When Dennie Wright went to sign up for Affordable Care Act insurance last year, it wasn’t a hard decision. His insurance agent told him he had only one insurer – Anthem Blue Cross – that he could buy from on the exchange, Covered California.

Wright lives in a modest house overlooking a pasture in Indian Valley. It’s a tiny alpine community at the northern end of the Sierra Mountains, close to the border with Nevada. He lives in one of more than 200 zip codes where Blue Shield of California has stopped selling individual insurance policies.

“That was new to us, you know, Covered California. Anthem Blue Cross was the insurance carrier. Then of course, three months later I have a heart attack,” says Wright.

More than once, he was flown across the state line to Reno for care. Wright and his wife, Kathy, now have piles of medical bills and insurance paperwork. Anthem Blue Cross covers emergencies when they happen out-of-state but not routine doctor care in another state.

But Wright says traveling to doctors within California is not as safe or as convenient for him as going to Reno.

He continues to see the Nevada doctors who put a defibrillator in his chest and saved his life. Anthem Blue Cross will pay for some of the bills, but the Wrights still don’t know if everything will be covered.

There are other insurance options for Wright, but not through Covered California. Although he didn’t need a subsidy, he was left in the same position as people in his area who do need financial help to buy insurance. They cannot take their business to a competitor, because the exchange is the only place customers can use federal subsidies to help them buy health insurance. And for those people, Anthem is the only option.

“I mean, you should have some choices, especially if you’re going to have one that’s not going to cover you in the places you choose to go,” Wright says.

Covered California Executive Director Peter Lee offered a different impression of choices in the marketplace last July.

“In every corner of the state, consumers will have at least two plans to choose from, and in most areas, where most of the Californians live, they can choose between five or six plans,” said Lee during an event to announce the marketplace’s 2015 plans and premium rates.

But in twenty-two counties in Northern California, there are zip codes where there is only one choice of insurer. There are areas near Monterey and Santa Cruz on California’s Central Coast that also have only one carrier.

Blue Shield of California said it had to stop selling exchange plans in areas where it couldn’t ensure an adequate network of doctors.

Covered California estimates that statewide, there are 28,896 Covered California customers who have only one choice of insurance carrier, slightly more than 2 percent of the total exchange membership as of November 2014.

Lee says now, the exchange is working to increase the range of choices in places where there are none. But he says the situation existed long before the exchange.

“The challenges of northern, rural counties have been there for a long time and are still a challenge that we’re trying to address head-on,” says Lee.

Lee says the exchange is encouraging existing plans to expand to areas where there are enough doctors. And it’s looking to bring new carriers in for 2016.

“We aren’t the solution to all the problems that have always been there in terms of challenges in rural communities, and that’s something we’re certainly looking at how to improve access and choice, and we’ll continue doing that,” says Lee.

Covered California should help increase the number of insurers, says consumer advocate Anthony Wright from Health Access. And he says policy makers should also lean on insurers and providers to participate in that market.

“Some of this is a combination of putting pressure on the insurers, and some of this is trying to do work to actually increase the number of providers on the ground in these areas, whether through more training, [or] incentives to be in some of these more rural areas,” says Anthony Wright.

Wright, the advocate, says more insurers in the marketplace makes it more likely people can get the care they need.

“At one level, we’re trying to make a functioning market, but it still means that consumers are at the mercy of the market.”

This year, people who want more choice than what Covered California offers must venture into the broader health insurance market if they can afford it.

This story is part of a reporting partnership with NPR, Capital Public Radio and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Department of Health and Human Services Secretary Sylvia M. Burwell Thursday called on Congress to look beyond the Affordable Care Act to find compromise on health care.

In remarks at the New America Foundation, Burwell cited several areas – including opioid abuse, Ebola, medical research and innovation – where Republicans and Democrats have sponsored legislation to work together to solve problems in the nation’s health care system.

As she has before, Burwell defended the health overhaul and urged Congress to “move beyond the back and forth of the Affordable Care Act and focus on the substance of access, affordability and quality.”  She makes no apologies for the law, which Republicans have voted numerous times to repeal in full or in part. That effort is expected to be part of the discussions this week at Republican lawmakers’ retreats.

But those disagreements should not stop Congress from also focusing on “other critical areas in health care where our common interests give us ample opportunities for common good – improving the quality of the care we receive while spending our dollars more wisely, reducing substance use disorders and overdose deaths, strengthening global health security, reaffirming American leadership in research, innovation and science, and building an innovation economy,” Burwell said.

In a statement, Sen. Lamar Alexander, R-Tenn., the new chair of the Senate Health, Education, Labor and Pensions Committee, welcomed Burwell’s remarks and said he looked forward to working with her.

