>>i got my small business healthcare renewal - $24k for the year.

In fairness, the ACA doesn't impact much on your business policy, or those of the majority of US voters on similar policies. There are disclosure and incentives for preventive care programs, but probably the biggest impact is that insurers must spend at least 80% of premiums on actual care.

So why are premiums rising?

The biggest perverse inventive is that if the insurer's share is 20%, increasing the premium increases their income without lifting another finger. Unlike Medicare and similar single payer models, there's no incentive for insurers to try to hold down prices.

Might as well tell you that these days when former colleagues from other first world nations visit the US, they report that doctors at the US healthcare coalface earn less per consultation/interaction than their foreign colleagues providing private care. And yet your healthcare costs twice as much. There was a time when physicians gravitated to the US from other first world nations; the flow is the opposite direction now, with your incoming physicians more likely to represent a United Nations of third world countries. The problem is that between the physician and patient there are too many others wanting to clip the ticket and they are highly motivated to prevent any disturbance to their busy clickwork. In your shoes, I'd be reconsidering my dislike for single payer care that may well be the least painful way out of this mess now. You can even keep the private aspect as long as reward and incentive is tied to best result for payer and patient rather than elite executives and shareholders.