WASHINGTON _ In Southern states where Republican opposition to the 2010 health care law has been strongest, Democrats are using heightened concerns about health care to woo undecided voters and challenge GOP candidates who don't support the Affordable Care Act and its key provisions.
After Republicans ran against the ACA, or Obamacare, to regain control of the House in 2010, Democrats were reluctant to embrace the law as polls showed only lukewarm partisan support for the health law. But as the law's popularity grew, Democrats saw an opportunity to fight GOP repeal efforts.
The Republican effort to dismantle Obamacare has continued. Nine GOP-led Southern states are part of a 20-state federal lawsuit that seeks to declare the ACA unconstitutional and scrap one of its most popular provisions, the one that requires insurance companies to offer coverage to people with pre-existing medical conditions.
Sixty-three percent of independent voters say protections for people with pre-existing conditions are "at least 'very important' to their vote _ making it (their) top health care issue," according to a recent Kaiser poll. Fifty-one percent of Republicans agreed.
With that kind of support, it's clear Democrats view health care as a winning political issue _ even in the South where Republican opposition to Obamacare, long a badge of honor for GOP lawmakers, could become a major liability in this crucial mid-term election year.
In states with early June primaries, nearly 38,000 television ads for Democratic congressional candidates mentioned health care, making it the top policy issue in pro-Democratic TV ads in those states, according to the Wesleyan Media Project.
Expect more of the same in the run-up to November, said Robert Blendon, a professor of health policy and political analysis at Harvard University.
"The ads are going to be very dramatic," Blendon said. "They're not going to be talking about 'your premiums went up 12.2 percent,' or anything like that. It's going to be the drama of millions losing coverage or millions of people losing the protections they have if they have a (pre-existing) serious illness."
The appeals won't likely change the votes of Republicans who see the elections as a referendum on President Donald Trump. But the messaging could energize Democratic voters and sway some Southern independents and wavering GOP voters.
"In close races, those people could really count," Blendon said.
Republican candidates should confront the issue head on, said Jason Pye, vice president of legislative affairs at FreedomWorks.
"Republicans are notoriously scared of health care because they think they're at a disadvantage," Pye said. "What they should be doing is looking at Democrats and pointing fingers saying, 'These are the guys who created the problems. We shouldn't be trusting them to go back there and fix it because they're just going to make it worse.' "
Southern voters would be amenable to that line of attack, said Pye, a resident of the metro Atlanta area.
"I see them being sympathetic to that. I see independent voters responding to that," Pye said. "But Republicans need to be better on messaging."
Republicans are making a mistake, Pye said, in letting Democrats frame the issue.
To that end, the House Majority PAC, a political action committee working toward Democratic control of the House of Representatives, has launched a summerlong $3 million digital ad campaign against Republican House candidates in 12 districts who voted for the GOP health care bill in 2017. In the South, the ads target GOP Reps. Andy Barr in Kentucky and French Hill in Arkansas.
In October, at the height of the campaign season, Health and Human Services is expected to announce 2019 premiums for Obamacare insurers on the federal marketplace. Rates could spike because of funding and regulatory uncertainties, as well as fewer young and healthy people signing up for coverage.
Republicans say rate hikes for marketplace coverage reflect the rising costs of requiring individual plans to cover essential benefits like mental health services, maternity and newborn care and pediatric services.
"You can't make these health insurance plans with all these different mandates and all these different requirements and expect premiums to go down," Pye said.
Michael Sparer, chair of the Department of Health Policy and Management at Columbia University, said the coming rate announcements will generate a tremendous amount of publicity.
"The fact that that announcement will come out in October, I think, is going to be politically helpful for the Democrats because they're going to try to blame Republicans for enacting policies that lead to higher premiums," Sparer said. The rate hikes could also help Republicans with their message that the ACA isn't working and is too expensive.
In Georgia, as in most places, the party divide on health care is stark. Georgia Democratic gubernatorial candidate Stacey Abrams wants to retain the ACA's guaranteed offer of coverage for people with pre-existing conditions.
"It goes against our values to deny people care because they have experienced childbirth, or have conditions like diabetes or cancer," Abrams said in a statement. "As governor, I'll join the bipartisan group of leaders across the country urging Washington to do the right thing and protect people with preexisting conditions."
Georgia's Republican gubernatorial candidates, Lt. Gov. Casey Cagle and Secretary of State Bryan Kemp, both support the 20-state ACA lawsuit that could eliminate those protections.
"Right now, there are thousands of Georgians already priced out of the market because of their pre-existing conditions and serious illnesses," Cagle said in a statement. "That's why I'm the only candidate with a plan to reform Georgia's health care system and marketplace so coverage is affordable and accessible statewide _ regardless of what happens in federal court."
The 20-state lawsuit, filed by Republican state officials, claims the ACA's "individual mandate," which requires most Americans to have health insurance, will no longer be constitutional after the Tax Cuts and Jobs Act of 2017 drops the tax penalty for violating the mandate from $695 to $0 in 2019. The suit claims a $0 penalty isn't really a tax and is unconstitutional based on a 2012 Supreme Court decision that held the ACA was, in fact, a tax.
The Trump administration, which won't defend the ACA in the case, argued in a brief that once the tax penalty falls to $0, the mandate and the law's protections for people with pre-existing conditions would also become invalid.
In the nine Southern states that are plaintiffs in the suit, Kaiser estimates that nearly 14.5 million working-age adults have medical problems that could have kept them from getting individual coverage before the ACA became law.
In a statement, Kemp said those with pre-existing conditions who can't find or afford insurance in a post-Obamacare world, could be covered through high risk pools for the medically uninsurable "without growing a welfare state."
The pools were commonplace before the ACA was adopted, but have a long history of high costs, poor funding and limited benefits, experts say.
"Obamacare is an absolute disaster and it needs to be repealed," Kemp wrote. "My top priority is finding workable, affordable solutions for individuals, families and small businesses _ not expanding government programs and creating new government jobs."
In South Carolina, Democratic gubernatorial candidate James Smith said, as governor, he would withdraw South Carolina from the ACA lawsuit, which he said was "pure politics and playing political games with the health of the people of our state."
