The time is drawing near for medical insurers to join the Affordable Care Act lineup, but the only ones who have signed up in Hawaii so far are the two that control 92 percent of the health insurance in the state.

While the eventual cost of health insurance remains a source of speculation in most states, Hawaii will need to draw more competitors to keep prices affordable.

The Affordable Care Act allows each state to design its own insurance exchange as private insurance companies compete to offer plans that meet the law’s coverage standards. Those include insuring anybody regardless of pre-existing conditions and following tiers of premiums. Enrollment starts Oct. 1 and coverage begins Jan. 1.

More competition generally drives down prices, and consumers in most states will be comparing five or more carriers when the new marketplace takes effect.

The Hawaii Health Connector, the state’s online health insurance exchange under the law, so far has only two players — Hawaii Medical Service Association and Kaiser Permanente Hawaii. Most mainland insurers are understandably reluctant to open offices in Hawaii or work with medical providers in Hawaii from far-away offices.

"If you are a patient, do you want to have to make a phone call back to the mainland if there’s no other office here in order to handle any issues that might arise with our insurance?" George Greene, president and CEO of the Healthcare Association of Hawaii, pointed out last December.

University Health Alliance, Hawaii Medical Assurance Association and other insurers have decided not to participate on the exchange, leery of competing against the state’s dominant health plans and uncertain about the eventual size of the market. Administrators of the Hawaii Health Connector hope they eventually will enter the market, said Connector spokesman Brian Fitzgerald.

Another possible entry to the exchange is Family Health Hawaii, incorporated last year by former Foodland and Times supermarkets executive Roger Godfrey. Former state Insurance Commissioner J.P. Schmidt, the new insurer’s CEO, has said Family Health might consider being part of the exchange.

"We’re hearing of some statewide or national plans looking to come into the marketplace," Fitzgerald said, "although nobody that we know of has submitted plans to the insurance commissioner or the Consumer Division to participate in the exchange at this point."

Rick Budar, the Connector’s chief marketing officer, told the Star-Advertiser’s Kristen Consillio that one of the Connector’s missions is "to create more competition and a level playing field."

It should be the No. 1 mission at this point. Fitzgerald said that a bigger customer base, along with certain administrative and marketing services provided by the Connector, will help insurers keep costs down. And HMSA and Kaiser will provide a variety of plans to choose from. But consumers can’t count on their good graces.

Already, HMSA executives have warned of a "rate shock" for consumers next year because of the demand for medical services among people who don’t have insurance now. Moreover, HMSA’s chief financial officer, Steve Van Ribbink, said the insurer intends to pass on to consumers the cost of a 2 percent fee on premiums to support the Connector’s operations.

"If you don’t go onto the exchange, you don’t have to pay it," he said. "So why would you go onto the exchange?"

Faced with such pessimism, the Connector’s administrators will have their hands full with their essential mission to keep the Affordable Care Act, well, affordable.