With the deadline fast approaching for insurers to decide whether they will participate in the Affordable Care Act’s insurance marketplaces next year, all eyes are on the shortage of options some consumers will experience. The number of counties without a participating insurer is low, but there are still concerns about the large swaths of the country where there will likely be only one carrier. This is often considered a problem for rural areas, but even some cities could face that situation this year.

In California, six counties — Monterey, San Benito, San Luis Obispo, Santa Barbara, Inyo and Mono — will have just one insurance company selling on the exchange after the decision by Anthem Blue Cross to pull out of the individual market in much of the state next year. Portions of seven other counties will also be served by only one insurer.

In this episode of “What The Health,” Mary Agnes Carey of Kaiser Health News, Sarah Karlin-Smith of Politico, Margot Sanger-Katz of The New York Times and Julie Appleby of Kaiser Health News discuss the insurance landscape. They also examine a bill passed by the Senate this month that allows people with life-threatening conditions to appeal directly to drugmakers to get access to unapproved experimental drugs.

The transcript below has been condensed and edited for clarity.

Mary Agnes Carey: The number of bare counties has dropped. Now we’re down to two — one in Ohio and one Wisconsin. Again, a bare county is one where an insurer has not yet come in to say they’re going to sell health insurance on the exchanges. But there’s also another issue out there about counties with one insurer. What does that mean for enrollment this fall and what might insurers do in response before open enrollment begins Nov. 1?

Margot Sanger-Katz: If you measure it against the rhetoric of the crafters of the Affordable Care Act, this feels like a little bit of a failure. There was a lot of hope that by creating this new policy structure there was going to be this kind of vibrant, robust, competitive marketplace. President [Barack] Obama talked about it as being like Travelocity — there are going to be just all of these choices. I mean that dream has not come to pass. But I think some context is helpful here. My colleagues Reed Abelson and Haeyoun Park did a story a few months ago where they looked at what consumer choice was like before the Affordable Care Act. Essentially, what they found is that there were a lot of parts of the country that really only had one carrier before.

And what we’re seeing is sort of a little bit of a regression to the mean. It seems like there are some parts of the country that are just not particularly conducive to a robust, competitive insurance market. And you know, speaking with an economist about this recently, a lot of the places that have just one carrier are rural markets. He pointed out to me when you move to a rural area, you’re actually forgoing consumer choice in a lot of parts of your life. There’s probably only one school in your area. There’s probably only one hospital in your area. But also there’s only one grocery store in your area, and you might have to drive pretty far to get to that grocery store. People who choose to live in rural areas, by and large, are choosing to have fewer choices in the marketplace and that may just turn out to be true for health insurance, too.

Julie Appleby: In some areas, though, we’re also seeing it in cities — like Knoxville, [Tenn.], is down to one insurer and they had to really work to get that insurer in there. I think for consumers what this means is your network might be more limited. You might not get to go to the doctor or hospital that you had previously gone to with this new carrier, and that’s going to be a problem. I think we’re going to see some effect in enrollment. Right? People are going to say, “You know, I don’t like this choice, I’m not going to sign up at all.”

Carey: Before the Senate left on its August break, it passed a law allowing people who are facing life-threatening diseases to get access to unapproved experimental drugs. Sarah, can you explain this law known as “right-to-try” — or, I think, you might call it “right-to-ask.”

Sarah Karlin-Smith: This idea of right-to-try has come from a wave of state laws. Thirty-seven states have a right-to-try law, and a number of other states have them pending. It basically allows patients who have been unable to get into a clinical trial, or have no other options left for medical treatment or are facing a life-threatening illness to request access to drugs that have passed the very first phases of human studies. It takes FDA out of the process. Normally, if you wanted to get what is kind of conventionally known as compassionate use [of drugs], the FDA would have to sign off. This skirts the FDA. But why a lot of people say it’s right-to-ask or right-to-hope is because we know that the FDA approves pretty much 99 percent of requests that make it to its door. What actually seems to be the stumbling block is a lot of times companies say no to patients, and they have a lot of legitimate reasons for that. Companies actually tend to have a difficult time filling their clinical trials. And they also just need to spend a lot of resources, money and time on that effort and the manufacturing of the drug, so it can be hard for them to say yes to every person. … You know, it sounds really good on paper, but it’s unclear what impact it’s going to have because we know in the state laws there’s really very little evidence it’s made any difference for patients.

Carey: What do you think is going to happen in the House?

Karlin-Smith: I think there’s a good shot, if Speaker [Paul] Ryan is interested in taking it up. It’s a very popular idea among Democrats, so even though sometimes right-to-try is seen as a Republican/libertarian idea, it has gotten bipartisan support in the Senate.

Sanger-Katz: This debate makes me think a lot about clinical trials and the way that we feel about them. Scientists love randomized controlled trials, where you take a population of people and give some of them a drug or some other kind of treatment and you give the other group a placebo or an alternate treatment. It’s sort of the gold standard for evaluating whether the thing works. But patients don’t like that. You know, if you’re someone with a life-threatening illness and you think that there’s a drug that could have promise for your condition, you won’t necessarily want to be in a clinical trial. You want to just get the drug. You don’t want to necessarily be in the placebo arm and help science but not get the potential benefit.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher or Google Play.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.