One of the untold elements of the rapid decay underway in the ObamaCare exchanges is the massive shift toward the Medicaid managed care companies, and away from the traditional commercial insurers like UnitedHealth Group and Aetna. In short order, ObamaCare is evolving into a Medicaid marketplace. Not only in terms of the design and quality of the narrow-network plans that are being offered, but in the actual carriers that sell those policies.

Advocates in Washington of the Affordable Care Act have been fighting tooth and nail to preserve the president’s signature health-care law—and they’re fighting even harder to expand it in the states. Conservative lawmakers in our home states of Utah and Florida recently defeated a combined three proposals to expand Medicaid under ObamaCare. They were absolutely right to do so, as the fiscal messes in states that did expand Medicaid demonstrate.

“Everyday people with good health insurance and ready access to medical care die of preventable diseases,” my friend John, a retired surgeon, wrote me recently. My friend was lamenting a recent article appearing in many Idaho newspapers about the tragic death of a woman with asthma. Her death was blamed on lawmakers who have refused to expand government-run programs like Medicaid to include able-bodied, childless adults.

Yesterday’s post discussed what we know about Obamacare as its third open enrollment season commences. Here are four major questions about the future of Obamacare that remain unanswered.

Douglas Holtz-Eakin is the president of the American Action Forum and a former director of the Congressional Budget Office. He also served on President George W. Bush’s Council of Economic Advisers. With the Affordable Care Act’s insurance marketplaces beginning their third open enrollment this week, RealClearHealth talked to Holtz-Eakin about what’s working, what’s not working, what can be done today to address problems with the law, and what should be on the agenda of a new administration in 2017.

Obamacare’s third open enrollment season kicked off yesterday, beginning the next chapter in its turbulent history. Today’s post discusses what we know about Obamacare. Tomorrow’s will discuss what we don’t yet know.

States that accepted Obamacare expansions have had Medicaid enrollment increase 18 percent, and total Medicaid spending grow 17.7 percent, a recent report from Kaiser Family Foundation has shown. Alternatively, states that chose not expand under Obamacare had Medicaid enrollment increase 5.1 percent and total spending grew 6.1 percent.

This is not particularly surprising. Obamacare has certainly led to more being enrolled within Medicaid—which has been costly for taxpayers.

Among many other changes to the health care system, the ACA created an expansion of Medicaid – made optional by the Supreme Court in 2012 – funded largely by federal dollars. Thus far, 30 states and the District of Columbia have accepted the Medicaid expansion. And as should be expected, states that expanded the program have seen spending grow much faster than those that didn’t. In a recent report, the Kaiser Family Foundation found that total Medicaid spending grew nearly 18 percent in expansion states, though the state share of growth was relatively low (less than 4 percent). And while health care has remained relatively quiet as a campaign issue, Governors Kasich and Christie – both Republican presidential hopefuls – expanded Medicaid (and both have defended this expansion) in their respective states.

Beginning in FY 2014, policy changes introduced by the Affordable Care Act (ACA) have been driving Medicaid enrollment and spending growth. This report provides an overview of Medicaid enrollment and spending growth with a focus on state Fiscal Year (FY) 2015 and state Fiscal Year 2016. Findings are based on interviews and data provided by state Medicaid directors as part of the 15th annual survey of Medicaid directors in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured (KCMU) and Health Management Associates (HMA). Information collected in the survey on policy actions taken during FY 2015 and FY 2016 can be found in the companion report. Key findings related to Medicaid enrollment and spending growth are described below.

Mercy will be the 58th rural hospital to close in the United States since 2010, according to one research program, and many more could soon join the list because of declining reimbursements, growing regulatory burdens and shrinking rural populations that result in an older, sicker pool of patients. The closings have accelerated over the last few years and have hit more midsize hospitals like Mercy, which was licensed for 75 beds, than smaller “critical access” hospitals, which are reimbursed at a higher rate by Medicare.