“We have plenty we disagree on, but we also have plenty of issues that are important to millions of Americans upon which we should be able to get results, including, for example, getting life-saving drugs, treatments and devices through the FDA to patients faster; remodeling the health care delivery system; and improving global health security,” he said.

While repealing or replacing the health law is an avowed target for many in the GOP, Republicans are likely more eager to work with the administration on legislation to extend funding for the Children’s Health Insurance Program (CHIP) and to overhaul the way Medicare pays physicians, known as the sustainable growth rate, Burwell said.

“I think those fall into the category of things where I think there will be bipartisan support,” she said. “I think those are very clearly legislative issues that Congress will take the lead in terms of timetable and focus. … I see both of those in that category of greater possibility for working together.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

In health insurance prices, as in the weather, Alaska and the Sun Belt are extremes. This year Alaska is the most expensive health insurance market for people who do not get coverage through their employers, while Phoenix, Albuquerque, N.M., and Tucson, Ariz., are among the very cheapest.

In this second year of the insurance marketplaces created by the federal health law, the most expensive premiums are in rural spots around the nation: Wyoming, rural Nevada, patches of inland California and the southernmost county in Mississippi, according to an analysis by the Kaiser Family Foundation, which has compiled premium prices from around the country. (KHN is an independent program of the foundation.)

The most and least expensive regions are determined by the monthly premium for the least expensive “silver” level plan, which is the type most consumers buy and covers on average 70 percent of medical expenses. Premiums in the priciest areas are triple those in the least expensive areas.

Along with the three southwestern cities, the places with the lowest premiums include Louisville, Ky., Pittsburgh and western Pennsylvania, Knoxville and Memphis, Tenn., and Minneapolis-St. Paul and many of its suburbs, the analysis found.

Starting this month, the cheapest silver plan for a 40-year-old in Alaska costs $488 a month. (Not everyone will have to pay that much because the health law subsidizes premiums for low-and moderate-income people.) A 40-year-old Phoenix resident could pay as little as $166 for the same level plan.

That three-fold spread is similar to the gap between last year’s most expensive area — in the Colorado mountain resort region, where 40-year-olds paid $483—and the least expensive, the Minneapolis-St. Paul metro area, where they paid $154.

Minneapolis remained one of the cheapest areas in the region, although the lowest silver premium rose to $181 after the insurer that offered the cheapest plan last year pulled out of the market. Premiums in four Colorado counties around Aspen and Vail plummeted this year after state insurance regulators lumped them in with other counties in order to bring rates down.

Cynthia Cox, a researcher at the Kaiser foundation, said the number of insurers in a region was a notable similarity among both the most and least expensive areas. “In the most expensive areas only one or two are participating,” she said. “In the least expensive areas there tends to be five or more insurers competing.” She said that other factors, such as whether insurers need state approval for their premiums and the underlying health of the population, may play a role as well in premiums.

The national median premium for a 40-year-old is $269, according to the foundation’s analysis.

Alaska’s lowest silver premium rose 28 percent from last year, ratcheting it up from 10th place last year to the nation’s highest. Only two insurers are offering plans in the state, the same number as last year, but the limited competition is just one reason Alaska’s prices are so high, researchers said. The state has a very high cost of living, which drives up rents and salaries of medical professionals, and insurers said patients racked up high costs last year.

Ceci Connolly, director of PwC’s Health Research Institute, noted that the long distances between providers and patients also added to the costs. Restraining costs in rural areas, she said, “continues to be a challenge” around the country. One reason is that there tend to be fewer doctors and hospitals, so those that are there have more power to dictate higher prices, since insurers have nowhere else to turn.

By contrast, in Maricopa County, Phoenix’s home, the lowest silver premium price dropped 15 percent from last year, when Phoenix did not rank among the lowest areas. A dozen insurers are offering silver plans. “Phoenix, during the boom, attracted a lot of providers so it’s a very robust, competitive market,” said Allen Gjersvig, an executive at the Arizona Alliance for Community Health Centers, which is helping people enroll in the marketplaces.

The cheapest silver plan in Phoenix comes from Meritus, a nonprofit insurance cooperative. The plan is an HMO that provides care through Maricopa Integrated Health System, a safety net system that is experienced in managing care for Medicaid patients. Meritus’ chief executive, Tom Zumtobel, said they brought that plan’s premium down from 2014. The insurer and the health system meet regularly to figure out how to treat complicated cases in the most efficient manner. “We’re working together to get the best outcome,” Zumtobel said.

Katherine Hempstead, who oversees the Robert Wood Johnson Foundation’s research on health insurance prices, found no significant differences in the designs of the plans that would explain their premiums. “In most of the plans – cheap or expensive – there seemed to be a high deductible and fairly similar cost-sharing,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.