The goal of universal coverage has long eluded the Affordable Care Act — especially in rural areas. Because insurers have less financial incentive to offer plans in less densely populated places, residents have an especially hard time finding health coverage through the ACA exchanges.

The dire state of rural health access was driven home for me recently when I went looking for health coverage. After returning from several months out of the country, my husband and I signed up on healthcare.gov and put in his family’s address in Caroline County, a rural area outside Richmond, Virginia. While we expected to find few options, especially compared to our previous address in Northern Virginia, we were both shocked by the results. Our search turned up just two insurers and eight plans. All of them included a deductible and charged exorbitant rates for two people in their thirties.

As a point of comparison, we decided to look up the rates for a similar silver-level plan in Pittsburgh (Allegheny County), where we’re moving later this year. The premiums were almost half of those in the rural Virginia exchange, and we could easily select a zero-deductible plan, instead of the hefty $3,600 deductible we were saddled with in the other plans.

So what was the big difference in the Pittsburgh marketplace? There were four times as many plans available, with a greater number of enrollees ensuring a diverse mix of health levels (i.e. not just older, sicker populations). Had we been stuck with the rural exchange options long term, we would have had an annual health plan price tag of $18,000. For the median-earning couple in the county, that would amount to 31.5 percent of their household income (not including any prescription drug costs or copays).

The situation is even worse in single-insurer counties, which now make up more than half of the counties in the US. Alabama residents, for example, are only able to purchase ACA plans through Blue Cross Blue Shield, which requested a 15 percent increase in premiums for 2018. And many of those single-insurer counties are rural, lower-earning places.