The ACA Isn’t Stable: A Rebuttal to the Wall Street Journal

How enrollment losses, subsidy cliffs, and skewed averages are being misinterpreted

Recent WSJ commentary frames ACA markets as resilient. But once Medicaid transitions, new enrollment declines, and survivor-biased premium data are accounted for, the picture shifts toward contraction—not stability.

In the April 3, 2026, editorial “The ObamaCare Crisis That Isn’t,” the Wall Street Journal Editorial Board argues that Democratic warnings regarding the end of enhanced subsidies have proven unfounded. The Board claims:

· The 1.2 million person decline in number of ACA enrollees was smaller than anticipated and enrollment remains high at 23.1 million nearly twice the 2021 level.

· The decline of 1.2 million enrollees was largely result of removing people who were enrolled in both Medicaid and in state exchanges or had committed fraud.

· Average monthly premiums $137 or $73 for subsidized enrollees remained manageable and had not in fact risen.

· The most significant cost increase were limited to blue states with expensive mandates.

The objective of this essay is to systematically go through and evaluate these WSJ claims against broader economic data, state-level premium comparisons, and the clinical realities of coverage loss.

Concern One: The Omission of Medicaid-to-Exchange Transitions

The WSJ Claim: The 1.2 million decline in Exchange enrollment is a minor correction caused by the removal of “ineligible” enrollees and the curbing of “fraud.” This suggests the expiration of pandemic-era subsidies did not cause a meaningful loss of coverage.

The Counter-Analysis: Viewing Exchange data in isolation ignores the movement between Medicaid and the ACA Marketplace. Under the 2025 Tax Act, Medicaid eligibility was significantly tightened through 6-month redetermination cycles and stricter work requirements.

The Exchange acts as a safety valve for those losing Medicaid. If 2 million people were removed from Medicaid due to the 2025 tax bill, a healthy system would see those individuals transition to the Exchange.

If the Exchange lost 1.7 million previous members and only gained 500,000 “refugees” from Medicaid, the total number of people losing ACA-style coverage is significantly higher than the “1.2 million” headline suggests.

The 2026 CMS report shows a 13% drop in “New Consumer” sign-ups. In a year where Medicaid rolls were being cut, new sign-ups should have spiked.

Concern Two: The missing context of the 6.8 million growth

The WSJ Claim: There are 6.8 million more enrollees today than in 2023 and nearly twice as many as in 2021, implying the system remains robust despite the reduction in subsidies.

The Counter Analysis: This growth actually suggests the enhanced credits were a successful way to expand coverage. In addition, the WSJ does not account for other factors behind the growth of state exchange enrollment.

Between 2021 and 2025, many small businesses dropped coverage because heavily subsidized ACA plans were more affordable for their employees. This “crowd-out” means many of the 6.8 million were simply shifted from private employer budgets to the federal budget. One of the impacts of this substitution was lower costs for some small businesses, not a bad outcome.

This KFF article shows that a lot of the expansion of state exchange enrollment during the Biden years came in conservative states including Texas, Mississippi, Georgia, Tennessee and South Carolina that had higher uninsured rates.

Concern Three: The “Paperwork Barrier” vs. Actual Fraud

The WSJ Claim: The removal of 1.5 million people from the rolls is a victory for “program integrity” and a necessary step to stop subsidies going to those who “didn’t submit income records.”

The Counter-Analysis: The editorial conflates procedural ineligibility (paperwork errors) with intentional fraud. Data suggests this aggressive “cleaning of the rolls” creates a high-cost burden on the healthcare system.

Audits show that roughly 77% of Medicaid “improper payments” are due to “insufficient documentation”—meaning the person may legally qualify but failed to navigate new, stricter 6-month filing windows.

Double Counting of Medicaid and state exchange enrollments is often a timing issue caused by state data lags. Cutting these people instantly results in a coverage gap where the individual has no insurance for 30–60 days.

