Some of the Affordable Care Act’s biggest problems — namely, rising premiums and declining competition among insurers — are most acute in rural areas. Rural areas also tend to vote for Republicans. Yet Republicans are making no serious push to fix those problems with the individual insurance market, my colleague Caitlin Owens notes.

The problem: Conservative solutions tend to revolve around bolstering competition, in an effort to lower prices. But it’s hard to rely heavily on a competitive market in places that simply don’t have enough people to sustain one.

• In sparsely populated areas, one especially sick consumer can have a disproportionate effect on an insurer’s expenses. A small population also means less demand for doctors and hospitals — giving those providers the upper hand in price negotiations with insurers.
• For both of those reasons, these regions aren’t very attractive to insurers, and are expensive for the ones that are interested.

The solutions: Reinsurance probably could have helped in some of these areas. It gained some bipartisan traction earlier this year, but ultimately that deal fell apart.

• Republicans have mainly focused on ways to let healthy people leave the ACA’s markets, which helps them, but only makes things worse for the people who need coverage for pre-existing conditions.
• Democrats have some ideas — a public option, expanding the ACA’s subsidies to shield more people from their high premiums — but none of these are going anywhere.

The bottom line: This will get worse before it gets better.

Go deeper: Caitlin has more at Axios.com.

Tech companies aren’t doing enough to combat the illegal sale of opioids, which are often advertised on their platforms, FDA commissioner Scott Gottlieb said in a speech yesterday. He specifically name-checked Twitter, Facebook, Instagram, Reddit, Google, Yahoo and Bing.

Key quote:

“Internet firms simply aren’t taking practical steps to find and remove these illegal opioid listings,” Gottlieb said. “There’s ample evidence of narcotics being advertised and sold online. I know that Internet firms are reluctant to cross a threshold; where they could find themselves taking on a broader policing role. But these are insidious threats being propagated on these web platforms.”

What’s next: Gottlieb said the FDA will meet soon with tech industry officials to discuss options like “altering search algorithms” to show users websites for treatment programs when they try to search for illegal prescription drugs.

My colleague Bob Herman has the lowdown on the newest federal filings showing how much CEOs of major health care companies made in 2017. (Bob is calculating these based on actual realized stock gains.)

Edwards Lifesciences

• CEO Michael Mussallem: $42.6 million
• Pay ratio: 849:1 (median employee made $50,195)

LabCorp

• CEO David King: $32.7 million
• Pay ratio: 786:1 (median employee made $41,609)

Quest Diagnostics

• CEO Steve Rusckowski: $12.9 million
• Pay ratio: 267:1 (median employee made $48,194)

Tenet Healthcare

• CEO Trevor Fetter (fired last year): $12.8 million
• Pay ratio: 251:1 (median employee made $50,922)

Express Scripts

• CEO Tim Wentworth: $8.7 million
• Pay ratio: 165:1 (median employee made $52,509)

The overall chances of dying from an infectious disease are decreasing in the U.S., but the probability can vary greatly from county to county, Axios’ Alison Snyder reports this morning.

The bottom line: Overall death rates dropped between 1980 and 2014 for HIV/AIDS, tuberculosis and other infectious diseases. But from 2000 to 2014, deaths from diarrhea-related diseases increased in the U.S. That may be largely because of an aging population that is more susceptible to bacteria that has become resistant to antibiotics.

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