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Data: Kaiser Family Foundation; Map: Lazaro Gamio / Axios

Some of the Affordable Care Act's biggest problems — rising premiums and lackluster competition among insurers — are most severe in rural areas. And those areas tend to be conservative, but there's little serious effort among Republicans to address these problems.

Why it matters: Rising premiums put health care further out of reach for middle-class people in these areas. At some point, they're going to want to hear workable solutions from their elected representatives.

The problem: By definition, rural areas are sparsely populated. So there's not much competition among hospitals and other providers, which means insurers don't have much leverage to negotiate lower prices. And with fewer customers overall, one very expensive patient can have a disproportionate impact on a plan's bottom line.

  • “Conservative approaches to dealing with health costs tend to revolve around a competitive market, but the challenge with rural areas is you don’t have the ingredients for a competitive market," said Larry Levitt of the Kaiser Family Foundation.

What they're saying: Broadly, Republicans have focused on proposals that would make it easier for healthy people to extricate themselves from the ACA's insurance markets. Those consumers would likely pay less, but costs and competition would only get worse for the people who need the coverage guarantees the ACA provides.

“This boils down to money for services. One way or another you have to come up with the money, find a way to get the price of the services down, or find a way to not use all of the services.”
— Joe Antos of the American Enterprise Institute

The other side: There was some bipartisan support earlier this year for a new reinsurance program, which would offset the costs of insurers' most expensive customers. Experts said it would have helped, including in rural areas. But it fell apart.

  • Democrats have proposed a slew of ideas they say could help ease the burden in sparsely populated regions, mostly at taxpayers' expense — including a public option, an expansion of the ACA's premium subsidies, or new caps on payments. But none of those ideas have any real chance of actually happening, at least any time soon.

The bottom line: Reinsurance is by far the most bipartisan solution to the rural problem. Even that couldn't get through this Congress, and lawmakers aren't expected to return to health care policy before the midterms. This problem will likely get worse before it gets better.

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