The Trump administration on Monday issued new rules for health plans sold through Affordable Care Act marketplaces, in a move that shifts much of the control over insurance standards from the federal government to states and gives Americans new ways to avoid penalties for failing to carry coverage, the Washington Post reported.

The 523 pages of rules released late Monday afternoon mark the first time the Trump administration has been responsible for an annual exercise in which the government sets forth the standards for insurers planning to participate in ACA marketplaces a year ahead, the Post wrote. 

The rules add two broad exemptions from the ACA’s requirement that most consumers be insured. The change offers escape hatches that will be retroactive two years, even before a recent tax law ends the penalties completely starting in 2019.

People living in areas where only one insurer is selling plans in the marketplace — which includes most of Iowa — now can qualify for a “hardship exemption.” Additionally, residents who oppose abortion and live in places where the only available plan covers abortion services can also file for an exemption. Federal health officials and private researchers have shown that about half of U.S. counties have only one ACA insurer this year.

State insurance regulators and insurers are still grappling with changes authorized by the Trump administration’s October 2017 executive order. That order allows small businesses to form association health plans, makes it easier for individuals to buy short-term health insurance plans that cost less and have less comprehensive coverage, and loosens rules on how businesses could use health reimbursement accounts. 

Earlier this month, Gov. Kim Reynolds signed legislation that allows the Iowa Farm Bureau Federation to build a self-funded health benefit arrangement for Iowans forced from the individual market due to high premium costs. It also allows small employers to band together to create affordable health care options for their employees.