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Dennie Wright lives in Indian Valley, a tiny alpine community at the northern end of the Sierra, close to the border with Nevada.

Wright works as a meat cutter in a grocery store and lives in a modest home overlooking a green pasture. He also lives in one of the 250 zip codes where Blue Shield of California stopped selling individual policies in 2014. As his insurance agent explained it, Wright had only one choice of companies if he wanted to buy insurance on Covered California, the state's health insurance exchange. That lone option was Anthem Blue Cross, so Wright bought one of the Anthem policies.

"That was new to us, you know, Covered California," Wright says. "Anthem Blue Cross was the insurance carrier. Then of course, three months later, I have a heart attack.

Shots - Health News

To Curb Costs, New California Health Plans Trim Care Choices

More than once, he was flown across the state line to Reno for care. Wright and his wife, Kathy, now have piles of medical bills and insurance paperwork. Though Anthem Blue Cross covers emergency care out-of-state, it doesn't cover routine doctor care outside a patient's home state. But Wright says traveling from his home to doctors on the California side of the mountains is not as safe or as convenient as going to Reno.

He continues to see the Nevada doctors who put a defibrillator in his chest, and saved his life. Anthem Blue Cross will pay some of the bills, but the Wrights still don't know if everything will be covered.

There are other insurance options for Wright, but not through Covered California. Although he didn't need a subsidy, he was left in the same position as people in his area who do need financial help to buy insurance. People with lower incomes can't readily take their business to a competitor, because the state exchange is the only place customers can use federal subsidies to help them buy health insurance. So for these people who are pinched financially, Anthem is the only option.

"I mean, you should have some choices, especially if you're going to have one that's not going to cover you in the places you choose to go," Wright says.

Last July, Covered California Executive Director Peter Lee offered a different impression of choices the marketplace would offer.

"In every corner of the state, consumers will have at least two plans to choose from, and in most areas, where most of the Californians live, they can choose between five or six plans," said Lee during an event to announce the marketplace's 2015 plans and premium rates.

Northern California Pricing Region

Almost half of the Covered California members who have one choice of insurer live in Northern California.

Source: Covered California

Credit: Alyson Hurt/NPR

Shots - Health News

A Single Insurer Holds Obamacare's Fate In 2 States

But in 22 counties in Northern California, there are zip codes where there is only one choice of insurer, even if that company offers a few different plans. There are areas around Monterey and Santa Cruz on California's central coast that also have only one carrier.

Blue Shield of California said it had to stop selling individual plans in areas that didn't have a hospital contracted with Blue Shield. The insurance firm said it had offered doctors in those areas rates of payment that would keep premiums low, but not all doctors accepted the payment terms.

Covered California estimates that statewide, there are 28,896 Covered California customers who have only one choice of insurance carrier — slightly over 2 percent of the total exchange membership as of November 2014.

Lee says the exchange is now working to increase the range of choices in places where there are none. But he says the problem predated the exchange.

"The challenges of northern, rural counties have been there for a long time," Lee says, "and are still a challenge that we're trying to address head-on."

He says the exchange is now mulling how to bring more insurer competition to these areas in 2016.

"We aren't the solution to all the problems that have always been there in terms of challenges in rural communities, and that's something we're certainly looking at — how to improve access and choice," Lee says. "And we'll continue doing that."

Shots - Health News

Two Doctors Weigh Whether To Accept Obamacare Plans

Covered California should help increase the number of insurers, says consumer advocate Anthony Wright from Health Access. And policy makers, he says, should lean on insurers and providers to participate in that market.

"Some of this is a combination of putting pressure on the insurers," he says, "and some of this is trying to do work to actually increase the number of providers on the ground in these areas — whether through more training, [or] incentives to be in some of these more rural areas."

Having more insurers in the marketplace, says Anthony Wright, would make it more likely that people can get the care they need.

"At one level, we're trying to make a functioning market," he says, "but it still means that consumers are at the mercy of the market."

This year, people who want more choice than Covered California offers, must venture into the broader health insurance market — if they can afford it.

This story is part of an NPR reporting partnership Capital Public Radio and Kaiser Health News.

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Affordable Care Act

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Today, the World Health Organization issued a 14-part report on Ebola: from the moment it started until now.

We asked our team of Ebola correspondents to look at the sections and pull out the points that seemed most interesting – details that may have been overlooked or forgotten, stories that show how the virus turned into an epidemic.

Where it all began

Goats and Soda

Could A 2-Year-Old Boy Be 'Patient Zero' For The Ebola Outbreak?

The very first human case of Ebola in this outbreak may have been due to deforestation by "foreign mining and timber operations" in Guinea, which brought residents in closer contact with bats. The first victim was an 18-month-old boy in Meliandou, a village of just 31 households. He had been seen playing near a tree infested with bats before he got sick. The child developed fever, black stools and was vomiting on Dec. 26, 2013, and died two days later. Health officials first thought he had cholera.

