HCR Update from Mark Sanna: The lack of competition in nearly a dozen states could present problems when the insurance exchanges that are part of the Affordable Care Act launch in October. The exchanges are supposed to give Americans who do not get health insurance from their employers the opportunity to choose from an array of private insurance plans. The idea is to generate competition between insurers that will lead to lower premiums. But in states with a dominant insurance carrier, competition and lower prices may not arrive for quite some time.