WASHINGTON — The high costs of health care are a driving force animating House Democrats in the swing districts that will decide control of Congress next year, with the electoral consequences of their votes to impeach President Trump unclear and a court ruling that left the fate of the Affordable Care Act in limbo.
From the suburbs of Seattle, Chicago, Philadelphia and Richmond, Va., to East Lansing, Mich., and Southern California, first-term Democrats see the worries about health care that secured their 2018 elections playing out again in 2020, and they are eager to run toward them.
“I have done 15 town halls in my district this year and the top issue I have talked about is lowering prescription drug costs,” said Representative Andy Kim, Democrat of New Jersey, who has made addressing health care costs the central point of his legislative agenda and his re-election campaign. “The cost side of things is something people see on a daily basis. It’s something tangible that they understand is a problem.”
The House majority in 2020 will be decided in roughly two dozen districts like Mr. Kim’s in south central New Jersey, where Republican voters outnumber Democrats, but where a Democrat nonetheless picked off a Republican incumbent in 2018. Democrats hope the debate over rising health care costs will give them a decisive advantage, especially in suburban districts where Mr. Trump, who has failed to deliver on his promises to lower drug prices, remains unpopular.
The Republicans’ relentless attempts to repeal the Affordable Care Act when they were in charge helped Democrats take back the House in 2018. Now, even as the future of the law hangs in the balance in the court system, with an appeals court striking down the individual mandate last week but further delaying any resolution, much of the Democrats’ political message has moved from how to save health care to how to pay for it.
“I’m confident health care will be a huge part of the election discussion next year,” said Nathan Gonzales, the editor of Inside Elections, a nonpartisan analysis of congressional races. “Democrats want to talk about health care, in part because they believe it was a key factor in helping them win back the House in 2018.”
Representative Abigail Spanberger, Democrat of Virginia, recalled how in 2017, when she was running for her first term, a major concern she heard from voters was the potential loss of protections for those with pre-existing conditions.
“That was top of mind,” she said. “Then it would go into the cost of premiums and cost of prescription drugs. Now the starting point is the cost of drugs, and, ‘Oh by the way, I want to make sure pre-existing conditions are protected.’”
House Democrats passed far-reaching legislation this month that would empower the federal government to negotiate lower prices for scores of prescription medications, all but force pharmaceutical companies to offer those prices to all consumers and cap out-of-pocket drug costs for Medicare beneficiaries.
Republicans have labeled the House bill a form of socialism, and they dislike the notion of the government negotiating directly with drugmakers, even though Mr. Trump was among the first people in Washington to promote the idea. The Republican-controlled Senate is unlikely to take up the House bill. But Democrats are set to run hard on it, providing them another point of contrast as they go back to their districts.
Over 80 percent of Americans believe that Congress should work to lower prescription drug costs for as many Americans as possible, according to the Kaiser Family Foundation, which has been tracking public opinion on health care issues for two decades. The foundation found that Americans viewed lowering prescription drug costs and continuing the A.C.A.’s protections for people with pre-existing conditions as the most important priorities for Congress.
When Representative Elissa Slotkin, Democrat of Michigan, went looking for a district office in Lansing after her 2018 victory, she picked a building that housed a large health care center that served low-income residents, underscoring the central policy theme of her campaign. On a recent Monday morning, she attended a round-table event at the center with health care workers and Michigan’s governor. A patient advocate who lives in Ms. Slotkin’s district, Sarah Stark, held up vials of insulin that she said now cost her $335 each. “People are losing their homes, and their ability to put food on the table,” Ms. Stark said.
Ms. Slotkin said the “single most common question” she hears while speaking to constituents involves health care costs: “People will pull me aside and clutch my arm and say: ‘I can’t afford my prescription drugs. My son is rationing his insulin. I can’t afford my coverage. I’m paying more in health care and prescription drugs per month than I am for my mortgage. I’m underwater.’”