Anger in Guinea

The Ministry of Health publicly described the outbreak as ""nearly under control' as early as 15 April. But cases were on the rise. In September, Forecariah, a mining town in western Guinea, had a case fatality rate among Ebola patients of at least 80 percent; the virus was spreading among patients and staff in a large regional hospital. As the mob in Forecariah grew to more than 3,000 heavily armed youths, WHO-led epidemiologists became the target of their anger. The epidemiologists had to flee for their lives.

The first in Sierra Leone

Ebola arrived when an infected woman seeking the services of a faith healer crossed the border from Guinea. The healer became infected and eventually died. Her funeral became ground zero for the epidemic in Sierra Leone. Epidemiologists eventually traced 365 Ebola-related deaths to that single funeral.

Not enough doctors

Before Ebola struck, the three hardest-hit countries — Guinea, Liberia and Sierra Leone — had a ratio of about one to two doctors per nearly 100,000 people.

A shocking burial connection

Goats and Soda

Liberians Meet Death With Flowers, Trumpets And Cameras

Funeral practices in Liberia and Sierra Leone include rinsing a corpse and having mourners bathe in that water. The assistants of socially prominent members in secret societies in these countries have also been known to sleep near a highly infectious corpses to allow "the transfer of powers." A whopping 80 percent of Ebola cases in Sierra Leone are estimated to be linked to these funeral practices. In Guinea, it's 60 percent of Ebola cases.

Ebola in the air

Never before had air travelers brought the Ebola virus to a new country. That happened twice in this outbreak, when one infected individual flew from Liberia into Lagos, Nigeria, on July 20 and another from Liberia to Texas on Sept. 30. As the report notes, every city with an international airport is, in theory, at risk of an imported case.

The littlest victims

By the end of 2014, charities in West Africa were struggling to care for more than 30,000 Ebola orphans.

No isolation

In the early summer, no hospital in Liberia had an isolation ward. Facilities lacked protective equipment, and only a few medical staff were trained in the basic principles of infection control. As a result, treatment of the first hospitalized patients actually "ignited multiple chains of transmission" and eventually led to an exponential growth in Ebola cases throughout the country.

Continuing toll on health workers

Goats and Soda

Fallen Heroes: A Tribute To The Health Workers Who Died Of Ebola

Despite progress in Liberia, infection control at health facilities is still a major problem. Six health workers were infected just in the first week of December. Health officials are investigating.

Tough laws

Sierra Leone used especially aggressive measures to try and contain the virus, though it's unclear what impact these had. Over the course of the year, the government quarantined more than half of the country's 14 districts and passed a law imposing a jail sentence of up to two years on anyone found to be hiding a patient.

Malaria builds a bridge

As part of its response, the Sierra Leonean government used an anti-malaria campaign to try and win back the public's trust in health care workers, whom they thought were possibly spreading the disease. With new Ebola cases still rising in December 2014, health facilities distributed anti-malarial medicine to tens of thousands of households in areas with the highest rates of Ebola and where fear was causing people to avoid contact with health workers. The WHO report says the program was well-received and boosted trust in the government.

The need for rapid testing

Many Ebola patients have been in a hellish limbo for days or longer while waiting for blood samples to be schlepped along rutted roads, to be tested for the virus. WHO is currently evaluating 19 different rapid blood test kits, which can be sent off to health outposts in remote areas. If a reliable one is found, that could make a big difference for patients waiting to find out if their fever is caused by Ebola, malaria or any number of common diseases in the area. Rapid results can also help doctors manage the care of sick people more easily.

Internet aid

WHO was able to track possible Ebola cases in nonaffected countries with the help of a "dedicated internet search engine." The system combs through the web for rumors and hints suggesting an Ebola case and can translate from many languages. From mid-October to year's end, the system picked up more than 183,000 alerts that were then screened by epidemiologists. More than 150 required further investigation.

An unacceptable difference

More than 70 percent of Ebola patients treated in West Africa died compared to a 26 percent death rate for foreign medical staff who were evacuated to countries with specialized treatment. WHO calls this difference "unacceptable."

West Africa

ebola

World Health Organization

Federal workers with a pressing need can take an advance of up to six weeks of sick leave, under a new policy unveiled by President Obama Thursday. The White House is urging Congress to make paid sick leave mandatory in the U.S.

The president signed a memorandum today instructing federal agencies to advance up to six weeks of paid sick leave to workers who need the time to care for a new child, a family member, or for similar uses.

As for the private sector, the White House says 43 million workers do not have paid sick leave. And the new push to help them has been building for months now.

"U.S. labor laws date to the 1930s, a time when most families had a stay-at-home mother," NPR's Jennifer Ludden reported a year ago, when she interviewed state legislators about paid sick leave. "The only federally mandated leave covers just half of the workforce, and many people tell pollsters they can't afford to use it because it's unpaid."

The Obama administration says the lack of paid sick time creates situations in which employees can't take time to recover from illness, or their children are sent to school with a fever because their parents can't take time off from work to stay home with them.

NPR's Scott Horsley reports:

"President Obama is calling on Congress to pass a bill that would give all workers the opportunity to earn up to seven paid sick days per year. He's also encouraging state and local governments to pass their own paid leave requirements, even if Congress fails to act.

