>>Have you ever lived under a single payer plan? I have. Why don't you try living under one for a few years and then speak from experience? It is a way of rationing health care.

Every health system has rationing. Pre-ACA (and ignoring the millions without good access to care:) US insurers rationed via exclusions, refusal/delayed approval for expensive care and/or strategic rescission. There was a good reason why healthcare costs were the biggest cause of bankruptcy for the middle class- because care they needed was so heavily rationed by payers. This behavior is stopped by the ACA, so at face value, rationing isn't as onerous for patients now. Which is why people who focus only on premium cost, are grasping the wrong end of the wrong stick IMHO.

As Tamar notes, the ACA assists millions more to access care, so those people are no longer rationed out of the market either.

I don't want to demonize the insurers too much - because if they weren't rationing and simply paid out on every bill, your premiums would rise and rise, for which of course you'd blame the ACA rather than your own dislike of rationing.

I do see a potential problem with insurer margins capped at 20% by the ACA. While this prevents gouging, it also removes the incentive for the payer to try to control costs. Rising cost justifies rising premiums and makes shareholders smile as the 20% margin follows suit. Profit increases without needing to fight for new business or traditional competition if prices are on the up. Worse, successfully driving down the cost of care inevitably reduces premiums if margin is capped, which then reduces your share, so price competition is worse for insurers.

In this respect you could point fingers at the ACA, though it doesn't make sense to criticize rationing when it's ineffective rationing/perverse incentives against rationing that causes premiums to rise if margins are capped.

Finally, Michael C made a very good point about most insurance being for cover for catastrophe, whereas health insurance is expected to include routine care. There's no incentive for innovative policies allowing people only to access health insurance in the event of catastrophe and there's no incentive for patients to moderate their consumption of services. In fact, some people calculate their consumption of healthcare and feel they got a bad deal unless their consumption exceeded their premium cost. This attitude drives up premium cost and has nothing to do with the ACA and everything to do with moral risk if people are inadequately insured.