Rural Americans don't have much choice when it comes to healthcare. Here, an emergency room in Lancaster, PA.
Rural Americans don't have much choice when it comes to healthcare. Here, an emergency room in Lancaster, PA. - 
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When you think of the healthcare marketplace, you think of options and choices. 

But since the rollout of the Affordable Care Act, one thing's been clear: Options are not a given. Alabama is among a dozen or so states where every county has just one--or maybe two-- insurers. Experts are noticing a pattern: Folks in rural towns seem to have the fewest choices, and the costliest plans.

In Blount County, Ala., most people work at either the school board or at a chicken processing plant. On a recent Saturday morning, a handful of locals gather at a church to learn about their health insurance options.

Chris Mosley, a supervisor with Birmingham Health Care, tells them that here, as far as insurance companies go, it's slim pickings.

"In Blount County, if an individual is going to participate, they're going to have to buy either a bronze, silver, gold or platinum plan specifically from Blue Cross and Blue Shield of Alabama," he tells the audience. "Because as I say, the other competitor is not competing in your county, OK?"

In Alabama, Blue Cross and Blue Shield pretty much owns the health insurance market. In 64 of Alabama's 67 counties, it's the only insurer through the federal healthcare exchange. People in the other three counties also have Humana as an option. But, Mosley says, "Most people don't know about Humana. It's not a company that people are very familiar with."

Cynthia Cox, a policy analyst with the Kaiser Family Foundation, says most insurers under the Affordable Care Act are offering multiple plans to choose from. The issue is, it's usually just one company offering all the plans.  

"Enrollees in these areas will be able to choose between different levels of coverage, but the bigger issue is the lack of competition," she says.

Mike Doonan, executive director of the Massachusetts Health Policy Forum, says that can have a profound effect on consumers.

"So the less competition there is in the marketplace, the less incentive there is for health insurance companies to keep their premiums low," Doonan says.

And Cox adds that where one insurer dominates, you see higher premiums.

"For example, a 40 year-old in an area with just one insurer might pay $20 a month more than if they were living in an area with multiple insurers," Cox says.
Access is tougher in areas with just one carrier. In rural New Hampshire, Anthem Blue Cross and Blue Shield is the only carrier through the exchange, and it just cut the number of hospitals in its network.

So why are rural areas being hit so hard? Well, because there are fewer people there.

But Mike Doonan, of the Massachusetts Health Policy Forum, says even in states where there's virtually no competition, there's one huge incentive to keep premiums affordable.

"They do want to attract people and get them enrolled," he says. "And if they do put their premium rates too high, then people are going to opt to pay the penalty."

Especially healthy people, he says.

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