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Politics Counts: Health Care Premiums and the Midterm Elections



The costs of those plans differ from place to place. In states that rely on the federal insurance exchange, a move across a county line or from an urban to a rural area can mean a jump of more than $100 a month in premiums. Those jumps could sway how the ACA is viewed in November, especially in the suburbs — and that could matter in close House and Senate races where a few thousand votes could make a difference.

For months now, groups opposed to the health-care law have been spending millions on attack ads against it, particularly in states with key House and Senate races. And, more recently, insurance companies have begun advertising to get people enrolled.

But underneath that political fight, the cost differences remain. They are part of the private insurance system on which the law is built. Insurance costs have always varied from one locale to another, depending on the providers and available plans. The difference with the ACA is that people are now required to purchase one of those plans.

An examination of health-care premium data reveals some clear patterns nationally. Breaking down the costs by county, using a typology from the American Communities Project at American University, shows counties around major metro areas tend to do better as a group.

Click on the graphic for a larger view.

Counties that fall into the Big City, Urban Suburb, Middle Suburb or Exurb categories in this breakdown have an average monthly premium of about $199 for a Silver package for a 21-year-old. Rural counties, particularly counties with Native American and African American populations, generally face higher premiums, more than $230 on average.

But the impacts of the premiums are bigger than simple costs. There are three key points in understanding how premiums might affect different communities’ views of the ACA. First, are costs. Second, are how many in each community are uninsured. And third is household income, how much do families have to spend.

On all those points, big metro areas tend to do best. Overall, they are wealthier with fewer uninsured and higher incomes.


Three Key Elements to ACA Cost Impacts

County Type

Average Silver Plan Premium for a 21-year-old

Percent Uninsured

Average Median HH Income

Big Cities, Urban Suburbs, Middle Suburbs, Exurbs




Native American Lands




African American South




Graying America




Working Class Country




There are a lot of variables behind those numbers, of course. Rates changes with different ages and family situations and there are subsidies for those who qualify, but the general urban/rural differences remain. And those are averages, in some states the differences can be much more acute – especially in some states with big Senate races this fall.

Consider Georgia, where Republican Sen. Saxby Chambliss is retiring; his seat is currently labeled as Lean Republican by the Cook Political Report. The lowest health insurance premiums in the state are clustered around Atlanta. The southwest corner of the state, where incomes are much lower, rates average $150 a month higher or more.

Now look at this map of the 2012 vote in the state and you’ll see President Barack Obama won his biggest number of votes around Atlanta in counties like Clayton, DeKalb and Fulton. Those counties mean the most to Democrats in the state and the voters who have to buy insurance under the ACA will be paying less than voters elsewhere. That may make them more sanguine about the law — or at least less hostile to it — at election time.

Or look at Michigan, where Democrat Carl Levin in retiring; his seat is currently labeled as a Toss Up. The lowest premiums in that state are around the Democratic stronghold of Detroit, in the tri-county area of Wayne, Oakland and Macomb. In Michigan’s rural north, rates are much higher, in some places more than $100 a month higher.

The 2012 vote map shows the counties around Detroit were crucial to Mr. Obama’s win in Michigan. Again, the low premiums there might help blunt the attacks on the ACA.

What does all this mean for 2014? The ACA’s cost impact may depend a lot on the specific state and race. There are many races that simply won’t be close because strong partisan leanings push the electorate heavily one way or another. But there will be others like Georgia and Michigan where it could matter a lot.

In some ways it will likely harden partisan differences. Republicans, who are predisposed to dislike the ACA, are more likely to live in rural areas, where premiums are more likely to costs more. They’re going to have more reason to rally against the law this election year. Democrats, who polls show are more likely to approve of the ACA, are also more likely to live in urban areas where they will likely pay less for coverage.

The real key, however, may be suburbanites. Swing voters may be an endangered species, but they still exist, especially in the suburbs and they can make a crucial difference in close contests.

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