IMHO if VA, Medicare and federal employee coverage were a gov't backed NPO insurance company, that could provide a baseline and competition. Of course, that would have to also cover the administration and congress. That would act as both a baseline and incentive to compete, with that corporation open to state, company and individual plans.

As to pharmaceutical costs, there's two things that need to happen First is that extension patent approvals must be significantly reduced (requiring moving more of the patent fees up to the application stage to cover more review/appeal costs). The second would be statutory licensing for all patents on medication after say 5 years, allowing for generics at a fixed patent licensing fee after the patent is 5 years old.

Those would be things to improve competition.