President Donald Trump devoted a large section of his State of the Union address last Tuesday night to the issue of health care. He repeated his claim that he would “protect patients with pre-existing conditions”—a claim that has no connection to any policy his administration has pursued. He promised to “never let socialism destroy American healthcare,” a reference to the Medicare for All idea endorsed by Bernie Sanders and Elizabeth Warren. And he mentioned plans and touted accomplishments related to coverage costs, pricing transparency, and prescription drug prices.

It is clear the president believes that health care will be important in this year’s presidential race. Even last March, he was telegraphing that belief: “Let me tell you exactly what my message is,” he told reporters then. “The Republican party will soon be known as the party of health care. You watch.”

Then, in October, Republicans started dropping in some states an ad that tried—emphasis on tried—to be clever about the problems of health care. In the ad, a comedian tells the audience at a comedy club, “Somebody asked me about ‘Medicare for All’ the other day, and I said, ‘Don’t you mean ‘Mediocre for All’?” Everyone laughs with exuberance.

For all the optimism and triumphalism about health care in the State of the Union address, polls show that Trump is in a giant hole on this issue; it will be tough for him to dig out between now and Election Day.

One poll that clearly spells out the problem for the president and his party is the Great Lakes Poll conducted published to little attention on January 21. It is important because it surveyed people in only four states—Ohio, Pennsylvania, Michigan, and Wisconsin. Trump won the last three states by a total of 77,000 votes in 2016, and their combined 46 electoral votes put him over the top. If the rest of the states were to vote in 2020 the same way they did in 2016 but just those three states flipped, Trump would lose in the Electoral College with 260 votes to his Democratic opponent’s 278.

One question in the poll was especially relevant to health care, and unlike the questions in most previous national polls, phrased very directly: “Do you approve or disapprove of the way Donald Trump is handling healthcare policy?”

The results show Trump and the Republicans have a big problem in these key states. When the survey was weighted to match the demographics of the polled states, 51 percent of Pennsylvania respondents said they “somewhat” or “strongly” disapprove of how Trump has handled health care, as did 53 percent of Michigan respondents and 56 percent of Wisconsin respondents. By contrast, only around 35 percent of the respondents in those states “somewhat” or “strongly” approve of Trump’s handling of health care.

As bad as those numbers might seem for Trump, his real vulnerabilities become clear when you look into the poll’s details. Women really dislike his handling of health care, with 53 percent disapproval in Pennsylvania, 59 percent in Michigan, and 58 percent in Wisconsin. Exit polls in 2016 showed Trump lost to Hillary Clinton among women in each of those states (by 42-55 in Pennsylvania, 42-53 in Michigan, and 43-53 in Wisconsin); he can’t afford to lose even more ground.

More striking is how this could play out among independents. In each of these three swing states, a plurality of independents says health care is the issue most important to them—more important even than the economy or national security or climate change. And the numbers don’t look good for Trump:

In Pennsylvania, independents made up 20 percent of the 2016 electorate and Trump won them 48-41. In the Great Lakes Poll, he is now losing independents to “the Democratic Party’s candidate” by 26-37 (with 36 percent still undecided). And they disapprove of his handling of health care by 52-32.

In Michigan, independents were 29 percent of the 2016 electorate and Trump won them 52-36. In the Great Lakes Poll, he’s losing them 23-40 (with 37 percent still undecided.) They disapprove of his handling of health care by 54-26.

In Wisconsin, independents were 30 percent of the 2016 electorate and Trump won them 50-40. In the Great Lakes Poll, he’s losing them 22-41 (with 37 percent still undecided). They disapprove of his handling of health care by 62-26.

Among all the respondents in the Great Lakes Poll—that is, not just the independents—Trump is currently losing Pennsylvania by 37-47, Michigan by 34-47, and Wisconsin by 34-48. In those states, as in most of the country, the Republican and Democratic voters are mostly locked in. But among independents, as shown above, the “undecided” numbers remain very large.

Much will depend on who the Democratic candidate turns out to be, but whoever it is, Trump will need to get the independents on his side by at least the same margins as he did in 2016. If health care is, as these independents say, their most important issue, and if they disapprove by large margins of Trump’s handling of health care, his challenge is formidable.

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What makes this polling significant is how it sets up this race at its start, since it aims to understand the mindset of voters in states that are really in play and shows us how health care could become a decisive issue in the 2020 election.

“The aging population in these states is big in terms of numbers, and [health care] is a big issue for them,” Robert Alexander, a political science professor at Ohio Northern University and one of the academics overseeing the Great Lakes Poll, told me in an interview. “These people in these states aren’t looking 20 years down the road on how they get health care, it is much more immediate for them. This is a very real issue, and instability doesn’t sell well. Trump’s policy seems to be based on more chaos, and while that might be appealing to some voters on other issues, it doesn’t seem to be that way for the people we polled.”

Lauren Copeland, a professor of political science at Baldwin Wallace University and another of the academics associated with the poll, explains how attitudes toward Obamacare have shifted. “People are really skeptical of new policy changes that are imposed upon them,” she told me. “What seems to have happened is that the voters [still] saw Obamacare as a new policy in 2016, and were a little leery of it. But now it is the standard in many ways, and most people don’t want to lose it now.”