"The White House says more generous leave policies would boost productivity, reduce employee turnover, and encourage more moms to stay in the workforce."

The push for wider access to paid sick leave comes after a report by the White House Council of Economic Advisers, which cited "research that shows that paid and unpaid leave can help workers balance obligations at home and in the workplace—and help parents and those with medical needs remain in the workforce."

"The United States is currently the only developed country that does not offer government-sponsored paid maternity leave," the report stated. "Many of these countries also provide paid paternity leave, elder care benefits, and generous paid sick leave."

Today, the administration also promoted the Healthy Families Act, which would let millions of U.S. workers earn up to seven days of paid sick time each year. The legislation would apply to employers with at least 15 workers.

President Obama's budget will propose more than $2 billion in funding and grants to help states install their own sick leave systems.

The plan met with some criticism, including Forbes contributor Tim Worstall, who predicted that the changes would result in lower pay and are unnecessary.

"Those who value the ability to take paid sick leave presumably have self-sorted themselves into jobs where they get it and those that don't haven't," Worstall wrote.

Only a few U.S. states and the District of Columbia have approved laws making paid family and medical leave mandatory. Washington state also has a parental leave law on its books, but the state has postponed its implementation due to problems funding it.

Some U.S. cities have passed similar laws — but in recent years, several states have taken preemptive steps barring others from doing so.

About 60 percent of American workers are eligible for sick leave under the Family and Medical Leave Act, the White House says. But the administration adds that despite providing up to 12 weeks off work, the FMLA doesn't do enough by itself, as it doesn't require the workers to be paid during the time off.

"For too many Americans, unpaid leave is unaffordable," The White House says. "Moreover, evidence shows that mothers, who do typically take some time off in order to give birth, are more likely to return to their jobs and to stay in the workforce if they are able to take paid maternity leave."

parental leave

sick leave

maternity leave

In the United Kingdom, British Gas employs 30,000 workers. Five of them could be said to carry a torch that has been burning for two centuries. They are the lamplighters, tending to gas lamps that still line the streets in some of London's oldest neighborhoods and parks.

As these lamplighters set out on their nightly rounds, they don't actually carry torches and don't wear top hats and waistcoats. In their blue and gray jackets with the British Gas logo, they look like 21st-century utility workers.

"I was originally doing central heating installation," says Garry Usher, who oversees the team.

About 15 years ago, Usher found out he was being assigned to the lamplighters crew. He nearly laughed at his boss, since everyone knows London went electric more than a century ago.

"I thought he was taking the mickey actually," says Usher.

Translation: he thought his boss was pulling his leg, but he wasn't.

London still has about 1,500 gas lamps. The group British Heritage decided to preserve them after almost all the others were replaced by electric lamps. These look almost exactly the same as when they were first installed 200 years ago. They're just a little taller to accommodate modern traffic.

On a recent night, Usher leans a ladder against a lamppost, climbs the rungs, and opens the small glass door at the top of the lamp. Inside, a little ticking clock triggers the flame to go on and off at the right time each night.

These clocks must be wound by hand.

"I'll manually turn it round," says Usher.

He moves the dial, and a flame jumps up to catch on little silk nets, known as mantles. The mantles are covered with a substance called lime, which produces a bright white light.

i i

Garry Usher oversees the five lamplighters employed by British Gas. Each night, members of his crew wind up, by hand, the clocks that control when the lamps, like this one at St. John's church in Smith Square, turn on and off. Rich Preston/NPR hide caption

itoggle caption Rich Preston/NPR

Garry Usher oversees the five lamplighters employed by British Gas. Each night, members of his crew wind up, by hand, the clocks that control when the lamps, like this one at St. John's church in Smith Square, turn on and off.

Rich Preston/NPR

In the early 1800s, London's West End theaters realized how useful lime could be to illuminate a stage.

"It shone really bright across on their star, and so the star was the person that was in the limelight," says Usher. "So that's where that comes from."

Usher is literally standing in the limelight, steps from the River Thames, a stone's throw from Big Ben and the Houses of Parliament. It's a quintessential London scene.

He's joined by Iain Bell, British Gas' operations manager and a history buff. Bell describes what this area would have looked like before the lamps arrived.

"The streets would've been pitch-black. They would've been very smoggy. They'd have been quite dangerous, because the only light the public would've had would have been a candle," Bell says.

If you wanted to walk to the local pub, you could hire a child known as a link boy to light your way with a torch.

"Some of the link boys weren't as nice as you'd expect them to be," says Bell. "They actually would mug you. So they'd take you down a dark lane, and then you'd be set upon and robbed."

When street lights arrived, nightlife in London transformed.

At first people were justifiably afraid of the lamps. Bell says the gas pipes were poorly made, from shabby materials.

"We're talking wood. We're talking mud wrapped around it. So there were a lot of leaks. There was a lot of fires. There was a lot of explosions," he says. "So the public were terrified."

Even today, diggers often come across the remains of old wooden pipes.

The gas lamps that still stand in London are now protected by law. If one is knocked down, it is replaced with an exact replica. They cast a calming, mellow light, maintained by these few remaining lamplighters — literal keepers of the flame.

England

London