The voter anger over healthcare that once propelled Republicans to the majority in the House and Senate is now buoying Democrats' hopes for the midterm elections.

When Democrats passed and rolled out Obamacare, voters shouted down lawmakers at town halls and rallied in huge demonstrations to protest changes in coverage, rising premiums, and the loss of their doctors.

Now, Republicans are facing the same threat for attempting to undo the healthcare law, formally known as the Affordable Care Act. There's been a massive shift in voters’ attitudes, and their outrage is now centered on the possibility of people with pre-existing conditions losing coverage. Democrats, in turn, are campaigning confidently on healthcare with an enthusiasm not seen since Obamacare passed.

“We see healthcare as the defining issue of the cycle,” said David Bergstein, spokesman for the Democratic Senatorial Campaign Committee. “Voters consistently say that this is their top issue. … Both concern over cost and concern over how the GOP agenda would cut coverage for pre-existing conditions have been the centerpiece of the messaging on this issue.”

Democrats are, in large part, framing the battle about healthcare generally, not Obamacare specifically. At every turn, they are casting themselves as the protectors of sick people, and Republicans as antagonists. Candidates across the country are cutting campaign ads highlighting Obamacare’s rules blocking insurers from turning away sicker people, from charging them more, or from refusing to pay for coverage associated with their illness.

Only the elections will reveal whether the strategy works. But the provisions, for people who have pre-existing conditions such as cancer, asthma, migraines, or diabetes, have consistently polled well among most voters.

“Now members are consoling constituents at town halls who were afraid they would be losing protections for pre-existing conditions,” said a senior Democratic aide who was present for the backlash his party faced in 2010.

Most TV ads by House and Senate Democrats are focused on healthcare, the Wesleyan Media Project found in a recent analysis. In the ads, Democrats often avoid calling the Affordable Care Act by its name. Instead, they keep the focus on protections for sick people by noting a lawsuit by Republicans to throw out the healthcare law, as well as actions by the Trump administration to weaken it, and failed Republican attempts in 2017 to take it apart. Many share stories about their own medical conditions.

“You have a perfect storm against Republicans where approval of the ACA is at record high, awareness of the protections has finally broken through, and their repeal plan went over like a lead balloon,” said Jesse Ferguson, a Democratic strategist.

A red state survival strategy

Sen. Joe Manchin, D-W.Va., running for re-election in a state that went heavily to Trump, personifies the enormous shift in the politics of healthcare over the past few years.

This election season, Manchin has recycled an infamous campaign ad from 2012, in which he took a gun to an environmental “cap and trade” bill from Democrats, showing that he would put the priorities of his state ahead of his party. At the time, he promised to “repeal the bad parts of Obamacare.”

In the new video, he's instead shooting a copy of the Republican anti-Obamacare lawsuit, calling it “dead wrong.”

His opponent, GOP Attorney General Patrick Morrisey, is among the attorneys general who support the lawsuit.

Missouri Attorney General Josh Hawley is another. He is running against Democratic Sen. Claire McCaskill, whose campaign is releasing a series of 30 video interviews over 30 days with supporters who have pre-existing conditions. McCaskill has also highlighted her own history with breast cancer to accentuate the importance of the protections included in Obamacare.

The timing of the Republican lawsuit has helped Democrats center their campaigns on healthcare. Twenty Republican state officials have asked the courts to strike down Obamacare, arguing that it must fall because it is about to lose a key provision, namely the individual mandate requiring that people get insurance. The GOP tax law enacted in December zeroes out the penalty starting next year, rendering the mandate inoperative.

Adding to the political sensitivity of the issue, the Trump administration did not defend the law in court, but rather agreed with the plaintiffs, though it asked to toss only the rules on pre-existing conditions.

Democrats have said that the lawsuit is an attempt by Republicans to pick up where their congressional repeal efforts left off. Seventeen Democratic officials are defending Obamacare, and a ruling is expected soon. It is likely to face an appeal and may end up before the Supreme Court.

“From a campaign perspective, they could not have picked a worse time to remind voters about their healthcare agenda,” Bergstein said.

