Tom Perriello, a Virginia Democrat who was swept from the House in 2010, in large part because of his vote for the Affordable Care Act, is trying for a comeback this year — but far from running away from that vote more than a dozen years ago, he’s embracing it.
“What’s aged politically even better than my support for the A.C.A.,” Mr. Perriello said, “was the fact that I was pushing right to the end for it to be stronger.”
“When I got kicked out of office,” he added, “I kept fighting for things like Medicaid expansion in Virginia.”
A Democrat embracing this issue might not seem like a novel concept; the party has been more trusted on health care for a while now, though the public hasn’t often seen it as a top issue. But in 2026, Democrats like Mr. Perriello have a new script on health care that could prove more potent. It’s affordability, not access.
And polls show that when voters say that affordability is their biggest concern, for many, they’re talking about health care.
“Health care costs are out of control,” said Shawn Spencer, 48, of Greene County, Va. “I don’t have insurance, so I’m paying a boatload when I need care.”
Such concerns are particularly acute for working-class white voters, such as Ms. Spencer, whom Republicans will need to win in November. The costs of health care and housing ranked nearly even as top affordability concerns for the group, in a recent New York Times/Siena University poll.
Ms. Spencer voted for President Trump and considered herself more of a Republican, she said, but feels as if party leaders have not shown that they care about health care costs.
“At this point I would vote for the party that can help me afford to stay healthy,” she added.
In 2009, the nascent Tea Party movement urged voters to “pack the halls” as members of Congress returned home for summer recesses, and they did. Angry constituents mobbed town-hall meetings shouting, “Kill the bill!” One analysis of the Republicans’ 2010 landslide calculated that “yes” votes on the Affordable Care Act in swing districts like Mr. Perriello’s cost Democrats 25 seats, which would have been enough to hold the House.
But the act cut the uninsured rate nearly in half by 2023, to 7.9 percent of Americans down from 14.4 percent in 2010, largely through an expansion of Medicaid.
As more people began to get health care through the expansion, public attitudes toward the law began to shift. Most Americans now view it favorably, according to polling from KFF. Much of the gain in support has come in the last five years, especially from Republicans.
Around 60 percent — including about one-third of Republicans — also see health care as a right that the government should provide, a reversal from 2010, when most Americans said providing health care was not the government’s responsibility, according to Gallup.
But in July, Republicans passed the president’s tax-cuts-and-spending bill, known as the One Big Beautiful Bill Act, which is projected to cost at least 10 million Americans their health insurance, including 7.5 million through cuts to Medicaid and 2.1 million through changes to the insurance marketplace set up under the Affordable Care Act, according to the Congressional Budget Office.
The Medicaid cuts do not kick in until after midterm elections, but the subsidies for health insurance purchased on the Affordable Care Act’s marketplaces expired at the end of last year. Americans who relied on them are seeing premiums more than double, on average.
“Everywhere I go, people have a story,” said Christina Bohannan, the Democrat running in a rematch against Representative Mariannette Miller-Meeks, a Republican physician in Southeastern Iowa. “This is a problem of middle-class families everywhere, and people are beginning to realize that.”
Ms. Bohannan lost in 2024 by less than 800 votes, making Ms. Miller-Meeks a top target for Democrats. Health care advocacy groups have already paid for billboards along rural stretches of highway, telling voters their congresswoman backed the largest Medicaid cuts in history: “That’s not very Iowa nice.”
Ms. Miller-Meeks, like other Republicans, has avoided talking about the health care cuts in public. The National Republican Congressional Committee advised members last year not to hold public town hall meetings.
So one constituent, Jill Kordick, went to Washington in January to try to talk to Ms. Miller-Meeks about the rollback of the marketplace tax credits. Ms. Kordick, a 63-year-old retired hospital administrator, said she had never been political, but her premiums for a third-tier marketplace “Bronze” plan had shot up from $900 a year to $9,600.
Ms. Kordick did not get that conversation.
“My perception is she does not wish to speak with people,” Ms. Kordick said in an interview in Iowa this month. “She will only speak and attend controlled, antiseptic events.”
In October, Ms. Miller-Meeks was captured on tape telling a group of Iowa Republicans that she would hold a town hall event “when hell freezes over.” She then agreed to one in November, calling it on 24 hours’ notice. Constituents demanded to know why she had allowed the House Energy and Commerce Committee, on which she sits, to approve the Medicaid cuts.
When the crowd cheered the question, the congresswoman thanked them for cheering the committee’s work to “strengthen and preserve Medicaid” by imposing work requirements and fighting fraud. Her security team led out a man who had shouted that she had taken away health care from millions of people.
