“So what happens to those insurers who remain outside the exchanges, which are all of them now?”
In reality, only those purchasing through exchanges will qualify for federal subsidies, so it seems unlikely any insurers would remain outside exchanges.
Second, this fee is particularly bizarre in light of health insurance industry profits, which average only 6-7% (return on revenue). Thus, the exchange fee is equivalent in magnitude to private health insurers trying to raise their profits by 50%. If they did so, progressives would scream bloody murder, but when government does the same thing, it’s “all good.”
So as long as the subsity is way more than the fee then it is worth it.
The states that let the Feds set it up were not worried about the Subsidies anyway,