I agree that, in theory, there is no actual "federal health insurance program" except insofar as the law stipulates what must be included in all plans to satisfy the govt minimum coverage for health insurance programs that are offered.
Yes, it would be ironic if the issue of the "exchange" concept were eventually responsible for leading to a single-payer system. However, an oversight in the law was the failure to provide for funding for a "Federal Exchange", even though it stipulates the Fed govt has the authority to establish such an exchange.
Since the law is so massively complex; and different parts could have been written by different individuals, or groups of individuals, that might be a reason for its inconsistencies.
It would seem reasonable that the insurors would want to participate to compete for a large consumer base that is mandated to purchase their product. However, if the price for these private sector plans is very expensive, then there might be a consumer demand for a govt option.
The concept of a "high risk pool" worked for auto insurance; however, even though auto insurance can be expensive, there are limits in its liability so the cost is relatively small compared to health insurance which has much higher limits of liability. And there are some insurors who do not offer products in some states. I'd have to guess that the profit margins, at a competitive price, are not attractive enough to do so.
I've never quite understood why it was not possible to cross state lines to purchase health insurance. With life and auto insurance, an insurance company gets a license to sell its products in a state, and satisfies that state's criteria for doing business in the state. The fact that Prudential had its home office in NJ doesn't prevent it from doing business in PA ... and, indeed, it (now owned by Metropolitan) sells group health insurance in PA. So, not sure what all this talk is about not being able to cross state lines for health insurance.
It is reasonable for states to have requirements, like reserves, for an insuror doing business in the state. Consumers should be assured that their insuror will have sufficient funds to actually pay their claims when they are made. However, an insuror in Iowa might have low rates, but if they sold a policy in NJ, they might actuarily have to charge nearly as much as those companies residing in NJ since the cost of care in NJ may be higher than it is in Iowa. The Iowa company might enjoy some savings by having its bricks and mortar in a place that is less expensive than residing within NJ, where the bricks and mortar are quite expensive.
We've discussed the premium increases people have seen ... but I think there was also a requirement in the law that the premiums were going to be reviewed by govt to assure that a certain percentage of premium MUST go toward benefits provided. You will recall the "refunds" that the insurors were required to issue if their prescribed ratio had been exceeded. So, the govt has provided the mandatory minimum coverage that must be offered; and also has limited/mandated how much is allowed for administration and profit on their products.
If truly the number of doctors and hospitals (per capita) decreases, that would seem to lessen competition (while demand increases) for the services of those remaining. Will prices go up even more?