Democrats are not very active in Illinois’ 14th Congressional District, according to their new representative in Congress, Lauren Underwood (D-IL). “[The] Democratic Party did not traditionally send Democrats to the state legislature [from the 14th District],” she said, “so our community was not a priority for the state party.” In spite of the precedent in her district, Underwood used her experience as a nurse and healthcare policy expertise to build a message centered on protecting the healthcare of her constituents that resonated with her district. Her victory in November 2018 sheds light on how Democrats can appeal to areas of traditional Republican strength as well as indicates voters’ current priority issues.
The 2018 Election: A New Blue House
Underwood’s election follows two eventful and tumultuous years of unified Republican government. Following President Donald Trump’s 2016 victory and the establishment of Republican majorities in the House and Senate the following year, Republicans began to make good on their promises to repeal the Affordable Care Act (ACA). Last July, when the Trump administration announced that it would freeze $10 billion in payments to risk-adjustment programs necessary for stabilizing insurance markets (though the department of Health and Human Services backed down from this decision a few weeks later) it indicated that the Trump administration was only partially willing to enforce the ACA.
Additionally, the Trump administration has made it easier for citizens to access insurance with fewer consumer protections, and has severely cut the budget used for outreach on education about enrollment. These efforts strongly signalled Trump’s opposition to the law and his desire to see it repealed. Congressional Republicans, aiming to fulfill the promise they had been running on since 2010, quickly moved to repeal and replace the ACA.
In May 2017, the House passed the American Healthcare Act (AHCA), which would partially repeal the ACA. Forecasts by the Congressional Budget Office estimated that passage of the bill would result in an additional twenty-three million people becoming uninsured over the next ten years, mainly as a result of cuts to Medicaid.
Like many Americans, Underwood was concerned by Republican efforts to repeal and replace the ACA in 2017, so she sought assurances from her representative, Randy Hultgren, that he would protect pre-existing conditions. When he voted for AHCA and, in Underwood’s view, broke that promise, she decided to run.
“I believed him because it’s personal,” she said. “I got really upset because I believe that representatives should be transparent and honest about their vote.”
Underwood ran for Congress in what has historically been a deeply Republican district. Once the home of former Republican House Speaker Dennis Hastert, Hultgren, in his last election in 2016, cruised to reelection with nearly 60 percent of the vote. In spite of this, Underwood found that it was the high level of interest in the district, with six other Democrats competing with her for the nomination, that complicated her run.
“We didn’t have the bench of experienced campaign staffers that would be able to work on all these competitive primaries,” she said. “We had seven people running in the primary here in the 14th District and that was not unique.” It became clear that, even in territory traditionally hostile to Democrats, there was broad support for candidates who were upset and worried about how Congress was handling healthcare.
A poll from the Kaiser Family Foundation named healthcare as the top issue for voters in the midterm elections. Democrats appeared to control the messaging on that issue, with 75 percent of all healthcare-related ads coming from or expressing support for Democratic candidates. This heavy emphasis on healthcare, combined with Democrats largely controlling nationwide messaging on the issue, led to a rout in the House of Representatives last fall, with Democrats picking up a whopping forty-one seats and demolishing the Republican majority.
Democrats ran on many different messages across the country. Some candidates, such as Katie Porter of California, advocated for a “Medicare for All” system. Others, such as Underwood herself, favored more incremental improvements to the ACA. The approach of running on different messages in different areas worked brilliantly, allowing candidates in liberal districts to propose sweeping changes to the healthcare system without endangering candidates, such as Underwood, trying to win in territory friendlier to Republicans. Although the Democrats ran on many different messages and lacked consensus in 2018, circumstances made such a strategy feasible and effective.
However, all Democratic candidates expressed opposition to Republican efforts to gut protections enshrined by existing law. Now that Democrats are firmly in control of Congress, Republicans’ legislative efforts are dead.
Underwood brings a rich professional background with her to the 116th Congress, and has many policy ideas designed to protect and expand access to affordable healthcare both for residents of her district and people across the country. In January, she was appointed to the House Committee on Education and Labor, which, among other things, provides oversight over federal policy regarding healthcare. As a Democrat on the committee, Underwood now has the power to enact the change and provide the oversight that she campaigned on last year. She believes that the Trump administration has not adequately enforced and resourced the ACA, and that the House of Representatives has done little, if anything, to address this.
“Any program that’s starved of resources will fail,” she said. “That’s not a secret and that’s what we’re seeing happen with the Affordable Care Act.”
She believes that problems were created on both a small and large scale, from the Trump administration’s decision to reduce funding for enrollment outreach to the administration’s 2018 decision to freeze risk-adjustment payments to insurers.
“We’re seeing higher prices, fewer choices, and overall less satisfaction because people don’t feel like they have truly affordable healthcare coverage,” Underwood said.
Underwood believes the House needs to take a more aggressive role in ensuring the executive branch is properly and effectively enforcing the ACA. “Part of the conclusion of the 2018 [election] cycle is that the American people want their healthcare coverage, and so it’s going to be up to the House of Representatives to provide that oversight,” she said.
