A health-care bill that both of Iowa's senators voted for early Friday had drawn sharp concern hours earlier from the sole health-insurance carrier planning to sell individual policies in Iowa next year.

A Medica executive suggested Thursday afternoon that the "skinny repeal" of the Affordable Care Act could make Iowa's rickety market for individual health insurance even shakier.

Republican senators considered the bill after more extensive repeal proposals were voted down earlier in the week. One of the main functions of the proposal would have been to rescind the Affordable Care Act requirement that most Americans obtain coverage. The bill was narrowly defeated early Friday, but Iowa Sens. Chuck Grassley and Joni Ernst voted for it.

Medica Vice President Geoff Bartsh expressed his company's doubts Thursday in an email to the Register. "Congress is debating a number of items that have the potential to impact the individual market significantly. If they repeal the individual mandate and do nothing else, they will be taking the one action universally understood to be bad. Premiums go up and the market becomes more unstable,” he wrote.

Iowa's largest overall health insurer, Wellmark Blue Cross & Blue Shield, agreed with Medica Thursday that simply repealing the coverage requirement wouldn't work.

Insurers nationwide aired similar concerns this week. They worried that the "skinny repeal" bill would leave in place Obamacare’s requirement that insurers accept applicants with pre-existing health problems, but would cancel the accompanying requirement that almost everyone obtain insurance. The carriers feared that would let people put off buying insurance until they developed an expensive health problem.

"Eliminating the individual coverage requirement by itself will likely result in fewer people covered and a deterioration of the risk pool, which will increase premiums," an industry group, called America's Health Insurance Plans, wrote to Senate leaders Thursday.

Individual insurance is the kind of coverage people buy if they’re not offered insurance by an employer or a government program, such as Medicaid. Under Obamacare, many moderate-income Americans receive subsidies to help pay the premiums. Two large carriers, Aetna and Wellmark Blue Cross & Blue Shield, announced this spring that they would stop selling such policies for 2018 because of financial losses and unpredictable risks.

Medica, a relatively small carrier based in Minnesota, plans to continue selling individual health plans in Iowa, but it has proposed a 43 percent premium increase and it still could pull out of the market. If that happened, about 72,000 Iowans could be left with no choices for coverage for next year.

Bartsh, the Medica executive, pressed Thursday for measures that would help carriers shoulder risks. “We and many others continue to urge Congress to act quickly to stabilize the individual market in 2018,” he wrote.

He said the measures should include continuing Affordable Care Act payments to help pay the costs for moderate-income consumers and re-starting a “reinsurance” program, which helped pay costs of a relatively small number of patients who had particularly expensive health problems.

Wellmark dominates other parts of Iowa’s health insurance market, including for policies provided via employers. It has said it would re-enter the individual market if the government takes steps to stabilize risk. On Thursday, spokeswoman Traci McBee said Wellmark agreed with Medica that simply repealing the Obamacare coverage requirement could make Iowa's market even shakier than it already is.

McBee reiterated that Wellmark wants Congress to institute a “strong incentive” for people to maintain health insurance coverage before they get sick. Wellmark favors a rule under which people who go uninsured for a substantial amount of time would have to wait at least a year to regain full coverage. In the meantime, such people could purchase limited “catastrophic” plans.

“This incentive promotes individual responsibility and avoids circumstances when insurance is purchased only when immediately needed. With continuous coverage, we do not believe an individual mandate is necessary,” Wellmark leaders have written.

Both of Iowa's senators contend Congress urgently needs to repeal the Affordable Care Act, and they have said stabilizing Iowa's shaky individual-insurance market is a key objective.

Grassley told reporters Wednesday that his immediate goal was to "get something through the Senate" so a compromise plan could be worked out with the House. When asked Thursday for a response to Medica and Wellmark's concerns about the latest Senate proposal, Grassley spokeswoman Jill Gerber echoed the Republican's statement from the day before.

"The Senate needs legislation to get to a conference committee and continue the debate. Obamacare under current law has collapsed, and legislative action is needed to fix the problems," Gerber wrote in an email.

A spokeswoman for Iowa's other senator, fellow Republican Joni Ernst, did not immediately respond to a request for comment on the insurers' concerns. She and Grassley both voted for the bill early Friday. After the 49-51 vote, Ernst released a statement expressing resolve to keep working on the issue. "We don’t have the option to sit back and do nothing; Iowans are demanding relief from Obamacare," she wrote. “I am disappointed that the Senate was unable to advance important changes to this flawed law. We must now continue to find ways to work on behalf of Iowans and the American people who have been negatively impacted by Obamacare to find affordable, patient-centered solutions that work for them.”

Iowa Insurance Commissioner Doug Ommen has proposed a “stopgap” plan, under which the federal government would temporarily redirect some subsidies and help carriers cover the costs of members using more than $100,000 worth of care per year. Federal officials are considering his plan, but they haven’t approved it yet. Wellmark has said it would continue selling individual policies in Iowa next year if the stopgap plan is adopted.

Many of the 72,000 Iowans in question qualify for Obamacare subsidies to help pay for their premiums. However, some make too much money to qualify for that help, and they face the prospect of paying fast-rising premiums on their own.