While not in the US insurance system, I have had a keen interest in the ACA and the subsequent political events and discussions on health care.
It seems to me that the ACA created an environment that was way too complicated and that IF a national healthcare insurance system is to be successful, it needs to be truly national - meaning the same insurance (rates, options, coverage extent, etc.) across states, counties, etc., and of course single-payer. If a truly national single-payer system were implemented the insurance companies would be relegated to selling top-up policies to cover co-pays and whatever the national system might not cover (for example, hot springs treatment, single patient rooms, etc.).
I am following conversations in cancer forums in the US and UK, and the hoops US citizens must jump thru seem onerous in comparison to the UK, and what I have here in Japan.
Of course there is a cost ? since nothing is free, but in the US that cost is simply paid to the insurance companies, paid into the medical industry thru higher (non-negotiated) costs, or bourn thru suffering by those who are ill and unable to obtain care appropriate to their illness as determined by their physician. It seems to me that the real issue in the US is whether one believes that having a healthy populous is important or not as a government priority ? and at a level comparable to military security, infrastructure, the rule of law, education, the economy, etc.