Copeland points out that many people were wary of social security programs in the 1930s, but that, over time, Social Security “has become the third rail in politics, and any politician knows opposing any part of it means losing their office. Health care is moving into that territory, and our polling shows that Trump is hitting that third rail. If Democrats don’t screw up their messaging on this issue in these states, they can win them.”

It is worth taking a moment to look more closely at how politics and health care policy intersect in Pennsylvania, Michigan, and Wisconsin.

First, while these three states did not have big Democratic additions to the U.S. House of Representatives in the 2018 midterm elections, they each elected or re-elected Democratic governors in 2018: Tom Wolf was re-elected in Pennsylvania; Gretchen Whitmer was elected to a first term in Michigan in 2018; and Tony Evers was elected to a first term in Wisconsin. All three of these governors succeeded Republicans.

Whitmer was chosen to deliver the Democratic response to the president’s State of the Union address last Tuesday night, and her speech emphasized the health care differences between parties. After describing her own family’s experiences with American health care—“For me, for so many Americans, health care is personal, not political”—Whitmer noted that “every Democrat running for president has a plan to expand health care for all Americans” while the president is “asking the courts to rip those lifesaving [healthcare] protections away.”

Health care was a big factor in each of the three states’ gubernatorial races in 2018. While Wisconsin has not expanded its Medicaid program, Pennsylvania and Michigan have, and about 1.5 million people from those two states have their health care now through the Medicaid expansion. (I have discussed the politics of Medicaid expansion in a previous Bulwark article.) Voters in the governors’ races sent a clear signal that health care should not be played around with but rather kept at least as is.

The Trump administration announced a plan last week that will transform the way Medicaid is funded in states that choose to participate. In the new arrangement, which is expected to result in some unspecified amount of savings for the federal government, federal funding for the Medicaid programs in participating states would be capped and would come in the form of block grants with instead of the traditional, open-ended grants. Those states would be permitted more flexibility in controlling how their Medicaid programs operate, including some alterations in eligibility. If Pennsylvania and Michigan were to pursue this option, it is likely that some of the 1.5 million Medicaid newcomers in those states would be cut from the program.

“A transition to block grants could transform Medicaid from a safety net program, designed to meet basic health needs for low-income Americans, to a program with funding limits that drive care rationing for the most vulnerable,” said Dr. Howard Burris, president of the American Society of Clinical Oncology, in a statement last week.

If federal Medicaid spending is cut significantly, it is likely that the health care business itself will take a big hit. Uncompensated emergency-room health care has fallen considerably with the adoption of Obamacare and the Medicaid expansion, with Pennsylvania, Michigan, and Wisconsin hospitals saving a combined $1 billion from uncovered people hitting their emergency rooms less from 2013 to 2015, according to the Center on Budget and Policy Priorities.

Health care and the public perception of health care have changed since the 2016 election. Medicaid is now by a majority of the public not as an entitlement issue but increasingly as a program that needs a large—or larger—public funding. And with this much money on the line, job growth in the health care industry is a political factor as well.

The apparent support of independents in these three swing states for Obamacare and Medicaid expansion might be further bolstered by other basic facts about the economics of health care. More than 650,000 citizens in these three states are getting federal subsidies for their Affordable Care Act policies; it may not be politically savvy to mess with their health care when you only won those three states by a total of 77,000 votes. Moreover, the largest percentage of workers in these three states are in health care and related businesses (13 percent of the workforce in Michigan, 14 percent in Pennsylvania, and 11 percent in Wisconsin) and the total number of “educational and health services” workers has now grown to more than 2.4 million in those three states. Between January 2017 and November 2019, 78,000 jobs were added in the three states in the “meds and eds” field, compared to just 19,800 manufacturing jobs there.

So, back to President Trump’s notion that “the Republican party will soon be known as the party of health care”: It seems hard to see how that could be true during the 2020 presidential campaign. The GOP pushed the “skinny repeal” of Obamacare in 2017 (with the late John McCain’s thumbs-down vote helping to kill it). The GOP has backed most of the agenda in the lawsuit by the 17 conservative states to overturn all of Obamacare. And the GOP is now pushing a policy that will leave more people without health care insurance than have it now.

Will the Democrats capitalize on this political opportunity and campaign on health care and the economy in these Midwest swing states? Can they leave the climate change and immigration rights and racial disparity issues on the sidelines? Can they ignore the urgings of political voices from California and Illinois and New York in the general election because how those states are voting is all but certain?

“If the Democrats are smart in their campaigning in these states, their message will be ‘If he gets reelected, Trump will be taking away your health care,’ and that will be an issue that pulls together their black and white voters,” said Rachel Bitecofer, assistant director of the Wason Center for Public Policy at Christopher Newport University.

“Those people who are affected by the health care changes proposed by the Trump administration will be extremely powerful in this election, but you have to realize which states count,” Bitecofer continues. “The Dems need to talk to people’s hearts in these Midwest swing states and not to their brains. They have to learn to talk to average people and make this a referendum on Trump and his handling of health care mostly. “

“But can Dems talk to average people? They need turnout in this election. Healthcare might do that.”