Aetna will complete its withdrawal from Affordable Care Act state insurance exchanges in 2018. The huge insurer, which overall is very profitable, said that continuing financial losses in the exchanges and uncertainty about the marketplaces’ future led it to decide to leave the last  two states  — Delaware and Nebraska — in which it has been on ACA exchanges. Just last week it said that it would stop offering ACA health plans in Virginia in 2018 and last month it  said it would leave Iowa.

Aetna Chief Executive Mark Bertolini has said that the ACA marketplaces were in a “death spiral,” which the nonpartisan Congressional Budget Office said isn’t true.

The exchanges have been undermined by the fierce opposition to the Affordable Care Act of the Trump administration and Republican politicians in Red States.

Insurers, for their part, complain that their ACA plans attract too few of the young and healthy customers needed to offset the expense of covering older people, who, of course, tend to have more serious  health problems than do younger people.

A major reason is that the financial penalties for people for not buying insurance are far too small.

For example, the penalty for not buying insurance for an adult is $625 per adult and $347.50 per child under 18. So a lot of younger healthy people decide to pay the fine, which is much cheaper than paying insurance premiums. And if they get sick or injured, they can go to a hospital ER, where all or some of the costs will be covered by the hospital, in the form of “charity care” and local, state and federal governments.

It’s all just another example of why  the U.S. healthcare system is near the bottom in medical outcomes and at the top in costs in the Developed World. It’s immensely complicated and contradictory, fee-driven and fueled by the desire of many, perhaps most, clinicians and hospital and insurance executives for maximum personal profit.

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