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Numerous Republicans who are supporting attempts to dismantle the Affordable Care Act are simultaneously campaigning for election on their support for a core provision of the ‘Obamacare’ law.

The GOP spent the eight years since the ACA was passed attempting to derail it in Congress, the White House and the courts. But those efforts have struck a nerve when it comes to a central element of the law: rules protecting insurance coverage for pre-existing conditions.

(Related: Democrats Aim to Turn Obamacare Into Asset From Burden in 2018)

It’s put Republican candidates from conservative states and swing House districts on the defensive, and given an opening for vulnerable Democrats such as Missouri Sen. Claire McCaskill and Indiana Sen. Joe Donnelly to highlight a favorable contrast with their opponents. For McCaskill, Donnelly and other Democrats running in Republican-dominated states, the debate also is a chance to talk about something other than their votes against Supreme Court Justice Brett Kavanaugh, which energized GOP voters.

The issue illustrates the shift in health care politics since Republicans exploited antipathy to the 2010 law to win subsequent elections. This year is different, as numerous polls show health care as the No. 1 issue for voters in the 2018 midterm elections and that protecting those with pre-existing conditions is overwhelmingly popular across party lines.

Third Rail

“It’s remarkable how much the ACA and the efforts to repeal it have made protections for people with pre-existing conditions something of a political third rail,” said Larry Levitt, senior vice president for health reform at the nonpartisan Kaiser Family Foundation. “You’d be hard-pressed to find a candidate running for office right now who says they’re against protections for pre-existing conditions, but whether they support actual polices to make that protection a reality is a different question.”

Democrats running in states or districts where Trump won in 2016 have zeroed in on the issue in their re-election campaigns.

McCaskill, one of the Senate Democrats most at risk on Nov. 6, has put the issue front and center in her campaign against Republican state Attorney General Josh Hawley. Hawley signed on to a lawsuit started by the Texas attorney general that aims to invalidate the Obamacare law.

Missouri Battle

“Josh Hawley decided to use your taxpayer dollars to file a lawsuit that would take away important prescription drug coverage for seniors through Medicare and end all of the consumer protections under the ACA — including protections for Missourians with pre-existing conditions such as asthma, high blood pressure, cancer or diabetes,” she wrote in an August op-ed for the Springfield News-Leader. Since then, she has posted video testimonials from more than two-dozen constituents who depend on the consumer protections.

Hawley last week released an emotional television ad in which he discusses his son’s chronic disease, and promises viewers: “I support forcing insurance companies to cover all pre-existing conditions, and Claire McCaskill knows it.”

Josh Hawley @HawleyMO Wanted to share a little about my family and our journey, and my commitment to protecting people with preexisting conditions — like my son #MOSen

The backdrop for the debate is the unsuccessful attempt by President Donald Trump and a Republican-led Congress to replace the Affordable Care Act with legislation that would’ve weakened the consumer regulations and, experts said, driven up costs for insurance for sick people while lowering them for healthy people.

Texas Lawsuit

After those efforts failed, the Justice Department backed the Texas lawsuit, which seeks to overturn the health care law on constitutional grounds. The Trump administration, meanwhile, has taken regulatory action to expand the use of short-term insurance plans that don’t have to comply with pre-existing condition rules.

Hawley campaign spokeswoman Kelli Ford said he’s supporting the lawsuit because he views the ACA’s requirement that all individuals have health insurance as unconstitutional. She said Hawley “wants Congress to mandate that insurance companies cover everyone with pre-existing conditions” but didn’t say if he supports requiring a set of benefits to be included in policies.

In his own op-ed published last week, Hawley suggested requiring insurers to offer plans at the same prices regardless of whether the consumer has or had an illness, and have the federal government step in to help pay for costs above a threshold.

