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.

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Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

5 thoughts on “You know where they really need the public option? Trump Country.”

  1. You must have missed the election returns for NH last November. Our Democratic former governor is now our junior senator, and the scion of a prominent Republican family (So who knew about Sununu? I guess not you) is now our governor. Sad.

  2. Now tell me why I should want to subsidize Trump voters if they won't even demand it for themselves.

    1. Because it's the right thing to do. Even if you are especially petty and mean-spirited, there are plenty of people who would be helped who didn't vote for Trump, or Republicans at all.

      1. I get it, but the ACA has had the unintended effect of putting the criminal Republican Party in control of the country. Fool me once…

      2. I agree. I'm fortunate to not qualify for the subsidies here in CA, but I'd face a knife fight to protect the pre-existing condition requirement and subsidies for people who need help.

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