Obamacare is a major issue in many midterm swing states, but few more so than North Carolina, Dan Roberts reports

The closest-fought election in this November's knife-edge battle to control the US Senate may come down to a referendum on a subject that everyone has an opinion on but few voters can claim to fully understand.

President Obama's healthcare reforms are proving the decisive factor in many midterm swing states, and few more so than North Carolina – a state he lost narrowly in the 2012 general election which is currently represented by Democratic senator Kay Hagan.

Yet with a every campaign rally, door step skirmish and exchange of artillery between Hagan and her Republican rival Thom Tillis in the war of the airwaves, the rhetorical battle of Obamacare becomes ever more divorced from the complex realities of US healthcare.

Retta Riordan stands more of a chance than most ordinary voters of fathoming out what is at stake. The 61-year-old pharmaceutical consultant has spent her professional career navigating the system as a compliance lawyer for the healthcare industry.

But even she fell foul of its arcane rules when moving from New Jersey to the outskirts of Raleigh, North Carolina, two years ago. A lapse between policies meant she had to reapply for health coverage in the private insurance marketplace, only to discover that a minor pre-existing medical condition rendered her uninsurable. A subsequent knee injury required routine surgery she could not afford.

Hobbled but determined, she began a ten-month Kafkaesque journey through the insurance jungle that only ended this year when new Obamacare rules banned insurers from excluding patients with pre-existing conditions.

Yet even this stark reminder of the previous system's many flaws has not been enough to silence the critics she meets constantly: from a receptionist at one of the medical clinics who admitted to simply “hating Obama” to others who falsely accuse her of mooching off the state.



“My sense when I talk to people who are actively opposed to Obamacare is they have most of their information wrong or are just taking their talking points from Fox News,” says Riordan. “I have never had anyone who came up with a good reason.”

'We have had a conservative revolution in this state”



At a rally for conservative Republicans last month in Charlotte, Obamacare soundbites proved a guaranteed way to fire up the audience. Yet even political activists start to get a little fuzzy when they stray into details.



Timothy Elkin, a 24-year-old from Asheville, North Carolina, is typical of a younger, hipper crowd drawn to Tea Party policies, but whom the establishment candidate Tillis will have to take with him if he is to defeat Hagan in November. “We have a federal government that forces us to buy Obamacare,” he told the rally for Tillis’s now-defeated Tea Party rival Greg Brannon.



“They expect young people, people that are not at a financial stable point in our lives, they expect us to subsidise the old and sick – that is insane.”



Another unlikely-seeming rebel against the insurance model who spoke at the same Republican rally is Clarence Henderson, an African American civil rights veteran who once took part North Carolina's famous 1960 sit-in protest at a whites-only Woolworth lunch counter in Greensboro.

Civil rights veteran Clarence Henderson in North Carolina.

"Healthcare is nothing more than a way to control the American public," he claims, drawing parallels with racial oppression.



With such heartfelt opposition to the notion that the state should interfere with the market for health insurance – however flawed – it is no wonder that Republican leaders in North Carolina have seized on the issue as their number one campaign message.



Speaking to reporters next to a golf course on the day he received an endorsement from former presidential candidate Mitt Romney, Tillis, speaker of the North Carolina general assembly, looks more at home in the prosperous suburbs and country clubs of Charlotte than a firebrand in the Tea Party mould.



But his record of passing conservative legislation in the state assembly has won over rightwing Republicans and terrified Democrats in equal measure. “We have had a conservative revolution in this state,” he tells the Guardian. “Whether it's cutting taxes, cutting spending, cutting regulations, medical malpractice reform, or election law and voter ID.”



Tillis is clear-eyed about what difference it would he make if his election tipped overall control of the US Congress in favour of his party. “Maybe we would have a Senate for the first time in a long time that solves problems,” he says. “A Senate that passes a budget; that repeals Obamacare, that asserts itself more when you have president Obama failing on foreign policy.”



'All healthcare, all the time'

Any hope that a new Republican intake in 2014 might ease the current gridlock with Democrats is dashed by Tillis who seems oblivious even to limited recent compromises in Congress such as over the federal budget. “It takes two to pass a budget ... when a budget gets signed by the president that's when they've solved the problem”, he says, despite the fact that both parties and Obama did agree just such a deal.



This heated ideological cauldron has been given more fuel in North Carolina in the shape of heavy advertising spending from both parties.



Democrats are quick to attack Tillis for receiving support from outside donors such as the Koch brothers and national groups such as the National Right to Life campaign, the National Rifle Association and the US Chamber of Commerce.



Republicans in turn are livid that national Democratic party money has already been spent trying to sway voters in the primary election battle between Tillis and Brannon. “They spent $6m meddling in Republican primary,” says Tillis. “That's unheard of and really a testament to the fact that they don't want to face us in November.”



Facebook Twitter Pinterest President Barack Obama during a town hall meeting on healthcare reform in Raleigh, North Carolina, in 2009. Photograph: Saul Loeb/AFP/Getty

But one thing both sides do agree on is that Obamacare is going to be top of the agenda, whether the Democrats like it or not. “If I had to hazard a guess, it will be probably be all healthcare all of the time from those guys,” says Ben Ray, a spokesman for Hagan's Greensboro-based campaign team.

At first, Democratic strategists seemed wary of playing into Republican hands by allying Hagan with Obama's controversial health reforms. She was reluctant to appear with the president on trips to the state and accused by opponents of even being wary of appearing on her own lest it draw attention to her national record.



But as opinion polls show an electorate that remains remarkably evenly split between the two candidates, there has been a noticeable shift in the willingness of Democrats in swing states such as North Carolina to take the healthcare debate head-on and actively seek to defend the president's record rather than hope it will go away.



Hagan, for example, has begun campaigning hard on Tillis's record in the state legislature where he led efforts to block North Carolina from taking advantage of a Medicaid subsidy available under the Obamacare – something she says would have benefitted 500,000 people in the state.



Given the Affordable Care Act's much-publicised website failings and divisive politics, there is still a preference for campaigning on other issues such as the economy, but Hagan's people increasingly recognise that this battleground is going to be defined by their enemy and there is little choice but to fight.



Republican threats to repeal Obamacare, as well as conservative North Carolina moves against unemployment insurance and voter rights, have also helped energise what risked becoming a lacklustre Democratic base in the state. “To be frank, the passion gap on our side has been plugged by Tillis's legislative record,” claims Ray, pointing to so-called Moral Monday protests last year that drew an estimated 20,000-100,000 people out to protests in Raleigh on issues such as women's healthcare, voter access and Medicaid expansion.



Nevertheless, Democrats are fully prepared for a bitter and close-fought battle come November. “It's going to be a slog,” concludes Ray. “We've got a darn near 50/50 state. We've got two very well funded races ... It will be a lot of things but it won't be boring. Things will get fairly heated over the summer and then [it will be a case of] hide your television set come fall.”

