🚨 How much more are ~120,000 #IOWA ACA enrollees *really* paying this year due to Trump/GOP policies? (spoiler: a lot more.)

IMPORTANT: See the original post in this series for an explanation of the methodology.

Regular readers know that I’ve been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.

I’ve written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and last week it was revealed that over 2.6 million ACA exchange enrollees had already been priced out of the market as of February, with the number almost certain to climb further throughout the rest of 2026.

As I’ve repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of February have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.

In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plasn with worse networks, referral requirements to see specialists and so on.

With that in mind, that’s exactly what I’ve decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.

Let’s look at IOWA:

Here’s a look at ACA exchange plan selections during Open Enrollment by household income level this year vs. last.

As expected, enrollment below the federal poverty level (FPL) has plummeted by nearly 60%, due mostly to the Trump Regime eliminating federal subsidy eligibility to low income legally-residing immigrants who have been U.S. residents for less than 5 years, along with some other categories of documented immigrants.

Enrollment at nearly every other income bracket has also dropped, in most cases dramatically. The only bracket where it increased (slightly) is the 300 - 400% FPL bracket, which likely consists mostly of households who normally earn slightly more than 400% attempting to squeeze in just below the subsidy cut-off threshold.

Overall, OEP plan selections were already down by nearly 10% before effectuated enrollment even began, with over 13,000 fewer Iowans enrolled out of the gate:

OK, onto the main analysis:

Here’s total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. The first table is based on official metal level tiers, but it’s the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.In the end, the average AV has dropped by 3.7 points year over year:

By combining these numbers with the average gross premiums per enrollee I’m able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 80% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like so:

In Iowa, the ~120,000 enrollees who signed up during Open Enrollment have seen their net premiums skyrocket by 67% on average.

In addition, their average out of pocket expenses have gone up by nearly 35%, for a combined average healthcare cost increase of 51%.

That’s an increase from ~$3,300 to over $5,000 per enrollee this year...$1,700 more apiece.

In addition, based on KFF’s net data, average deductibles also jumped by ~33% to around over $4,200 for single coverage this year, and the maximum (theoretical) out of pocket cut-off for all ACA enrollees went up by over 15% this years as well, to $10,600 for single coverage.

Next up: KANSAS.