 more in higher out-of-pocket premiums this year after the enhanced subsidies expired, with rural residents and farmers expected to be hit hardest unless Congress restores the aid.

Nicole Loew, a PhD-prepared nurse, researcher and rural health advocate from Chariton, said rural Americans experience higher maternal mortality rates, more chronic diseases, access to fewer mental health services, longer travel times for care and are more susceptible to hospital and clinic closures.

Loew said the Affordable Care Act’s insurance protections, preventive care requirements and income-based subsidies “made health care possible for millions of people, especially rural families,” because Medicaid use is higher in rural areas.

She warned that when people lose coverage, rural hospitals already operating on thin margins are left absorbing the cost of uncompensated care, increasing the risk of service cuts or closures. In many rural counties, she said, the Affordable Care Act was the difference between a hospital staying open or closing.

“Let's be clear, folks, people don't stop getting sick when subsidies disappear, they just become uninsured,” Loew told reporters.

Loew unsuccessfully ran for the Iowa Senate as a Democrat, losing to Republican incumbent and Iowa Senate President Amy Sinclair in 2024.

She said Thursday’s House vote “isn't about declaring the perfection of the ACA or that subsidies are the solution to our health care crisis, because they're not.

“Today's vote is about if people can make it to Friday, their next paycheck, if they can have heat and health care, and if they can even live to pursue happiness and liberty.”

Iowa City free clinic sees influx of patients

At a separate Wednesday press conference organized by Protect Our Care Iowa, Dr. Cecilia Norris, a family physician who works at a free medical clinic in Iowa City, said her clinic is already seeing an influx of patients who can no longer afford marketplace coverage.

“Yesterday, we had a line out our door before the clinic opened,” Norris said.

She said free and safety-net clinics are often where patients turn when they lose insurance or decide not to renew coverage because of rising costs. She said providers had anticipated an increase in demand but were unprepared for how quickly the impact would be felt.

“This has been a travesty,” Norris said, criticizing members of Congress for allowing the credits to expire without a replacement plan in place.

Jill Kordick, an ACA enrollee and constituent of Miller-Meeks, said the loss of the tax credits has dramatically increased her insurance costs.

With the subsidies, Kordick said she paid about $900 per year in premiums. Without them, she said her costs will rise to more than $9,000 this year — a tenfold increase — before accounting for higher deductibles, co-pays and out-of-pocket limits.

“Coverage looks very, very different when affordability disappears,” Kordick said, adding that she is now delaying care and weighing medical decisions against basic household expenses such as housing, utilities and groceries.

Kordick said the end of the subsidies also means fewer plan options and narrower coverage, compounding the financial strain for people who rely on the ACA marketplace, particularly older adults, the self-employed and rural residents.

“Look, I’m not here to argue that the ACA is perfect, because it is not,” she said. “But in the absence of congressional action to fix what's broken, the ACA, these tax credits, are a critical tool to bridge real gaps and keep people insured, while longer and larger health care reforms continue to remain stalled.”

‘Solve the problem’

Nick Larson, a farmer from Linn County, said his family buys coverage through the ACA marketplace after he and his wife retired from careers with employer-provided insurance. He said his family’s high-deductible plan now costs $1,864 per month.

While Larson said his family can absorb higher premiums for now, he emphasized that many Iowans cannot, calling the tax credits a necessary policy choice to help self-employed families afford coverage until Congress enacts broader reforms.

He criticized proposals that focus on expanding health savings accounts, saying they do little to address underlying affordability problems in a health care system where pricing is often opaque and provider networks are limited in rural areas.

Larson said flaws in the Affordable Care Act are real but warned against partisan finger-pointing, arguing that blaming Democrats or “Obamacare” does nothing to help families facing immediate cost increases. With Republicans now in control of Congress, he said, responsibility rests with GOP lawmakers to “solve the problem” and adopt policies that keep coverage affordable for self-employed and rural families.

Comments: (319) 398-8499; tom.barton@thegazette.com