Jack Hatch is a former state senator and was an author of every health care reform bill in Iowa from 2003 through 2014.

Health care is not a privilege. It is not a reward for good luck, good jobs, or good timing. It is a basic right. And in Iowa, health care, as an issue, has always been understood best when we remember that simple truth. There is another truth: health care is too expensive, in Iowa and across the U.S. 

For decades, our state has shown that when we lead with fairness, openness, and shared responsibility, we can build systems that work. Iowa passed meaningful health care reforms prior to the Affordable Care Act. We created bipartisan commissions to make policy. We listened to consumers, providers and other stakeholders. We debated publicly. And we acted with courage.

That tradition expanded children’s coverage to become the state with the highest percentage per capita for children covered by insurance in the nation as listed by the Kaiser Family Foundation (now known as KFF) in 2013. We led when we modernized health records. We led when we built patient-centered care. We led when we believed that health care reform required public conversation, not private contracts.

With the passage of President Donald Trump’s so-called “One Big Beautiful Bill,” Congress stripped subsidies for adults receiving Medicaid, and the Iowa legislature is now retreating on providing some Medicaid services to children and adults. Iowa is losing health care coverage for over 125,000 Iowans.

Last week, Republicans in the Iowa Senate approved Senate File 2422, which provides the opportunity to make Iowa the healthiest state in America again. But unfortunately, in its current form the bill (now pending in the Iowa House) would do the opposite. 

And the simple truth remains: we are not focused on providing the best health care for Iowans. Instead, we are engaging in political culture wars and not on making Iowans healthier.

Iowa faces a clear choice in 2026. We can protect and extend the Affordable Care Act’s individual marketplace, continue expanding Medicaid, and strengthen services for all Iowans—or we can allow instability to erode and inequality to widen. There is no neutral path. Doing nothing is a decision, and it is one that causes real harm to real people.

In Iowa, where self-employment, seasonal work, and small businesses make up a significant part of our economy, the individual marketplace is not a gap-filling system—it is the system. Ending or shrinking these subsidies does not punish Washington politicians—it punishes the neighbor down the street. As currently written, Senate File 2422 would increase health care costs for Iowans and limit access to the children and working families. 

If cost neutrality is the main goal of Senate File 2422, then the Iowa House should take advantage of the bill’s funding mechanism and support two significant cost-saving measures. The first is to incorporate Iowa Medicaid Director Lee Grossman’s recommendation to transition pharmacy benefits from private managed care to public administration. Grossman (appointed by the Reynolds administration) told lawmakers in January that the state projects $27.5 million in savings by administering pharmacy benefits through the Iowa Department of Health and Human Services. At a time when Iowa has a huge deficit, this is certainly smart.

The second funding mechanism is to provide for Iowans to buy Medicaid insurance. That is known as the “public option.” 

This is not radical. It is responsible. It is cheaper to keep people insured than to treat advanced illnesses. It is cheaper to manage chronic disease than to wait for crisis. It is cheaper to invest in stability than to pay for a collapse in affordability for working families.

But affordability alone is not enough. Coverage must also be real. That is why Medicaid expansion remains one of the most important moral and economic decisions Iowa has made. Medicaid is not charity. It is insurance for people whose jobs do not provide it, whose wages cannot absorb it, or whose lives have already been made harder by disability, age, or illness.

When Medicaid works, people get care early. They stay in the workforce longer. They rely less on emergency systems. They live with dignity. When it fails, the cost does not disappear—it simply shifts to jails, hospitals, counties, and individual family private insurance premiums.

Let’s be clear again: close to 125,000 Iowans will be losing their Medicaid benefits because of the biggest, ugliest bill the Republican Congress passed and Trump signed last July. Iowa’s entire Congressional delegation voted to cut Iowans’ benefits. Iowans never voted for this—they voted for lower costs, not less health care. And it’s no use waiting for Congress to act, because the Republican-controlled Congress can’t distinguish between protecting people and promoting the culture wars and their special interests.

Instead of complaining about how bad the Republican legislation is, both partisan caucuses should find a way to actually lower costs and expand coverage. Other democracies have found that balance and in Iowa, we have an opportunity to do so now.

Senate File 2422 uses the federal law to amend our state plan. It is called the 1115 Waiver. As the bill is written today, it will not reduce our Medicaid funding, because all it does is limit access for undocumented immigrants. But in truth, undocumented immigrants represent a very, very small cost to the program in Iowa. 

This bill represents the continuation of the culture wars Republicans have used to punish a small portion of the population. But in reality, it would punish many Iowa families and prevent Iowa from providing more health care, with benefits that would extend to many Iowans (not only Medicaid recipients).

Iowa must recommit to Medicaid as a public responsibility, not a private experiment. Expansion is not just about eligibility. It is about reliability. It is about provider access in rural areas. It is about continuity of care. It is about respect. In fact, Iowa needs to expand Medicaid services even further as a “public option” to all Iowans.

Recently, Democratic State Senator Catelin Drey of Sioux City announced she had been diagnosed with stage one uterine cancer. Speaking on the Iowa Senate floor, she explained why she shared the details about her medical condition: “I am not interested in pretending this is just a private medical matter. It is a public policy failure playing out in my body.”

Senator Drey’s situation is not rare. As the state with the second-highest cancer rate in the nation, Iowa needs to do more. It is not distant. It touches nearly every family in some way—through aging, injury, mental illness, or developmental conditions. Yet our systems still treat health care services as optional, negotiable, or expendable. Senator Drey’s courage is worth expanding health care for all Iowans.

Health care is also an economic indicator, and it provides for individual security our government should embrace. Because without it, none of the others hold. Education fails when children are unhealthy. Work fails when illness goes untreated. Retirement fails when medical bills wipe out savings. Families fail when systems abandon them.

The Iowa legislature should enact the Republican-appointed Medicaid director’s recommendation to reform the pharmaceutical services, and should go further to include a “public option” to purchase Medicaid coverage. 

We argue about budgets while ignoring human cost. We debate ideology while families debate which bill to skip. We praise efficiency while people wait months for care.

This is not leadership. Leadership is listening. Leadership is building systems in daylight. Leadership is admitting that markets alone cannot protect human life. Senator Drey’s decision to shed light on her journey to recovery is a remarkable opportunity for Iowans to see how she and her family must navigate our present chaotic system.

Like the 2007 legislature, Iowa should start by creating a gubernatorial and legislative commission to bring Iowa stakeholders together. Back in 2009, we even appointed former Governors Tom Vilsack and Terry Branstad as co-chairs of the legislature’s second Health Care Commission. This approach to bipartisan public discussion works. We can lead again.