Iowa’s new insurance commissioner was in Washington, D.C., last week, warning federal lawmakers the state has a big problem coming up in its individual insurance market.

Two of the three biggest providers selling insurance in the individual market announced they would no longer offer this coverage in 2018, and the third has announced it will likely pull out as well. This could leave thousands of individuals with no coverage.

“I’m not prepared yet to say they will have nothing,” Insurance Commissioner Doug Ommen said Friday during a visit to Fort Dodge. “But I think if nothing changes, they will have nothing.”

Most Iowans have nothing to worry about, he said. More than half of Iowa’s roughly 3 million residents have insurance through their employers, and those customers will not be affected.

People who were on Medicaid, and those who got onto expanded Medicaid thanks to the Affordable Care Act, won’t be affected by these changes either, Ommen said.

“We view that the Medicaid expansion was a really good bipartisan effort to address the uninsured issue,” Ommen said. “That provided expanded coverage to 144,000 Iowans.”

About 145,000 Iowans are in the individual market, and roughly half of those are safe, he said, because they kept the plans they had before the ACA took effect.

“You remember the president promised if you liked your plan you can keep it. So in Iowa we have about half of that 145,000 in the grandfathered and grandmothered plans,” Ommen aid. “That leaves about half of that in the area of real concern.

“That is the ACA compliant market. Those are people who are probably feeling a lot of stress right now, because of the fact that the federal government seems to be moving slowly in fixing it.”

Those roughly 72,000 people aren’t a big portion of the state, but they represent a big problem, he said.

“That’s a significant problem because these are real people with real health concerns,” Ommen said. “I’ve tried to be really clear, it’s going to require federal action in order to get relief for these individuals.”

Ommen said how to pay for the high risk people–those who require the more expensive treatments–is a key to current problems with Iowa’s insurance.

The ACA tried to fix this problem, but what works in one state may not work in Iowa.

“Part of the problem here in Iowa is I listen to the national debates, and say, ‘That’s not Iowa,'” he said. “The view was the high-risk pool doesn’t really work. It doesn’t work in some states. … What did work in Iowa maybe didn’t work in New Mexico.”

In Iowa there were assessments on insurance companies which helped fund a workable high-risk pool, he said.

The ACA made changes to that which didn’t work here, he said.

“You can’t take that cost and cover it by asking young, healthy people to come in and pay premiums that are reflective of their risk, and say ‘You’re going to pay a lot more money because we have to cover these high risk people,” Ommen said. “We’re talking about hemophilacs, people on dialysis. It’s not a large number of people, but they need care. They should have care. But you can’t cover the cost of that care by putting it in the individual market.”

The version of the health care bill passed by the U.S. House of Representatives does include waivers that would give states more local control, Ommen said. The Senate is now taking a careful look at that bill, he said.

“Congress needs to act. This is now federal law. I can’t change federal law,” Ommen said. “I can’t write federal law. I need a federal law that allows something that will work in Iowa.”