By Trudy Lieberman

As Obamacare approaches its fifth sign-up season, policyholders in many parts of the country are facing a marketplace with fewer choices and higher premiums.

A New York Times analysis has found that 45 percent of U.S. counties probably will have either just one insurer or no insurers to choose from. That means some 3 million people in nearly 1,400 counties might have only one carrier and about 35,000 people could have none.

Many of those counties are in rural states like Nevada, Colorado, Wyoming, Nebraska, Ohio, Kentucky, Missouri, Mississippi, and North Carolina.

In dollars and cents that means those living in areas without a carrier must buy coverage in the regular marketplace where they will get no subsidies to help pay their premiums. Subsidies are available only for people buying Obamacare policies on the state shopping exchanges.  About 85 percent of the 12 million Americans with Obamacare policies get subsidies, which make it possible to afford coverage.

For people with a single carrier in their county, limited options could mean high premiums for the policies available.

“Blue Cross is out of Wisconsin, Indiana, Iowa, and Nebraska,” says Washington D.C. insurance consultant Robert Laszewski. “In Tennessee Blue Cross is out of two major cities and for the carriers staying in, the rate increases are to the moon.”

The carrier will also be out of Ohio next year, a state where it had been a major insurer. This is not exactly the outcome that supporters of Obamacare had hoped for. The politicians who wrote the law and its advocates tried to defy the basic laws of insurance. They wanted to keep the private insurance market and still allow everyone sick or well to get coverage. In other words, Obamacare tried to square the circle.

But insurers make money by selling to healthy people while trying to minimize the claims they get from the sick. The ACA called for insurers to issue policies to everyone regardless of their health status. That meant thousands of very ill people came into the risk pool, and in many areas not enough healthy people signed up for coverage to balance them out. Laszewski noted that only 40 percent of eligible people signed up, a recipe for trouble in too many counties.

“The most difficult place to make the marketplace work is in rural areas,” says Timothy McBride, a health policy professor at Washington University in St. Louis. “It’s an intractable problem in some places,” largely because rural communities have low populations, and the percentage of unhealthy people tends to be higher than in the cities. “Policymakers were hoping they’d get this fixed, but they haven’t been able to do that.”