Democrats were once reluctant to engage with attacks on the law. But in the midterms campaign, the tide has turned

Donald Trump would like to believe it’s all about him. And there is no doubt that the extraordinarily divisive US president has helped drive turnout on both sides of the midterm elections.

But after their catastrophe of 2016, when Hillary Clinton was criticised for lacking a clear message to compete with “Make America great again”, Democrats realised that a pure anti-Trump message would not be enough. Instead, many have maintained a laser-like focus on a single issue: protecting Americans’ healthcare.

“In the midterms they were much more the pro-health insurance party than they were the anti-Trump party,” said Bill Galston, a veteran of six presidential campaigns and now a senior fellow at the Brookings Institution thinktank in Washington. “They worked very hard to avoid what was widely viewed as the mistake of 2016, which was to be seen as too anti-Trump.”

A Reuters/Ipsos poll of 2,673 Americans conducted between 1 and 28 October found that healthcare was the top issue on the minds of Democratic and independent voters heading into the midterms. For Republicans it was the No 3 priority behind immigration and the economy.

Republicans spent years obsessed with repealing Barack Obama’s 2010 Affordable Care Act (ACA), known as Obamacare, which introduced meaningful protections for Americans with pre-existing illnesses. But much to Trump’s chagrin, the effort failed in the Senate by a single vote last year.

Democrats warn that if Republicans keep control of Congress in Tuesday’s elections, people could lose coverage for pre-existing health conditions and other protections afforded by the law. Instead of blanket attacks on Trump, Democrats can focus on individual members’ records.

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Congressman Tom MacArthur of southern New Jersey, for example, is one of 67 vulnerable Republican incumbents in the House of Representatives who have voted to repeal Obamacare, according to Reuters. His Democratic opponent, Andy Kim, has hit him hard on the issue.

Laurel Smith, 58, who has a son with a rare genetic disorder, voted for MacArthur in 2014 and 2016 before he authored a last-minute amendment that resuscitated the repeal effort in the House in May 2017. “I voted for Tom MacArthur because I truly believed he was the best person for the job,” she told Reuters. “I’ve never been so disappointed in my life.”

The issue has left Republicans vulnerable to charges of hypocrisy. This year they filed a lawsuit to overturn what remains of the ACA and it was backed by the justice department, which said it concurred with the need to end the law’s guarantees that insurance companies could not deny coverage to people with pre-existing conditions.

As the issue gained traction in the midterms campaign, Republicans furiously sought to backpedal by releasing numerous ads that claim they do want protections for pre-existing conditions after all. Trump tweeted last month: “Republicans will protect people with pre-existing conditions far better than the Dems!”

But healthcare experts say the repeal of the ACA would have sent premiums skyrocketing for certain people with pre-existing conditions. Obama, hitting the campaign trail, has told a series of rallies: “Right at election time, suddenly Republicans are saying they are going to protect your pre-existing conditions when they’ve literally been doing the opposite … They are lying to you.”

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If Democrats prevail in the House, as polls and pundits predict, their ability to avoid getting bogged down in national debates over Trump, or his incendiary rhetoric, may have played a large part. It will also signify a shift from past cycles when they were reluctant to defend the ACA from Republican assaults because of its perceived unpopularity. Now the tables are turned.

Vulnerable Democratic senators in states won by Trump are also focusing on the issue. Joe Manchin of West Virginia has criticised his opponent, the state attorney general, Patrick Morrisey, for joining the lawsuit filed by Republican attorneys general seeking to overturn the ACA.

The Democratic senator Claire McCaskill of Missouri, whose campaign tour is called “Your Health Care, Your Vote”, has similarly attacked her Republican rival, the state attorney general, Josh Hawley.

In Florida, Governor Rick Scott, a Republican running for Senate, flooded TV with an ad promising to retain the protections for pre-existing conditions, even though Florida is one of the states involved in the lawsuit. Scott claims he had nothing to do with that action.

The Democrats Stacey Abrams and Andrew Gillum, African American candidates for governor in Georgia and Florida respectively, have emphasised healthcare expansion probably more than any other issue – rather than getting into racially charged brawls with Trump.

John Zogby, a pollster and author, said: “Democrats had to be more than just anti-Trump; that would only get them so far. They have come a long way in messaging. Healthcare in the nation is the number one issue by far for Democrats and for independents. Democrats own it.”

Even so, Trump has been inescapable and his divisive rhetoric on gender and race will no doubt produce a backlash.

Neil Sroka, the communications director for Democracy for America, a progressive political action committee, said: “In the era of Donald Trump, it’s almost impossible for anything not to be about Trump: people want a check on this administration. But if there’s any issue that hits people directly and you can get away with not being about Trump, it’s healthcare.”

Some Democrats have boldly embraced Bernie Sanders’ “Medicare for All” plan, despite Republicans comparing it to socialism. Sroka added: “There’s a lot of different flavours of Medicare for All. The fact that people are not shying away from that policy at the same time Republicans are trying warmed-over anti-socialist attacks is remarkable.”

Not all experts are in agreement about the clarity of Democrats’ final message, however. Whit Ayres, a Republican pollster at North Star Opinion Research, said: “If you go out and ask people what Democrats stand for, I bet you nine out of 10 would say they’re the anti-Trump party rather than they’re in favour of good healthcare.”