A costly vote

Many Democrats facing off against Republicans who voted to overhaul Obamacare are seizing on those failed efforts to gain an advantage. Dr. Kim Schrier, a pediatrician and a Democrat, is running for an open seat in Washington’s 8th District, and in an ad cast the repeal efforts as a deciding factor in getting her to enter politics.

The campaign for Rep. Jacky Rosen, D-Nev., who is looking to unseat vulnerable GOP Sen. Dean Heller, released an ad featuring cancer patients who fear losing Medicaid. The Republican healthcare bill in the Senate would have cut Medicaid, a government-funded program that pays for medical care for low-income people.

Even in deep-red Texas, Democratic Rep. Beto O’Rourke sees an advantage in running on healthcare against GOP Sen. Ted Cruz, warning that "the healthcare of millions of Texans is on the line."

"Things have taken a turn from 2010 to where they are today," one Democratic strategist said. "People don’t want their healthcare taken away and they don’t want their costs going up.”

Democrats are borrowing the attacks that Republicans years ago used against Obamacare, warning that their opponents' plans would amount to a loss of medical care for constituents.

Dr. Bob Kocher, an adjunct professor at Stanford University School of Medicine who helped write the Affordable Care Act, said portions of the law had been popular when polled, but that the way it was characterized by Republicans struck a chord with angry voters.

“We thought the concept together would prove to be popular and we were very wrong. It was part of the reason we got ‘shellacked’ in the midterms,” he said of the 2010 election cycle, borrowing a word former President Barack Obama had used.

"It had been villified and people lost track of what it was," he continued.

In polls, healthcare is edging out slightly ahead of the economy as the issue voters care most about. Support for Obamacare has improved since Trump took office. The most recent poll from the Kaiser Family Foundation finds that roughly 50 percent of voters view the healthcare law favorably, while 40 percent view it unfavorably.

There is still room for Republicans to push back. The most recent surveys do not break down opinions about Obamacare among people who have the types of plans the law created, who may have been paying less before the law and were more satisfied with their previous coverage. On the other hand, it also doesn't break down information for those who were uninsurable before the law.

Individual campaign ads also have overstated the number of people who would lose out if Obamacare were invalidated or if Republicans take another swing at repeal.

For instance, defenders of Obamacare suggest that as many as 133 million people who have pre-existing conditions could lose health insurance. A small fraction of that group, however, has an Obamacare plan. Most people in the U.S. have health insurance through jobs or government programs. Voters may also have a different idea of what constitutes a pre-existing condition than policymakers do.

“A lot of the arguments are being cast as if they affect a majority when in fact they affect a minority of people,” said Daniel Hopkins, political science professor at the University of Pennsylvania.

“It becomes an extraordinary challenge for voters to evaluate what this all comes to and what the world would look like without the ACA,” he continued.

Still, the rallying cry around pre-existing conditions appears to resonate with voters, and Republicans are tuning in as well. Every candidate has said that he or she supports protections, even as Democrats say the protections Republicans offer are weaker than the ones in Obamacare.

The House-passed replacement plan did not become law, but Republicans have pointed out that it contained language protecting people with pre-existing conditions.

Still, the House bill allowed some room for states to opt out of the rules protecting sick people as long as they set up alternative arrangements for high-cost patients. It would have given state governments the ability to allow insurers to charge higher premiums for certain enrollees and let plans omit some of the benefits required under Obamacare. It also would have cut federal Medicaid funding and lessened the assistance people get for buying private coverage. In practice, critics say, the plans would not have been affordable.

Republicans on defense

Republicans who have sued to undo Obamacare have sought to defend themselves by arguing that the lawsuit is separate from their political support for pre-existing condition protections. Hawley said the suit he waged against Obamacare on behalf of Missouri centered on its constitutionality.

“Sen. McCaskill would have you believe that the only way to cover pre-existing conditions is to keep all the failures of Obamacare. That’s simply not true,” he said in a statement. “I’m committed to covering those with pre-existing conditions, and we don’t have to break the Constitution to do it.”

Morrisey also made the argument that he favored protections for pre-existing conditions but believed Obamacare was the wrong way to address them. Manchin dismissed that rationale.

“Tell him to drop his lawsuit,” he told the Washington Examiner. “That’s all he has to do.”

