DES MOINES, Iowa — Josh Crist made the two-hour drive to the Iowa Capitol in April to celebrate Republican Gov. Kim Reynolds' signing of a new health care option designed to lower costs by skirting requirements of the Affordable Care Act.
The 35-year-old farmer and electrician from Tipton figured the new plans offered through the conservative and politically powerful Iowa Farm Bureau were certain to reduce the more than $2,000 monthly bill he pays for his family's health insurance. He had feared the cost would climb as his existing policy expires, forcing him to buy from an ACA exchange without help from subsidies.
But nearly four months later, Crist is still waiting to see the fine print on what exactly would be covered under the Farm Bureau plans, and he's no longer sure he'll sign up.
"There's a lot of unknowns right now," he said.
The new Iowa option, which Republicans and some Democrats in the Legislature pushed through before knowing many of the details, represents another attempt by GOP-controlled states to chip away at some of the federal rules imposed under the 2010 law championed by former President Barack Obama. It comes as the Trump administration says it's freezing payments under an "Obamacare" program that protects insurers with sicker patients from financial losses.
"Many Iowans faced a choice of going broke or going without health care coverage. And that's really not a real choice," Reynolds' campaign tweeted earlier this month. "That's why we found an Iowa approach to help our farmers and small business owners."
There is no state oversight of the new law, which the Iowa Farm Bureau is offering with assistance from an insurance company. Democrats argue cutting costs can only be achieved by slashing benefits, siphoning young and healthy customers away from the ACA market while increasing the burden for elderly and sicker recipients.
National health care experts have reacted skeptically, arguing it could be a moneymaker for the Farm Bureau but won't help people most in need.
"If you're collecting premiums from people who don't use health care services very much you can make money," said Sabrina Corlette, a health policy research professor at Georgetown University. "It's when you actually have to cover medical services that insurance becomes a less-profitable business."
Iowa Insurance Commissioner Doug Ommen said about 26,000 residents quit buying individual policies this year "due to the demoralizing rates faced by Iowa citizens not eligible for subsidies caused by structural defects in the ACA." Some of that group may have found work that offered insurance or joined a small group policy.
Ommen's office estimates only about 600 Iowans continued to pay premiums out of their own pockets last year. Many others likely gave up on buying health insurance altogether, determining it's unaffordable.
Many self-employed Iowans who buy their own insurance are farmers, which is why the Farm Bureau stepped up to offer policies.
Under the law, the Farm Bureau will decide coverage options and prices, pay claims and assume the financial risk. Wellmark Blue Cross and Blue Shield will process claims and provide access to its network of clinics, doctors and hospitals.
By not technically being labeled insurance, the law allows the Farm Bureau to ignore ACA rules and operate without consumer oversights provided by the Iowa Insurance Division.
The Farm Bureau, a nonprofit with 159,000 members, modeled its plan after a Tennessee law approved in 1993. It was promoted as a way to serve people who can't afford insurance sold through marketplaces established by the ACA.
Wellmark Chief Administrative and Legal Officer Cory Harris rejected arguments that the Farm Bureau policies will provide skimpy coverage.
"Who would buy that? Farm Bureau hasn't gone through all of this to offer a product that the market doesn't want," Harris said.
A Farm Bureau spokeswoman said there are still no specifics to offer about the policies, noting it could be October or November before they offer plan details to members. The open enrollment period for the ACA runs from Nov. 1 through Dec. 15.
Sarah Lueck, a health policy expert at the Center on Budget and Policy Priorities, said Iowa's "mystery plan" approach contrasts with other states, such as Wisconsin and Minnesota, which have tried to keep premiums stable by compensating insurers that accept high-risk clients.
"How this rolls out, when it rolls out and how many people they're going to try to touch, can have a big impact on the rest of the insurance market," she said.
Reynolds has argued Iowa's insurance market was "robust" before the Affordable Care Act and that the Farm Bureau plans would be similar to some offered years ago.
Iowa had one of the lowest uninsured rates in the country back then, although "comprehensive health insurance was unaffordable for many lower to moderate income earners," according to an analysis earlier this year by the state's insurance commissioner.
Now, a big concern for some Iowans is that the new Iowa law allows policies with lifetime caps on coverage, which is prohibited under the ACA.
The Farm Bureau also could require applicants to complete a lengthy health questionnaire, base premium costs on existing conditions or deny coverage to cancer survivors or those with chronic ailments like diabetes. A Tennessee questionnaire, for example, asks whether the applicant in the past seven years has been treated, diagnosed or experienced symptoms of any of nearly 70 medical conditions including varicose veins, high cholesterol, celiac disease, headaches and back pain.
That's troubling to Erin Mobley, a 31-year-old PhD student at the University of Iowa who was diagnosed with a form of cancer when she was 6. While she has been in remission for years, Mobley still visits with multiple doctors to ensure she stays healthy.
"It makes me a little nervous to think what could happen," she said.
Karen Pollitz, a senior fellow at the nonpartisan Kaiser Family Foundation, questioned Iowa's decision to give the Farm Bureau so much autonomy in offering health coverage.
"It's like states saying, 'We don't want to offer public schools,'" she said.