As depicted in medical literature (and dramatized in series like The Pitt), losing access to maintenance medications for chronic conditions like asthma leads to a massive spike in Emergency Room visits. Basically, a monthly subsidy of ~$500 for Symbicort is significantly cheaper for the taxpayer than a single $2,000 ER visit. See Emergency Department Visits for Acute Asthma by Adults Who Ran Out of Their Inhaled Medications (published in Allergy and Asthma Proceedings and indexed via NIH/PubMed) or The Lancet: Asthma Commission Report or Episode 13 Season Two of the Pitt.

Concern Four: The Statistical Illusion of “Average” Premiums

The WSJ Claim: Average monthly payments of $137 ($73) for subsidized consumers) are “hardly a great hardship reduction” as they mirror 2022 levels.

The Counter-Analysis: These averages are a classic example of survivor bias. The “stability” in the price is caused by the mass exit of the population from some of the more expensive cases.

People earning over 400% FPL faced 100%+ price hikes. They have largely fled the system. When the people with the highest premiums leave the data set, the mathematical “average” of those who remain stays low.

Many who stayed “bought down” from Silver to Bronze plans. They pay the “low” $73 premium but have seen deductibles spike from $5,300 to $7,500+. They are severely under-insured. This problem is about to get a lot worse because of the proposed HHS regulations, which I recently reviewed.

The increase in state exchange health insurance costs for some people over age 60 may have delayed retirements prior to the age of Medicare eligibility. The decision to retain employer based insurance rather than retire and switch to state exchange may lower premiums because state exchange premiums are age rated.

Concern Six: The “Blue State Mandate” Myth

The WSJ Claim: Premiums in “Blue” states are double those in the rest of the country due to mandates for social care, such as gender-affirming care and IVF.

The Counter-Analysis: The claim that blue states are more expensive is not consistent with other data See this KFF table for state cost estimates.

· Standard Silver Plan, premiums in “Red” Texas ($661) are actually higher than in “Blue” California ($570).

· The disparity is even more pronounced in the mid-Atlantic, where West Virginia ($1,073) is roughly 75% more expensive than its neighbor Virginia ($612).

West Virginia’s premiums are among the highest in the nation primarily because of the “double whammy” of an uncompetitive hospital market dominated by a few consolidated systems and a high-risk patient pool with the country’s highest rates of chronic diseases like diabetes and heart disease.

Actuarial data shows that “social” mandates like IVF or gender-affirming care typically account for only 1% to 3% of total premium costs. These are marginal “carve-outs” in a framework where 75% to 85% of a premium is dictated by provider prices and chronic disease management.

Blue states are not a burden to red state taxpayers because on net they pay more to the Treasury than the receive while red state get more than they give.

Conclusion

The “stability” celebrated by the Wall Street Journal editorial board is a snapshot of a shrinking market rather than a sustainable system. By pricing out the middle class and forcing the near-elderly to choose between their health and their retirement, the expiration of enhanced subsidies hasn’t solved a crisis—it has simply moved it from the federal balance sheet to the kitchen tables of American families.

A Note on the Limits of Editorial Discourse

The complexity of healthcare economics—where variables like hospital consolidation, regional risk pools, and federal subsidy structures intersect—rarely lends itself to the brief, high-level format of an op-ed or editorial. While the Wall Street Journal provides a valuable platform for policy debate, the board’s recent reliance on selective statistics to support a “Blue State Mandate” narrative serves as a reminder that opinion pieces are often an insufficient mechanism for exploring such intricate issues.

When data is curated to fit a specific ideological lens—such as focusing on marginal social mandates while ignoring the massive cost impacts of provider monopolies—the resulting commentary risks being more misleading than informative. For a framework as vital as the ACA, a commitment fact-based analysis is a prerequisite for any meaningful discussion on reform.

Deep Dive: Expert Video Analysis For a visual breakdown of how the 2026 subsidy expiration is reshaping the health insurance landscape, I highly recommend this KFF briefing: KFF Expert Briefing: The 2026 Coverage Gap and the Subsidy Cliff