Last month, Medica, the last remaining Obamacare insurer in Iowa announced that it was considering leaving the state’s insurance exchange. Today Medica decided it would stay in the marketplace but would be asking for a steep increase in premiums next year. From the Des Moines Register:

“When you find yourself as the only ones between people getting access to care and people not getting access to care, your view of the situation becomes very different,” Medica Vice President Geoff Bartsh said in a prepared statement. “We’ve filed with the intent to provide access to insurance for all Iowans, whether they are farmers, small business owners or other individuals who need coverage.” The relatively small, Minnesota-based carrier told Iowa regulators Monday that in order to stay in the market, they would need to increase premiums by an average of 43.5 percent.

Doug Ommen, the Iowa Insurance Commissioner, has the ability to deny or alter rate requests submitted by Obamacare insurers, but in this case, Medica has the state between a rock and a hard place. That’s because Medica can still pull out of the market if it is not satisfied with the rate set by the state. That would leave about 72,000 people in the state with no option for insurance. So the commissioner will be highly motivated to give Medica what it wants. But today as the rate request was announced, Ommen also worried that the spike in rates could do further damage to the market:

“We appreciate and understand Medica’s desire to provide coverage in all of Iowa’s 99 counties. That is our goal as well,” Ommen said in a prepared statement. “We are concerned that Iowa has hit a point within our market’s collapse that a 43% rate increase will drive healthier, younger, and middle aged individuals out of the market. Iowa’s individual market remains unsustainable and needs a fix from Congress.”

Two other carriers, Aetna and Wellmark Blue Cross & Blue Shield, announced earlier this year they would not participate in the Iowa market in 2018.