You know where they really need the public option? Trump Country.

I don’t know why people are focused on President Trump, when I have cool cartograms of which U.S. counties are down to only one ACA marketplace plan.

Map produced by Todd Schuble. Red and blue shades indicate governor’s party affiliation as of Election Day, 2016.

Cartogram produced by Todd Schuble. Red and blue shades indicate governor’s party affiliation as of Election Day, 2016.

The cartogram is weighted by population, and illustrates four important facts about America and health reform:

• The standard U.S. map does not accurately reflect the experience of most people. Americans cluster on the coasts and in densely-populated metropolitan areas. Sparsely-populated areas such as northern Nevada or Montana that cover many square miles are over-represented in the standard maps. And these maps distort our understanding. If cattle and corn fields bought health insurance, we’d have a reasonable fear that ACA is collapsing. That’s not the reality.
• Democrats are terrible at winning down-ballot elections away from the bicoastal liberal states. That’s a huge political consequence of the Obama era.
• Republicans are terrible at operating successful ACA exchanges. Only one big blue metropolitan area-Philadelphia, PA, was down to one plan. Basically, every other major struggling area is in a red state. Huge sections of the deep south, Arizona, Oklahoma, and the mountain states are down to one marketplace plan.
• Rural areas such as northern Nevada are terrible places for marketplace competition. They are too sparsely populated to support real competition.

ACA marketplaces may never work very well in sparsely-populated rural areas. Hence a great irony. Trump country may be the locale in greatest need of a Medicare or Medicaid alternative to private plans. Democrats would face a knife fight to enact a public option. Once it’s enacted, I suspect Trump country would never let it go.

More from me here, at healthinsurance.org.