Fight for 2020 and Beyond
Democrats next year will be presented with a golden opportunity: to make Trump a one-term president. With nine major candidates currently announced and more likely to come, there is no shortage of Democrats eager to earn the distinction of unseating Trump and the honor of serving as president.
However, though many Democrats believe that the 2018 midterm elections demonstrated that Trump is in a weak position, he nonetheless enjoys a good deal of support from his base and remains a formidable candidate. Democrats will be confronted with important questions about what they stand for, as they try unseating a prepared and ruthless incumbent.
Like last year’s House candidates, presidential candidates have many different ideas on how to solve America’s healthcare problems. On one hand, Bernie Sanders has been advocating for years for the implementation of a “Medicare for All” system similar to what has been implemented in Scandinavian countries. Others are more cautious, such as Amy Klobuchar, who instead believes that it is too soon to discuss “Medicare for All,” and that we should instead focus on what is workable now, such as a public option. As Democrats spend the next year and a half determining who their next nominee will be, the healthcare battle will rage on.
However, Democrats will also be forced to defend the gains they made last year again in 2020. Pending special election results in North Carolina, Republicans will need somewhere from 18–20 seats to recapture the majority. However, with thirty-one Democrats representing districts won by Trump, Republicans have plenty of targets. Representing a district that Trump carried 49–45 percent, Underwood is one of them. Already, she has been named a top target by the National Republican Congressional Committee (NRCC), the campaign arm of the Republican House Caucus, and has already drawn two Republican challengers.
Additionally, numerous election ratings organizations, including Inside Elections and the Cook Political Report, have labeled her bid for reelection a “toss-up race.” Furthermore, because parties out of power tend to overperform in midterm elections, 2020 is not likely going to be as strong a year nationally for Democrats as 2018 was. Nonetheless, Underwood remains undeterred, convinced that her message will appeal across her district no matter what year it is or who she is sharing the ballot with, saying explicitly that “the idea that, the kind [of message] that worked in 2018 won’t work in 2020 is something that I kind of reject.”
Underwood emphasized focusing on the needs of her district, citing its unique nature as half-rural and half-suburban. “[Since] my district is half-rural, the rural healthcare, making sure we have rural hospitals and workforce development issues, and the availability of medicine, remain important,” she said. While Underwood understands that these priorities may be outside “the gold agenda item” for the Democratic Party’s healthcare platform, she nonetheless remains committed to fighting for these priorities in the House.
Underwood also emphasized her independence from the national party, a valuable political asset in a swing district. When asked about next year’s presidential contest, she declined to commit to supporting whoever the Democratic nominee might be. And even if she does end up supporting the eventual Democratic nominee, Underwood noted that she would maintain her own healthcare platform regardless of any discrepancies between her and the candidate’s agenda. While Underwood hasn’t announced her intention to seek reelection, she has made it clear that, at least on the issues most important to her, she values her independence, and believes that it will help her successfully win reelection next year.
The Democratic Party lacks a consensus on what healthcare should look like going forward. Last year, Democratic House candidates were united in their opposition to the AHCA, using it as proof that Republicans were a threat to basic healthcare rights. However, the similarities largely ended there, as different candidates proposed various alternatives to the status quo. Presidential candidates are similarly divided on how to move forward. As a result, Democrats will spend the next year and a half divided over a battle of ideas. Additionally, the 2016 presidential election demonstrated that the end of primary season does not end debate and dissent on an issue. The division and contentious debate surrounding healthcare leads one to wonder if consensus among Democrats is even possible when it comes to this issue. Underwood has acknowledged this, saying that “I may or may not agree with their healthcare platform” of the eventual Democratic nominee. The future for Democrats appears challenging when it comes to healthcare policy consensus. Whether or not this poses an insurmountable problem remains to be seen.
Democrats’ fortunes will partially depend on steps taken by the current administration as well as the courts. In December, a federal judge in Texas struck down the entirety of the ACA as unconstitutional. On March 25, the Department of Justice concurred, stating that it has “determined that the district court's comprehensive opinion came to the correct conclusion and will support it on appeal.” Additionally, Trump appears to be interested in attempting another healthcare legislative effort, declaring that the Republicans would soon be known as the “party of healthcare.” Such efforts may shift the conversation back towards the form it adopted in 2017, when Democrats railed against Republican efforts to gut existing protections guaranteed by the ACA. While this shift may be temporary, continuing threats to the current healthcare law may enable Democrats to run on the same message, pushing back more difficult conversations about healthcare within the party.
Underwood, running on an issue she was passionate about, saw untapped potential in a longtime Republican stronghold. She used her message about protecting healthcare to flip territory that was until recently viewed as an impossible reach for Democrats. From suburban California to rural West Virginia and every district in between, Underwood’s path was replicated across America as healthcare became the defining issue for Democratic hopefuls.
Presented with both the House majority and opportunity to unseat Trump next year, Democrats face renewed challenges as healthcare remains the priority for voters. Underwood’s story and path to victory illustrates a possible path for Democrats going forward. While she has no plans to run for president next year (and won’t be old enough anyway), her path should help map Democrats’ plans for the future.
The image featured in this article is courtesy the Institute of Politics. The original can be found here.