One of the big promises of the Affordable Care Act was that encouraging insurance companies to compete to sell their health plans would drive down prices.
Here in Austin, people who choose to buy health insurance on the federally-run health insurance marketplace have dozens of plans to choose from. Texans in many rural parts of the state will find far fewer. But they're not necessarily more expensive than in urban parts.
Take Loving County. It's pretty rural. According to the Census Bureau, just 71 people were living in this West Texas county in 2012, down from 82 in 2010.
Considering how remote it is, you might think health insurance for people living there through the federally run marketplace is more expensive than in Travis County.
"Where I think you’ll find across the board that rural areas have fewer choices as far as the number of insurers and plans to choose from, it’s not fair to assume from that, that they are paying higher premiums," says Stacey Pogue, senior health policy analyst with the Center for Public Policy Priorities in Austin.
Pogue says that in Loving County, a full-price bronze plan from BlueCross BlueShield for a 27 year old costs about $133 a month, without any tax credits. In Travis County that same plan would cost about $144.
A bronze plan is the least expensive category of plans. A silver plan – the second least expensive – with BlueCross could cost $233 for a 27 year old in Loving and $251 in Travis.
Although Melissa Perryman, an insurance broker in Austin who's also with the Texas Association of Health Underwriters, says it’s important to make sure both plans have the same deductibles when comparing prices, she says she's not surprised that they are actually cheaper in rural Texas.
"The centers of influence if you will, and the specialty centers, the cost of care has always been more expensive," Perryman says. "A doctor visit in Houston versus a rural area is more expensive because of overall cost and training and their renown they will warrant those higher rates."
Don McBeath says though rural Texas only has one or two insurance companies in the marketplace, finding a plan is not the biggest challenge. He is the director of government relations for the Texas Organization of Rural and Community Hospitals (TORCH).
"The challenge sometimes is finding an insurance plan that has your local doctor and your local hospital on it," McBeath says.
Texas has a shortage of doctors – especially in rural areas. According to TORCH, rural Texas has counties with as many as 50 percent of residents uninsured. McBeath says Census data shows that 14 of the 15 counties with the country’s highest uninsured rates are in rural Texas.
"As a whole, people in rural Texas are older and they’re poorer," McBeath says. "So there are other challenges certainly for people to access health care besides whether just they can find an insurance plan or whether it’s affordable. The bigger challenge is there aren’t enough providers."
That’s not surprising if 64 counties of the 254 in the state don’t have a hospital.
That doesn’t stop FirstCare from offering insurance plans in rural West Texas.
"We've served them for decades … and this is an exciting year where many people are positioned to gain access to coverage they haven't had," says Merit Smith, FirstCare's vice president for strategy. "And we want to serve them and we want to serve our community so we wanted to participate in the exchange."
Other companies decided to hold off before joining the marketplace.
In a statement to KUT, UnitedHealthcare says the company will evaluate the marketplace after 2014 and decide if it will bid to participate in the Texas exchange.
TORCH's McBeath says even if there were more plans available, it doesn’t mean rural Texans would rush to get insured.
"A lot of people don’t want to be found. It’s just how it works," McBeath says. "They don’t want to sign up for a plan that knows who they are and where they are. There’s a lot of reasons and it’s complicated."