Listened to a bit about this on the radio today. An interesting aspect was one of marketing, which surprised me. Basically, you need younger, healthy people to get insurance to keep costs reasonable. But if it is hard to enroll, or they don't know how, they will just risk skipping insurance. Meanwhile the people with cancer or diabetes will do whatever they have to to sign up, even if it means hours on the phone on hold, whatever. So California spends a ton on marketing, and keeps open enrollment open longer, and in response they get more healthy people signed up, which lowers costs and keeps the insurance companies happy....which is one of the reasons they still have 11 plans to offer in that state versus what is happening in other places. If the insurance company knows only the very sick are likely to sign up they will cut their losses and run.
Of course, we just decided to shorten enrollment periods, cut the marketing budget to 1/10 of what it was (and the marketing budget also goes to upgrading the sign up websites), take away payments to the insurance companies, stop enforcing penalties for not signing up, etc. Basically, everything possible to make sure only the very sick sign up. Sigh.