In some counties, the Medicare Advantage program gorilla has a hard time pounding its chest. (Photo: iStock)

The Medicare Advantage program is looking like a gorilla in much of the country — but not everywhere.

In some counties, the program has a tough time competing with the traditional Medicare program for hospitals, physicians and enrollees.

Related: Medicare Advantage enrollment up, but participation varies by state, carrier

The Medicare Part A program covers inpatient hospital services.

The Medicare Part B program covers physicians’ bills and bills for outpatient services.

Congress created a third major Medicare program, Medicare Part C, to give private insurers a chance to use Medicare Part A and Part B subsidies to provide an alternative to traditional Medicare coverage.

The Medicare Advantage program, the biggest and best-known Medicare Part C program, now provides coverage for about 18 million of the 57 million Medicare enrollees.

The Centers for Medicare & Medicaid Services tracks Medicare Advantage plan enrollment data for about 3,300 counties. One of the columns in its Medicare Advantage enrollment spreadsheets shows the Medicare Advantage penetration rate, or the percentage of Medicare enrollees in a county who have Medicare Advantage plan coverage.

In the 50 U.S. states and the District of Columbia, the county penetration rates range from 0.4 percent, in Juneau, Alaska, to 71 percent, in Red Lake County, Minnesota.

The median penetration rate in the 50 U.S. states and the District of Columbia is about 24 percent.

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Typical Medicare Advantage plan providers offer managed care plans. Some counties have low Medicare Advantage penetration rates because the number of hospitals and doctors is too low for use of a managed care network to make much sense.

When retirees are unhappy with Medicare Advantage plan provider directories, they typically combine traditional Medicare coverage with Medicare supplement insurance, or Medigap coverage. Retirees using Medigap coverage with traditional Medicare can use any provider that takes Medicare. 

In more populous areas, the counties with low penetration rates tend to be the ones where providers have the financial strength to resist offers from health insurers’ managed care networks, and many retirees have the cash to pay for a combination of traditional Medicare and Medigap coverage.

Those are, clearly, challenging markets for agents who sell Medicare Advantage plans, and rich markets for agents who sell Medigap plans.

To come up with a list of 10 counties in which the Medicare Advantage penetration rate looks awful, we first filtered the CMS penetration table data to exclude counties with fewer than 50,000 Medicare enrollees eligible to buy Medicare Advantage coverage. Those counties may have too few Medicare enrollees and providers to make Medicare Advantage plans sustainable.

In the 244 counties that remained after we filtered out the small-fry penetration rates ranged from 5 percent, in one county in California, up to 65 percent, in Dade County, Florida. The median penetration rate in those counties was about 36 percent.

Here’s a look at the 10 counties with the lowest penetration rates, along with YouTube videos to give you a taste of what those counties are like.

The Lake County, Illinois Convention and Visitors Bureau posted a video of this county, which appears to be more fun for tourists than for Medicare Advantage plan marketers. (Video: visitlakecounty/YouTube)

10. Lake County, Illinois

Number of residents eligible for Medicare: 103,334

Number of Medicare Advantage plan users: 13,672

Medicare Advantage plans’ share of Medicare enrollees: 13.2%

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Robert Myrick of Robert Myrick Photography posted this video about Falmouth, a historic town in Barnstable County, Massachusetts, in July 2013. (Video: Robert Myrick A.K.A.-REMROB/YouTube)

9. Barnstable County, Massachusetts

Number of residents eligible for Medicare: 71,843

Number of Medicare Advantage plan users: 9,383

Medicare Advantage plans’ share of Medicare enrollees: 13.1%

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New Castle County, Delaware, posted this video about a wellness fair and holiday craft sale in November. (Video: NCCDE/YouTube)

8. New Castle County, Delaware

Number of residents eligible for Medicare: 94,030

Number of Medicare Advantage plan users: 12,049

Medicare Advantage plans’ share of Medicare enrollees: 12.8%

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The University of New Hampshire Extension produced this video about life in Hillsborough County in December 2010. (Video: UNH Extension/YouTube)

7. Hillsborough County, New Hampshire

Number of residents eligible for Medicare: 73,903

Number of Medicare Advantage plan users: 9,436

Medicare Advantage plans’ share of Medicare enrollees: 12.8%

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The Baltimore County Department of Economic Development produced this virtual tour of some of the county’s local attractions in June 2013. (Video: Baltimore County/YouTube)

6. Baltimore County, Maryland

Number of residents eligible for Medicare: 154,356

Number of Medicare Advantage plan users: 19,165

Medicare Advantage plans’ share of Medicare enrollees: 12.4%

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The Montgomery County Economic Development Council posted this video about the advantages of living and working in Montgomery County in March 2013. (Video: Montgomery County Economic Development/YouTube)

5. Montgomery County, Maryland

Number of residents eligible for Medicare: 152,461

Number of Medicare Advantage plan users: 17,525

Medicare Advantage plans’ share of Medicare enrollees: 11.5%

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BK Bazhe made this video about Portsmouth, the biggest city in Rockingham County, New Hampshire, in March 2011. (Video: BK Bazhe/YouTube)

4. Rockingham County, New Hampshire

Number of residents eligible for Medicare: 60,068

Number of Medicare Advantage plan users: 6,822

Medicare Advantage plans’ share of Medicare enrollees: 11.4%

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The Anne Arundel County Department of Health posted this video of a local health care reform forum in September 2013, as the first, glitch-plagued Affordable Care Act individual major medical open enrollment period was about to begin.

3. Anne Arundel County, Maryland

Number of residents eligible for Medicare: 88,803

Number of Medicare Advantage plan users: 8,417

Medicare Advantage plans’ share of Medicare enrollees: 9.5%

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Rehoboth by the Sea Realty Company posted this video introduction to Georgetown, Delaware, the county seat of Sussex County, Delaware, in September 2013. (Video: RehobothByTheSea/YouTube)

2. Sussex County, Delaware

Number of residents eligible for Medicare: 61,964

Number of Medicare Advantage plan users: 5,063

Medicare Advantage plans’ share of Medicare enrollees: 8.2%

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Steve Sanders shot these aerial photos of Monterey County, California, in January 2014. (Video: Steve Sanders/YouTube)

1. Monterey County, California

Number of residents eligible for Medicare: 60,763

Number of Medicare Advantage plan users: 3,093

Medicare Advantage plans’ share of Medicare enrollees: 5.1%

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