The insurance companies lobby for and buy themselves such laws, and like all the other business friendly legislation they even write most of the bills themselves. Most people never read bills or even bother to keep track of of what their pols do, so obviously they're fine with this, and also the vast majority of business friendly legislation, so it's clear the pols aren't just popping up out of nowhere and just arbitrarily doing their own thing, so the semantics game fails. And, like I said, the VA works for a lot of people just fine, so obviously if it isn't working in some region then the problem is the people in that region and those they elect. And, I see I forgot to point out the reasons these insurance companies can set up these state monopolies is because of the 'states' rights' functions of governments, not the Feds; corporations are state-created entities, not Federal ones, so it's another case of right wing Constitutional literalism contradicting itself re 'free enterprise' and the like. If one attempts to 'reform' that and allow competition from other states, then one is going to have to nullify some 'states' rights' legal prerogatives to do so. Think that isn't a problem? ... The usual ad hoc handwaves don't work in this case, or mosto thers for that matter.