Robin Carlton pays about $650 a month for a plan on the Missouri health insurance exchange that covers him and his two teenage kids. That monthly total is $200 higher than what he paid last year, due in part to the expiration in December of covid pandemic-era premium tax credits. But the self-employed St. Louis property manager isn’t in any hurry to investigate a new type of coverage that might be cheaper than his marketplace plan: farm bureau health plans. “Although I’m not a fan of rising costs, I’m not going to sacrifice coverage for my kids to save a buck,” Carlton said. Carlton finds himself among a growing number of Americans who have confronted difficult choices because of rising Affordable Care Act premiums and other affordability issues. For instance, a recent KFF poll found that many returning marketplace enrollees reported higher costs this year. In addition, most expressed worry about affording routine and unexpected medical care, as well as the cost of prescription drugs. Worries were greater among those with lower incomes and chronic health conditions. And about 5% of respondents said they had switched to some type of non-ACA coverage. Health policy experts say such concerns are giving new legs to alternative forms of coverage — for instance, farm bureau plans. As of this year, Missouri is one of 14 states that allow health coverage through state farm bureaus, grassroots membership organizations that advocate for the agricultural industry and rural interests. An annual membership in the bureau typically costs $30 to $50, and in many of the states anyone can join. With membership comes the option of buying into the health plan. Plan details vary by state, but they typically share many features of marketplace plans, including coverage of a wide range of services, a broad practitioner network, and a way to file complaints. But because states have passed laws exempting farm bureau health plans from health insurance requirements, they don’t offer many of the coverage protections provided by insurance. That means their benefits and coverage rules may be less generous or predictable than Obamacare plans. Crucially, farm bureau plans don’t have to accept everyone who applies for coverage. People must pass underwriting first, a process in which plans evaluate applicants’ medical history and health conditions and decide whether to offer them coverage. This practice was routine before the ACA passed, and people were often rejected due to preexisting medical conditions. Because farm bureau plans can turn down people with expensive chronic conditions or a history of cancer or other medical issues, farm bureau plans may be 30% to 50% cheaper than unsubsidized marketplace plans, plan managers say. As people struggle to keep family farms afloat, they may face Obamacare premiums totaling thousands of dollars a month, leading some to forgo coverage, said Missouri Farm Bureau president Garrett Hawkins. “We’re trying to present another option,” he said. Sowing Choices In 2026, with the expiration of enhanced premium tax credits, average ACA premium payments were estimated to increase by 114% for subsidized enrollees who retained their marketplace plan, according to KFF. Last year, Missouri was one of four states that passed laws permitting farm bureau health plans. The others were Alabama, Florida, and Ohio. Although the number of states offering them has ticked up in recent years, farm bureau health plans aren’t new. Tennessee has been offering the coverage since 1947. Tennessee’s Farm Bureau Health Plans administers the plans in 10 of the 14 states that permit them. In Missouri, the farm bureau offers several plans with varying deductibles, copayments, and annual limits on out-of-pocket spending. Many of the benefits and cost-sharing amounts look like the coverage someone might get on the state health insurance exchanges or through an employer. They include emergency care and hospitalization, physician office visits, prescription drugs, free preventive care, and dental and vision services. Members have access to providers through the UnitedHealthcare Choice Plus national network. Hawkins said he’s pleased with the interest the plans are generating. People could apply for coverage through the website starting Jan. 1, and by mid-March, 520 people had submitted applications, he said. It’s uncertain how many of those people will clear the underwriting hurdle and buy a farm bureau plan, however. Farm bureau health plans can deny coverage for any reason. Even if coverage is offered, plans in Missouri don’t cover any preexisting conditions for at least six or 12 months. In addition, plans may exclude coverage of any benefits related to a “known risk” for two to seven years, depending on the issue. So people with a range of conditions, such as diabetes, high cholesterol, heart problems, or successfully treated cancer, may be turned down or have to pay out-of-pocket for any related care for at least a year and possibly as long as seven years. “People don’t like that we underwrite, but if we did everything like the ACA, we’d be just like an ACA plan,” said Jason Beard, general counsel and chief compliance and privacy officer at Tennessee’s Farm Bureau Health Plans. “We’re trying to be an option for folks that would otherwise not have coverage.” Staying Rooted in Coverage Under the Missouri law, once someone is covered by a farm bureau plan, they can’t be kicked off or charged a higher rate if they get sick. That’s also true for the nine other states where Tennessee administers the plans, Beard said. “We do not contractually have the right to raise premiums or cancel plans based on [an individual’s] health experience,” he said. And yet, “it can be really confusing to people” because the plans look like insurance products, but they don’t have the same protections, said Anna Howard, principal for policy development, access to, and quality of care at the American Cancer Society Cancer Action Network. Someone with a history of cancer would be unlikely to get approved for a farm bureau plan in the first place, Howard said. If they were accepted, the services they might need would likely be excluded from coverage, she said. “We’re just concerned that there’s going to be more people enrolled in these plans now because there’s so many more states that are allowing them,” Howard said. Carlton, the self-employed property manager, knows firsthand how underwriting can limit coverage options. Before the Affordable Care Act required that anyone be accepted regardless of health status, Carlton, who has diabetes, had to buy coverage through his state’s high-risk pool, which was often the only option for people with preexisting conditions. Meanwhile, policy experts share Howard’s concerns. Insurance companies in the ACA marketplaces “have to offer maternity coverage, and they have to give you benefits on day one for a preexisting condition, and they can’t charge you more because you have that condition,” said Sarah Lueck, vice president for health policy at the Center on Budget and Policy Priorities. This creates an uneven playing field for insurers and drives up premiums for the people who can’t get into farm bureau plans. Farm bureau plans “get to use, you know, the standard market as a high-risk pool, essentially, if they want to,” Lueck said. Still, with the huge jump in premiums that many people are facing for ACA coverage, it’s easy to understand the appeal of farm bureau plans. “I’m not saying it’s a good thing that states have abdicated their regulatory responsibility here,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University. “I’m just saying that there are a lot of people out there who are struggling, who need health care, and simply can’t afford the premiums in these ACA marketplaces anymore.” Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact KFF Health News and share your story. KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF. USE OUR CONTENT This story can be republished for free ( details ). Fourteen states now allow health coverage through state farm bureaus. Though they generally share many features of Affordable Care Act marketplace plans, they aren’t insurance. Neither are they typically subject to federal or state health insurance requirements, and the benefits may be less generous or predictable than those of Obamacare plans.