Shotgun Blast

GOP Senate candidate Patrick Morrisey, West Virginia’s attorney general, has signed onto the Texas lawsuit. Joe Manchin, the only Democrat to vote for Kavanaugh, has made that a centerpiece of his campaign. He’s run a TV ad in which he fires a shotgun at a copy of the lawsuit, saying Morrisey would “take away health care from people with pre-existing conditions; he is just dead wrong.”

Donnelly and Montana’s Jon Tester, another Democrat running in a state where Trump won, are also trying to capitalize on the issue.

Rep. Dana Rohrabacher, a 15-term Republican who represents Orange County in California and faces perhaps his toughest re-election battle, released an ad last week saying that he’s “taking on both parties and fighting for those with pre-existing conditions.” Rohrabacher voted for his party’s Obamacare replacement bill that included state waivers from rules that prohibit charging higher prices to people with pre-existing conditions.

Dana Rohrabacher @DanaRohrabacher For me, healthcare is personal. When it comes to preexisting conditions I’m using my heart as well as my head, advocating a creative bi-partisan approach. bit.ly/2Rmtl7A

Trump has tried to counter by depicting himself as a champion for covering pre-existing conditions at recent rallies with Republican candidates, including Morrisey.

“I will always fight for and always protect patients with pre-existing conditions,” he said on Sept. 29 in West Virginia.

Facing Attacks

Republican Senate candidates who have faced attacks from Democratic opponents on the issue include Sen. Dean Heller of Nevada, Governor Rick Scott of Florida, Rep. Jim Renacci of Ohio and Rep. Kevin Cramer of North Dakota. All of them have supported their party’s efforts to unwind Obamacare.

Levitt and other health care policy experts say that pre-existing condition rules are unsustainable without mechanisms to expand participation and provide financial assistance.

Legislation has been offered by Sen. Thom Tillis, a North Carolina Republican, as a contingency for pre-existing conditions in the event the Texas lawsuit succeeds. Levitt said the protections are “something of a mirage” as they’d allow insurers to exclude benefits under some circumstances and charge higher premiums.

Another bill by House Energy and Commerce Chairman Greg Walden, an Oregon Republican. doesn’t accomplish its stated goal of preventing higher premiums for pre-existing conditions, Levitt said.

‘Details Matter’

“The details matter enormously in insurance regulation,” he said.

Texas Rep. Pete Sessions, locked in a competitive re-election race, helped shepherd the bill through the House as Rules Committee chairman that would open the door for insurers to raise costs for covering pre-existing conditions. He’s backed away from that by offering a separate bill with some protections as well as proposing a nonbinding resolution that calls for lower premiums, out-of-pocket costs, and more provider choices to people with pre-existing conditions.

The Sessions resolution was co-signed by Renacci and Cramer. Other signatories include GOP candidates facing difficult re-election challenges, including New York’s Claudia Tenney, Michigan’s Mike Bishop and New York’s John Faso, all of whom have taken heat for supporting the Republican-backed American Health Care Act, which passed the House and stalled in the Senate.

Some Republicans are counter-attacking by claiming Democrats are pushing to replace private insurance with a government-run health system, something most of the party hasn’t embraced. House Speaker Paul Ryan on Monday said the debate is presenting a “false choice” because everyone supports protections for pre-existing conditions.

Health care premiums have been on the rise in recent decades, before and after the ACA, squeezing middle-class families. Many obtained coverage for the first time after the law passed, including those with pre-existing conditions who had been shut out of the market. The uninsured rate among non-elderly adults fell from 18.2% to 10.3% since 2010, according to an August estimate by the Kaiser Family Foundation.

Even Republicans who voted against the House GOP bill are facing attacks because of the actions of their party leaders. An ad from Democrat Jennifer Wexton derisively labeled Virginia Republican Rep. Barbara Comstock “Barbara Trumpstock” and depicted her as being “against protections for pre-existing conditions. She voted against her party’s House legislation.

—With assistance from Anna Edgerton.

— Read GOP Governors Forming Plan to Leep ACA Medicaid Expansionon ThinkAdvisor.

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