As the New York Times documented last week, the choices and pricing of private health insurance will vary widely from state to state when the Affordable Care Act's exchanges launch this fall. In state-run marketplaces in California, Colorado and Oregon, residents will have a wide array of providers and plans to choose from. But in many poorer, often Republican led states, consumers may have few alternatives. And in some part of Mississippi, the state with the very worst health care system in the nation, there will be no choices at all.

As the Clarion-Ledger reported, almost half of the counties (36 of 82) in the Magnolia State will find no insurers in the federal marketplace which will launch on October 1:

Insurance Commissioner Mike Chaney says two insurers have announced offerings so far, planning to serve 46 counties.
Unless more companies sign up or the existing companies expand their plans, consumers in the remaining counties won't be able to buy health insurance through the online exchange. Coverage under those policies begins Jan. 1
"I don't know what to tell you about the other 36 counties," Chaney told The Associated Press in a phone interview this week. "You're just out of luck."

Not that Mississippians had much luck to begin with. Ranked dead last in the Commonwealth Fund's ranking of state health care systems, the Magnolia state has almost 500,000 people without health insurance, nearly 20 percent of its adult population ages 18 to 64. And in January, Republican Governor Phil Bryant declared that despite having the most meager Medicaid program in the nation, he would refuse the federal Medicaid expansion under Obamacare that could bring coverage to 160,000 of his residents, including those with cancer, diabetes and so many other conditions:

"There is no one who doesn't have health care in America. No one. Now, they may end up going to the emergency room. There are better ways to deal with people that need health care than this massive new program."

Not in Mississippi. So far, the state's current two insurers--Flowood-based Blue Cross & Blue Shield of Mississippi and UnitedHealth Group of Minnetonka, Minnesota--have not offered plans on the online marketplace beginning in October. While two others have come forward to serve 46 counties, the online marketplace won't include "swaths of the Delta region and southwest Mississippi, plus scattered areas elsewhere. Among those areas are Corinth, Greenville, Laurel, Natchez and Picayune."

The majority of Magnolia State residents will continue to get their health insurance through their employers or from federal programs including Medicare and Medicare. Mississippians can also continue to purchase individual coverage in the traditional insurance market. But in those 36 counties, they will go without the federal subsidies extended to families earning up to four times the poverty level. As the AP explained the impact, "A 2012 study by the Mississippi Center for Health Policy had projected that as many as 275,000 Mississippians could gain insurance through exchanges, with 230,000 of those benefitting from federal tax credits that could total $900 million a year." That's why federal officials have not yet determined whether residents in the "gap" counties will face penalties if they don't purchase insurance by January 1.
While the situation will likely improve in 2015 and 2016 as insurers recruit their networks of doctors, clinics and hospitals in the state and offer multi-state and national plans, as of now many Mississippians have a prescription for continued pain. It didn't have to be this way:

Chaney said he believed opposition to health care changes by many Mississippi Republicans, along with the deadlock over renewing or expanding the state-federal Medicaid program was scaring off insurers. Roy Mitchell, executive director of the Mississippi Health Advocacy Program, which has been pushing for expanded coverage, agrees.
"We're in a polarized atmosphere here were our governor denies the Affordable Care Act even exists," Mitchell said. "Mississippi is just a worst-case scenario in these things."

A worst-case scenario, it turns out, Governor Bryant appears committed to continuing.