ACA subsidies expire tonight—Dr. Ezekiel Emanuel pushes back on a Wall Street Journal piece cheering their end.

One last post for 2025. No “Year in Review” stuff for now. Just one more piece of timely analysis that we absolutely need to know now, and should amplify in our circles.

Thanks for reading my work and for your incredible support this year! I could not have done it without you.

Please have a safe night. More soon from Inside Medicine…

—Jeremy

With hours remaining in 2025, the “enhanced subsidies” that help families afford health insurance on the Affordable Care Act (“Obamacare,” or “ACA”) Marketplace are poised to expire. According to the nonpartisan Center on Budget and Policy Priorities, 22 million Americans will see their premiums (that is, how much they pay) increase.

The increases are not small potatoes.

Using a KFF calculator, a family of four non-smokers (two adults, two children) getting health insurance from the Affordable Care Act Marketplace in my county with an income of $100,000 per year, it’s pretty clear how substantial the increase in costs will be. Depending on the plan, that family will now have to pay $3,680 more per year, regardless of the plan they are on. Here’s a screenshot of the scenario I ran.

Two academics argue in The Wall Street Journal that this is just great!

However, according to a recent essay by Professor Ge Bai and Professor Elizabeth Plummer published in The Wall Street Journal, apparently this is a great thing.

First, read what they wrote. After that, we’ll get a response from Dr. Ezekiel Emanuel, one of the architects of the Affordable Care Act, a law that helped millions of Americans get health insurance after it was enacted.

Congress may yet extend ObamaCare “enhanced” premium subsidies. A new study shows why that would be a reckless act toward taxpayers.

Using health insurers’ mandatory filings, our study, published Friday in JAMA Health Forum, shows that the ObamaCare individual market has become a money pit for taxpayers. In 2024 they paid nearly 80% of the premiums for subsidized plans—compared with only 30% in 2014.

Taxpayers paid more than $114 billion directly to insurers in 2024—one-third more after inflation than in 2023, more than double the amount in 2020 (before the enhanced subsidies), and more than six times as much as in 2014. According to the Congressional Budget Office, this acceleration continued in 2025.

Why? Through regulations, ObamaCare banned affordable insurance options and destroyed independent physician practices, damaging the insurance and provider markets. Consolidation, administrative bloat, high prices and soaring premiums followed. Our study shows the correlation between premium growth and subsidy growth is nearly perfect.

That’s by design. Subsidies are calculated so that the premiums paid by subsidy-eligible enrollees for benchmark plans fall within a set percentage of their income, thereby transferring the financial exposure from rising premiums to taxpayers. In 2021 Congress expanded subsidy eligibility to higher-income households and lowered income caps for others, further burdening taxpayers. In August 2022, it extended these Covid-era subsidies through 2025.

Zero or near-zero premium plans proliferated as the subsidies approached or exceeded the premiums. In 2024, 90% of subsidy-eligible enrollees had access to plans with net premiums of $10 a month or less.

Higher enrollment brings more taxpayer dollars to insurers and brokers while providing political talking points for Democrats. It also creates incentives for fraud, as evidenced by findings from the Justice Department, the Paragon Health Institute and the Government Accountability Office. In a GAO report, 23 of 24 fictitious applications were approved for premium subsidies, and 18 were still covered a year later.

Reckless subsidies lured legitimate enrollees into ObamaCare plans who would otherwise have used employer-sponsored insurance, crowding out private funding with taxpayer dollars. We found that the market size for unsubsidized ObamaCare plans shrank by a quarter, from $23 billion in 2014 to $17 billion in 2024. ObamaCare is a poor value, a product few Americans would voluntarily purchase without subsidies.

Congress has thrown taxpayers under the bus—forcing them to pay for nearly the entire ballooning cost of subsidized ObamaCare plans, including fraudulent ones. Taxpayers in employer-sponsored plans are also saddled with higher premiums, higher prices and stagnant care delivery caused by ObamaCare’s market distortions.

What Congress sold to the American people as targeted assistance for lower-income families has become a broad entitlement with no spending limit. ObamaCare’s structural flaws and subsidy design are a direct attack on taxpayers’ hard work, sacrifice and discipline. Taxpayers, who keep the economy running and sustain care for the most vulnerable, deserve empathy and justice.

Ms. Bai is a professor of health policy and management at Johns Hopkins University. Ms. Plummer is a professor of accounting and medical education at Texas Christian University.

Dr. Ezekiel Emanuel responds.

After reading this essay, I found myself perplexed—if not confused. So, I asked one of the architects of Obamacare, Dr. Ezekiel Emanuel, what he thought. I’m grateful for his expertise. Here’s what he shared, exclusively with the Inside Medicine community:

Yes, enhanced subsidies do increase government payments. A large part of that increase is due to high healthcare inflation that began in 2023 and has continued since, rather than anything intrinsic to the ACA.

Yes, the ACA should be reformed. After 15 years without change, the original plan has run its course. There are many things that are not necessarily a result of the ACA in the healthcare system, but are in desperate need of fixing—like the concentration of hospitals, deductibles so high that they make a mockery of insurance, the wide variation in prices, the physician fee schedule that under-compensates primary care physicians, and the downward spiral of rural health access.

But let’s be serious: the main reason the ACA (and, more generally, the healthcare system) has not been adjusted is Republican resistance to any responsible discussion of healthcare. It has been 15 years since the ACA was passed and Republicans immediately started yelling “repeal and replace”—and we still lack any comprehensive repeal or even a coherent “concept of a plan” for a replacement. There has simply been a lack of alternative ideas from those opposed to the ACA.

As I have said on TV and in writing many times, no company would put a strategic plan in place and let it run for 15 years without adjustments. That is what Republicans have done to the ACA.

Also, the drop in enrollment in unsubsidized plans is tiny compared to the overall health insurance market, which covers more than 180 million people in the United States. That shift simply reflects how expensive people find health insurance.

And the idea that almost nobody would buy exchange-based health insurance if they had to pay entirely out of pocket for it? Sure. But the same logic holds for employer-provided health insurance. Who would (or could) pay $27,000 for employer-sponsored insurance if they had to cover the full cost without any subsidy?

With hours remaining in 2025, some states may take action soon after the new year. So, the fallout, both in terms of health and the politics, is unknown. Regardless, this is another unforced error for American health.

Which reminds me: 2026 is an election year…

Special thanks to Dr. Ezekiel Emanuel. His next book “Eat Your Ice Cream: Six Simple Rules for a Long and Healthy Life” will be published next week. It can be pre-ordered here.

If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.