That's a good point, Echo.
The ACA tried to make insurance more maintenance, so in that sense we have had maintenance since it passed. Before that, if anything was wrong with you that needed maintenance, you couldn't get insurance or were kicked off. COBRA was put in place, but that was collapsing if you ask me when the economy tanked and people went so long without finding jobs they could get a new plan with.
ACA itself was based on the idea of people who don't use healthcare to buy it anyway - that's an insurance concept. One of the reasons it's been problematic. Employer-provided insurance is the same thing, come to think - same pooling concept. Insurance is for the healthy. Preventive care is once a year to a GP for a weigh in. When s/he finds something, the process of getting kicked off begins.
One thing that interests me is the complaint about rising premiums since ACA. My premiums were always going up like that. When I worked for my English boss in our micro enterprise, we had the same problems as a company. The uptick has been on a consistent track for 30 years for me. I don't see that ACA made it worse. It was always going to be as bad as it is now.
I'm thinking the differences between states must be radical. (And that California has been subsidising a lot of the country. We get much less back from our contributions to the Federal level than other states; I do know that...haha. Attack attack on all y'all )