A new study in the New England Journal of Medicine suggests that the assumption that the ACA would lead to lower Emergency Room use was wrong as Medicaid expansion in Oregon produced a spike in ER visits. A surge in ER use will likely produce adverse health consequences for many and may be contributing to skyrocketing Medicaid expansion spending, which was 49% higher per enrollee in 2015 than the government expected.

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The end of Barack Obama’s presidency is near, and his most important domestic policy accomplishment is teetering and threatening to fall and smash to pieces.

Obamacare, or at least the most-touted part of it, is failing, and for not for mere technical reasons.

By expanding Medicaid, it got more people insured. But the president’s experiment manipulating private insurance markets has created no net benefit and is headed for disaster unless enrollment miraculously skyrockets.

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Bob Kocher and Ezekiel Emanuel, who worked in the Obama White House on health care reform, argue that it’s “misleading” to raise concerns about the fact that individual market health insurance premiums have nearly doubled under Obamacare. “Premiums today,” they say, “are 20% lower than the Congressional Budget Office predicted when the ACA was passed.” Their argument is nonsensically out of touch, and it illustrates why the designers of the ACA got so many things wrong. The unaffordability of exchange-based insurance is the ACA’s most serious problem. As research from Avalere Health has shown, enrollment in ACA-based insurance is alarmingly low among those whose incomes exceed 200% of the federal poverty level.

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President Barack Obama delivered a robust defense of Obamacare on Thursday, but also acknowledged his signature domestic achievement needs fixes as premiums rise and insurers are fleeing the law.

Obama hailed the achievements of the federal health care law six years after passage, providing coverage to an additional 20 million Americans and reducing the uninsured rate to the lowest level ever recorded. And he sought to remind Americans that they likely benefit from the law’s consumer protections, even though just a small fraction of the country actually buys coverage from Obamacare’s insurance marketplaces.

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Major insurers participating in Obamacare have won approval for substantial premium hikes next year in a dozen or more states. The increases range as high as 30 percent to 50 percent, according to new data.

Shaken by the decisions of Aetna, UnitedHealthcare, Blue Cross Blue Shield and other giants to pull out of many states after incurring hundreds of millions in losses, state insurance regulators appear more than willing to go along with these rate increases to prop up insurers remaining in the program.

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Under pressure to stabilize wobbly insurance markets nationwide, the Obama administration is making a new push to sign up Americans for health coverage through the Affordable Care Act, aiming to increase enrollment by about 1 million in 2017. With insurers canceling health plans or raising premiums by double digits in many parts of the country, that represents only modest enrollment growth over 2016.

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After months of health insurer exits from the Affordable Care Act marketplace in Arizona, state regulators have approved plans from two companies that will be the only marketplace insurance providers next year.

Blue Cross Blue Shield of Arizona will sell marketplace plans in every county except Maricopa County in 2017. The Phoenix-based insurer’s average rates will increase 51 percent, Arizona Department of Insurance filings show.

Maricopa County residents only option will be Centene Corp., which said it will sell its “Ambetter” plans. State regulators approved a 74.5 percent increase for Centene/Ambetter plans.

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The 40% “Cadillac” Tax on expensive employer-sponsored health insurance is on a deathwatch because both parties in Congress dislike it. It would be best if Congress were to replace the Cadillac Tax with a simple and clear limitation on the tax preference for employer-paid premiums, as is called for the House GOP’s “Better Way” health plan. For decades, economists have complained that the open-ended tax break for employer-paid health insurance premiums is a major distortion in the marketplace. This approach is fair and promotes more transparency in the health care marketplace.

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In the last moments of the final presidential debate Wednesday, the candidates used a question about entitlements to restate their positions on Obamacare. Donald Trump again vowed to “repeal and replace” the law and said that he was glad premiums had gone up, presumably to make his point that President Obama’s signature health care reform law was “destroying our country.” Hillary Clinton said repealing Obamacare would make maintaining the solvency of Medicare more difficult.

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State insurance regulators across the country have approved health care premium increases higher than those requested by insurers, despite a national effort to keep rates for policies sold on Affordable Care Act exchanges from skyrocketing, a USA TODAY analysis shows.

In eight states, regulators approved premiums that were a percentage point or more higher than carriers wanted, said Charles Gaba, a health data expert at ACASignups.net who analyzed the rates for USA TODAY. As of Tuesday, those states are Arizona, Pennsylvania, Colorado, Florida, Georgia, Kansas, Minnesota and Utah.

Pennsylvania regulators approved individual plan rate increases Monday of 33%, which is eight points higher than requested. Two insurers — Keystone Health Plan and Geisinger Quality Option — will also no longer offer plans on the ACA exchange for the state.

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