A spokesman declined to make the congresswoman available for an interview.
The cuts have hit rural areas particularly hard, as many farmers purchased insurance on the health law’s marketplaces. Around 15,000 Iowans declined to re-enroll in marketplace health insurance after the tax credits expired in December.
This is part of a broader trend. A KFF poll released this week found that about one in 10 dropped out of the marketplace, nationally. Most pointed to rising costs, with younger adults especially likely to now be uninsured.
Democrats are hoping the politics of health care will help them flip the congressional district just west of Ms. Miller-Meeks’s, as well. That’s where a health care company has closed clinics and laid off 67 staff members at a hospital in Des Moines, blaming the federal cuts for a projected $1.5 billion in annual revenue reductions.
The Democratic challenger there, Sarah Trone Garriott, has taunted the Republican incumbent, Representative Zach Nunn, for saying that it was “a myth” that the federal cuts would cause rural hospitals to close.
Ms. Trone Garriott, a Lutheran minister and former hospital chaplain, held a round table on health care this month in Ottumwa, where a primary care clinic that had treated generations of residents closed in February after a month’s notice.
A doctor, a nurse, a former mayor and a patient told reporters of the effects: 40 people lost their jobs, and many more now had to drive at least 40 minutes to the nearest clinic.
Julie Lawrence, a retired teacher, said she had seen three different primary care doctors in the last five years, and had been pleased with the last one — until the clinic’s closing put that doctor out of business. She is on a waiting list for a doctor at a clinic 40 miles away.
Her mother had been treated for two cancers at the shuttered clinic.
“I knew she had quality care, that she was taken care of,” Ms. Lawrence said. “What’s it going to be, you know, for my friends and for me?”
Dr. Peter Reiter, who worked at the clinic for 40 years, said the clinic’s closing had energized the community to vote on health care.
“Zach Nunn owns this,” he told Ms. Trone Garriott. “He needs to pay the price of accountability.”
Mr. Nunn declined an interview, but in a statement, he said he had led the effort to include a $50 billion rural health transformation fund in Mr. Trump’s signature bill, and was pushing bills to train more doctors and nurses.
Democrats such as Mr. Perriello, Ms. Trone Garriott and Ms. Bohannan are pushing not just to restore cuts made to the Affordable Care Act but to expand the law with a “public option,” which would allow Americans to buy government-funded insurance plans. Democrats had dropped that option from the health law in 2010, amid opposition from moderates.
Mr. Nunn has said the health law should be repealed — the position Republicans have taken since the act was passed. But he also joined 16 other vulnerable Republicans in the House in voting to extend the expanded marketplace tax credits.
Mr. Trump has said Republicans can work health care costs to their advantage, by painting insurance and pharmaceutical companies as greedy villains.
The president rolled out TrumpRx, saying it would offer what its website calls “the world’s lowest prices on prescription drugs.” Last month, Mehmet Oz, the administrator of the Centers for Medicare and Medicaid Services, joined one of the party’s most vulnerable members, Representative Rob Bresnahan Jr., at a northeast Pennsylvania hospital and a community college in his district, where they highlighted money from the bill that would go to train nurses for rural hospitals.
But the cuts keep coming. In rural Virginia, Augusta Medical Group has closed three health clinics over the last year, citing Medicaid cuts.
Republican politicians do have one hope; many Republican voters pinched by rising health care costs still blame President Barack Obama.
“It all started with Obama and his health care plans and ideas,” said Vicki Gentry, 63, a Republican in Harrisonburg, Va. “Trump is doing his best with this impossible mess.”
Then there are voters like Fred Henderson, 60, of Schuyler, Va., who illustrates how Republicans and Democrats diverge on priorities. As a small-business owner, Mr. Henderson is frustrated with health care costs, he said.
But, he added: “I am much more worried about public safety and immigration. Fixing that will make our economy and health care stronger.”
Crisscrossing the rural Virginia communities where he is likely to run — pending a redistricting vote in the state — Mr. Perriello often talks about health care, trade and farming in the same breath.
It is a far cry from the town halls where the former congressman was on the defensive in 2009. He is now on offense.
“Affordability can’t just be a buzzword,” he said. “It has to be an agenda. You have to look at both sides. It’s getting costs down and getting paychecks up.”
“Health care impacts both sides of that,” he continued. “It’s not only an enormous expense for people, it’s also the No. 1 reason so many people haven’t gotten a raise in years.”
Ruth Igielnik is a Times polling editor who conducts polls and analyzes and reports on the results.
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