Voters cite the rising costs of insurance premiums, higher deductibles, surprise bills from out-of-network providers and price increases for popular and often lifesaving drugs. Even those with employer-based insurance, once viewed as protection against rising costs, have watched their average annual premiums increase by 54 percent over the last decade. Added up, rising health care costs are hitting nearly everyone, nullifying the nominal gains in their paychecks.
“The Republican efforts at ‘repeal and replace’ ironically highlighted the protections in the A.C.A. that would be lost and generated more public support for the law than at any time since its passage,” said Mark A. Peterson, a professor at the Meyer and Renee Luskin School of Public Affairs at the University of California, Los Angeles. “Now more attention has turned to the other live issue that remains, that has largely always been present and that the A.C.A. has done little to forestall, and in some cases is perceived to have made even worse: out-of-pocket health care costs for individuals and families.”
Over the last few months, House Democrats, including many in their first term, have been churning out a slew of bills to address health care costs, holding town hall meetings in their districts on the topic, visiting health care centers and patient groups, and joining forces with advocates for lower drug prices.
Democrats are betting heavily that they have solidified an image as the protectors and defenders of the health care system, just as Republicans long dominated voters’ confidence on national security issues. They are aided in large part by their attacks on the pharmaceutical industry and a growing trend among Democratic candidates to loudly refuse drugmakers’ political donations. American voters have disdain for the pharmaceutical industry, according to polling by Gallup. The House Democrats’ playbook for 2020 will be to paint the Republican Party as doing big pharma’s bidding.
“The president has been playing Ping-Pong,” said Representative Lauren Underwood, Democrat of Illinois. “He stood in the House chamber and asked us for the authority to negotiate drug prices, and we delivered, and he walked away.”
Health care, Ms. Underwood said, “is central” to her re-election campaign. She has written 30 pieces of legislation this year, much of it health care related, like a bill signed Monday by Mr. Trump that was designed to make a cheaper generic form of insulin available to consumers more quickly.
Representative Kim Schrier, Democrat of Washington and a pediatrician, said that making her constituents aware of the House prescription drug bill is her biggest campaign priority. She recalled a recent town hall event in her district, shortly before Mr. Trump was impeached, where she expected the impeachment proceedings to dominate the conversation. “But what really got people’s attention was H.R. 3,” she said, referring to the bill. “That was like the grand slam.”
Most voters had never heard of the bill, she conceded. “This is why I am doing a lot of town halls, sending out mail to people in my district, and frankly it is what I will have to spend a lot of time on the stump and Facebook talking about,” she said. “Every time I am on TV, I talk about the cost of prescription drugs.”
Another factor that has highlighted the high costs of health care is the back-and-forth over Medicare for All, which has been central to the Democratic primary for the White House. The debate “shines a light on total spending,” said Allison K. Hoffman, an expert on health care law and policy at the University of Pennsylvania Law School.
“In our current system, the health care spending burden is divided among many parties, including employers, employees, the government and charities,” she said. “In Medicare for All, it’s all shifted to the federal budget, which makes people ask, ‘Why are we spending nearly 20 percent of gross domestic product on health care?’”
Republicans, who are fully aware of the drubbing they took over their attempts to unravel the Affordable Care Act, insist that they will not be caught flat-footed again, and that the debate over Medicare for All only fortifies them this time around.
“Republicans are on much better ground this cycle,” said Bob Salera, a spokesman for the National Republican Congressional Committee. “Voters want bipartisan action to lower the cost of health care and prescription drugs, not socialized medicine.”
Democrats like Ms. Schrier, who does not support the Medicare for All approach that has been embraced by several presidential candidates and large swaths of her party, may well find themselves caught between their most liberal constituents, who crave Medicare for All, and Republicans and more centrist Democrats who do not.
“I know there is a big movement to blow up the system, but I don’t know that we need to do that to make a meaningful change in people’s lives,” she said.