Aaron Albaugh peers out from under the brim of his cowboy hat, surveying the acres of hay fields in front of him. The fourth-generation rancher is raising about 450 cattle this year, in this remote corner of Lassen County, California.

His closest neighbor lives a half mile away. "And that's my brother," Albaugh says.

"If I want to go see a movie, it's 70 miles, round-trip," he adds. "If I want to go bowling, that's 100 miles, round-trip."

Living a half day's drive from civilization, you learn to do without, he explains. If your refrigerator breaks, you put your food on ice until the weekend when you can go buy a new one. With health care, it's the same thing.

"Put a Band-Aid on it," Albaugh says. "I was raised: 'You don't need to cry' and 'Suck it up, buttercup.' That's the way I still live, and I try to treat my kids the same way."

When people are already used to doing without health coverage, it's particularly annoying to have the government say you have to buy it, say Albaugh and many of his neighbors in Lassen, Modoc and Shasta Counties.

While Obamacare is largely viewed as a success in California – the state marketplace, Covered California, is one of the most financially stable in the country – it has not worked as well for folks in this rural, northeast corner of the state.

There are two insurers selling plans in each county here, but residents say that has not created enough competition to bring down prices. Plus, many doctors these residents are used to seeing don't take the marketplace plans.

"Being told you have to have insurance you can't afford, and then thatdoesn't cover what you need? You are stuck," says Modoc County resident Althia Cline, who decided to forego coverage – and a surgery she needs to help with her asthma.

Just like the movie theater and the bowling alley, most medical specialists are miles away. In Modoc County, there's no hospital or birthing center where a woman can have a baby.Tessa Anklin, who lives in Canby, Calif., gave birth to her son and daughter over the border in Oregon, an hour and a half away from home.

Anklin makes about $33,000 a year as a dental receptionist. Her husband does seasonal work baling hay and herding cattle at local ranches. While their kids are covered by Medi-Cal, neither parent gets health insurance through work, and before the Affordable Care Act passed, Anklin and her husband did without coverage for a while.

Two years ago, they bought a plan through Covered California. Their monthly premium was just $2 a month after the ACA subsidy, but their deductible was $10,000.

"We paid for all of our medical services and our prescriptions," she says. "We had no help until we reached the $10,000 deductible. So really, we had nothing."

Then, last year, their monthly premium jumped to $600. The plan was the same, Anklin says, and their household income was the same. And they still faced the same hour and a half drive to see doctors they almost never needed.*

Anklin thought of all the other ways she could spend that money.

"It makes the car payment. Almost your mortgage payment. Groceries for at least four months," she says. "That's a big difference, when you think about how little you actually use the health coverage."

That's the reason she decided to cancel her health plan this year and go without insurance. But she'll still have to pay a penalty when the next tax season comes around.

"It basically penalizes us one way or the other because we can't afford the coverage," she says. "So, that's kind of difficult — to be that middle-class person."

Anklin says she'd be happy to see Republicans get rid of Obamacare.

"To me, it's no good, if you have to force people to pay yet another something out of their paycheck," she says, "when they're already trying to survive with what they have. It should be an option."

But the Republican repeal and replace plan wouldn't make things much better for Anklin and her neighbors. Average premiums in California would double under the GOP plan, according to a recent analysis from the Kaiser Family Foundation. Anklin could end up paying more than $2,000 a month for coverage, according to Kaiser's county-by-county projections.

That's not what she had in mind as a fix.

"I'd love that insurance could be more affordable for families that need it, for families that work hard for it," Anklin says.

With the Republican bill now in flux, Democrats have been more willing to admit to Obamacare's flaws. The Dems agree that the rising costs of marketplace plans are the chief complaint they hear about, too.

Democrats have also said if the Republican bill fails, they'd be willing to work together on solutions, but it's not clear the parties could agree on one that would help people like Anklin.

If they can't, Anklin says she has no choice but to continue to go without coverage. Financially, it makes sense in the short term, but she still worries about an unforeseen surgery, serious illness or accident.

"If I ever have a problem," she says, "I know I will be paying for the rest of my life."

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*Premiums in this part of California went up an average of 10.6 percent in 2016, according to Covered California's rate booklet, and most premium increases are matched with an increase in subsidy. So the most likely explanation for why Anklin's premium jumped this much is that she lost her subsidy. This can happen if customers, intentionally or unintentionally, do not check a box on their application form that allows the federal government to verify their income, or, if customers do not file tax returns.

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

Copyright 2021 KQED. To see more, visit KQED.