 (Photo by Joe Raedle/Getty Images) By Carolyn Y. Johnson Iowa's last major Affordable Care Act insurer threatened on Wednesday to pull out from the state's marketplace next year, the latest step in a sudden collapse of the state's insurance marketplace that holds ominous signs for health care customers in states across the county. If Minnesota-based Medica follows through on its threat not to sell plans in 2018, Iowa could be the first state to lack any insurers on its exchanges in all but a handful of counties. At the start of 2017, Iowa outwardly appeared to be an Affordable Care Act success story, with three insurance companies selling competing plans on its exchanges broadly. But last month, two of Medica's competitors said they would exit the state's marketplace next year, citing financial losses. And on Wednesday, Medica released a statement saying its continued participation "is in question." Iowa's precarious position reveals how the departure of one insurance company from an exchange can have a domino-like effect on its competitors. If a company pulls its plans over financial concerns, it's often because it is losing money on too many sick members and too few healthy ones. The plans that stay in the game will likely inherit its members — and the financial challenge they pose. "It appears, at least on the surface... that this has created this cascading effect of insurers following each other on the market, not wanting to be the last one holding the bag," said Cynthia Cox of the Kaiser Family Foundation. "This could happen in other states that appear to have good competition and a good number of insurers participating." The situation in Iowa also reveals the increasing local-level toll levied by Congress' wrangling over the Affordable Care Act. The insurance industry, which has long depended on stability, is trying to is trying to react to a highly uncertain political environment that shows no signs of stabilizing soon. Amid arguments in Congress about the future of health reform, insurers must make practical decisions in the next two months whether to sell plans in the marketplace next year. Billions of dollars in federal payments that help reduce deductibles and out-of-pocket costs have become a political football, with politicians refusing to commit to long-term promises about the payments. And the future of the marketplaces longer-term is hard to read amid the uncertain fate of Republican attempts to repeal or replace the law. | 
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