Other Republicans are mobilizing to demonstrate their commitment to sick people. In response to the lawsuit, 10 Republicans in the Senate introduced a bill to keep pre-existing condition protections in place should the court rule to invalidate or weaken Obamacare. Three of them, Sens. John Barrasso of Wyoming, Roger Wicker of Mississippi, and Heller, are up for re-election. Again, critics say it falls short of Obamacare.

Stewart Boss, spokesman for the Rosen campaign seeking to unseat Heller, accused Republicans of “trying to rewrite their record on pre-existing conditions,” calling the introduction of the bill a “stunt” in anticipation of the election.

When it comes to healthcare, Republicans are waging battles on other fronts, promising to take another swing at repeal and saying the law did not live up to its promises.

“Democrats have misrepresented Obamacare for years,” said Abbi Sigler, spokeswoman for GOP Rep. Marsha Blackburn’s campaign in Tennessee for the Senate. “From promises that people would be able to keep their doctors and plans to assurances that costs would go down for middle class families, the American people have been deceived.”

Republicans say they still believe that voters will be motivated by the prospect of repeal. According to Kaiser Family Foundation polling, 66 percent of voters say a candidate’s support for continued protections for people with pre-existing health conditions is either the “single most important factor” or “very important” to their vote in the midterms. But repealing the ACA came in third, at 53 percent, and at one percentage point higher than voters who said stabilizing the law was important.

In defending the Republican stance, the Morrisey campaign pointed out that Manchin’s ad with the gun does not mention the healthcare law by name.

"Sen. Manchin doesn't mention 'Obamacare,' because he can't defend years of higher premiums as a result of Obama's healthcare law," said Nathan Brand, campaign spokesman.

But Democrats ultimately conclude they have the advantage over Republicans, who failed to come together on a alternative healthcare plan.

“ ‘Repeal and Replace’ was a bumper sticker,” McCaskill said. “They didn’t have any ability to replace. They couldn’t get the Republican votes. Now they want to wipe it all out with no replace.”

The path for Democrats is still murky. They had warned that actions by the Trump administration and Republicans would “sabotage” the law and make premiums soar, but that appears not to have borne out heading into the 2019 marketplaces. Average rate increases are settling below 4 percent, and more insurers are participating.

How much Obamacare customers ultimately pay for coverage depends on a variety of factors, including age, income, where people live, and whether they smoke. A minority of the population uses these plans, and their experiences will affect their vote.

“One of the challenges is that people’s experiences with the exchanges are going to be so variant depending on their previous insurance or what medical needs they have,” said Hopkins from the University of Pennsylvania. “It’s hard to draw concrete political lessons.”

As another retaliatory measure, Republicans are elevating and attacking the latest healthcare proposals from liberal Democrats, noting they seek not only to protect Obamacare, but to extend government involvement in healthcare. Several Democratic proposals would extend government-funded Medicare or Medicaid to more people.

“Democrats’ proposed multi-trillion-dollar takeover of our nation’s healthcare system would bankrupt our country and end Medicare as we know it,” said Steve Guest, spokesman for the Republican National Committee. “It’s just one example of how Democrats’ extreme agenda would halt the pro-growth policies the Trump administration has accomplished since coming to office.”

For instance, Republican Leah Vukmir, who supports repealing and replacing Obamacare, released an ad about her opponent, Sen. Tammy Baldwin, D-Wis., calling her proposed "takeover of healthcare" a "disaster" that woud result in higher taxes.

Individual efforts by states to head in that direction have shown that if Democrats win and work toward what they call "single-payer healthcare," they are likely to meet resistance similar to what they felt under Obamacare, presenting an opening for Republicans. Gallup polling shows that three-quarters of people with employer coverage are satisfied with the quality of their plans, and 54 percent say they are satisfied with the cost. While support for “single-payer” has risen, it crumbles when voters are faced with the prospect of higher taxes or more government involvement in healthcare, and the healthcare industry has pushed back.

“The advantage is to those who defend the status quo,” Hopkins said of policy positions. “It’s easier to argue, ‘They are threatening something we already have.’ The advantage goes to whichever party is playing defense.”

The article has been changed to correct a quote from Stewart Boss.