Right. Lets first recognize that all these "challenges" occur because we, as a society, don't want to live with the results of an entirely free market (where insurers would only sell policies to people after a medical exam and assessment of risk, etc). We want everyone, sick and healthy, poor and rich, to have basic medical care. So, we need to interfere to achieve these results. That interference could take many forms. There are ways to spread the high costs of providing basic insurance to the sick and elderly (by eliminating all physical exams/medical history reviews and making everyone pay the same thing. There are other ways, too.). There are ways to prevent people from getting insurance at the last minute or after they need it (the present law does this by making insurance mandatory, with fines for those who don't buy it. This may be unconstitutional, we'll see. There are plenty of other ways to accomplish this with waiting periods, mandatory durations before switching insurers, etc). All of this is do-able, and necessary if we want to achieve some of the social objectives that an entirely unfettered free market fails to achieve. If we do it right, we get many of the benefits of a market based system (competition, with attendant lower costs and higher quality). If, instead, we go with a command-driven centralized government model, I think we all know what we'll get.