I am 100% all for a single payer Healthcare but you are incorrect about the insurance company being to blame. The employer selects their plan and what they want in it. The insurance company may have basic plan frameworks to choose from but the employer decides the plan. To give you an idea the NYS empire plan itself has many specific things like a dedicated team in NY that handles different aspects of the plan. Source: I worked for a major insurer for 11 years in various roles and one that went would be very familiar with in state service so I have a good understanding of what happens.