House Republicans in vulnerable districts find themselves in a difficult position when it comes to their stance on healthcare access. President Donald Trump has an approval rating of 36%, the lowest of his second term, according to Gallup, and election watchers expect a referendum on the party in power in the midterms. Healthcare access relates to a central issue in the midterms — affordability — that political experts say Republicans can’t afford to neglect. But if Republicans stray too far from the president, they risk losing his support and alienating their base during the primaries.
The House vote earlier this month on the extension of Obamacare subsidies for three years, in which 17 Republicans joined Democrats, represents one of the rare cases of Republicans visibly drawing a line between themselves and party leadership. Although talks in the Senate on the issue have stalled, making it unlikely that Americans will see a policy solution this year, there’s a reason Republicans, several of whom are in vulnerable districts, made the leap, election experts say.
“The reasons the 17 Republicans broke with their party did so because they recognize healthcare is going to be a top issue this election,” said Erin Covey, U.S. House editor at The Cook Political Report with Amy Walter, a nonpartisan political report. “Obviously, affordability in general will be a big issue, but in particular, the cost of healthcare, and it’s going to be an issue Democrats are going to hammer Republicans on. … Republicans who voted for the subsidy extension are keenly aware of that, and most of them are in highly competitive races.”
The Republicans who broke with their party to vote in favor of the extension of the Affordable Care Act subsidies include Reps. Rob Bresnahan (PA), Mike Carey (OH) Monica De La Cruz (TX), Brian Fitzpatrick (PA), Andrew Garbarino (NY), Jeff Hurd (CO), David Joyce (OH), Thomas Kean Jr. (NJ), Nick LaLota (NY), Mike Lawler (NY), Ryan Mackenzie (PA), Max Miller (OH), Zach Nunn (IA), David Valadao (CA), Derrick Van Orden (WI), Rob Wittman (VA) and Maria Elvira Salazar (FL).
Six of them, Valadao, Nunn, Kean Jr., Lawler, Mackenzie, Van Orden are on the list of the Cook Political Report’s Republican toss-up races, but that still leaves several vulnerable Republicans who chose to vote against it.
The Cook Political Report lists 14 Republicans in the Republican toss-up category for competitive House races. Sabato’s Crystal Ball, a newsletter and website that provides political analysis, also lists 14 Republicans who share most of those names.
Rep. Gabe Evans (R-CO), who is expected to have one of the toughest races of the midterms, is on both of those lists and voted against the measure.
The rest of the vulnerable Republicans who voted no are Reps. Juan Ciscomani (AZ), Darrell Issa (CA), Mariannette Miller-Meeks (IA), Tom Barrett (MI), Scott Perry (PA), and Jen Kiggans (VA). Rep. David Schweikert (AZ) also voted against it, but is not running for re-election in the district and will instead be running for Arizona governor this year.
In total, eight of the 14 toss-up House Republicans on Cook’s list, and 9 of 14 spotlighted by Sabato’s Crystal Ball, including Evans, who’s on both lists, voted against the ACA subsidies.
The Democratic Congressional Campaign Committee, which aims to help Democrats take control of the U.S. House after the November midterms, announced on Jan. 9 that it would target 18 Republicans whom it considers vulnerable to losing their seats and who voted against the extension. The DCCC list includes Evans and others who are also on the Cook and Sabato lists.
Political experts and pollsters say they expect Democrats to hammer Republicans hard on the issue of healthcare, not only because of the expected economic impact of the expiration of ACA subsidies that voters may feel by election day, but also because voters may seek to hold them accountable for Medicaid cuts as a result of the One Big Beautiful Bill Act. Surveys have shown that voters tend to trust Democrats more on their handling of healthcare than Republicans.
“Republicans like to run on immigration and crime,” said Kyle Kondik, managing editor of Sabato’s Crystal Ball, a newsletter and website that provides political analysis. “Healthcare is something Democrats like to run on, and they have a story to tell. I’m sure Republicans will fight back and try to dispute that story, but there are subsidies going away, and there’s also Medicaid provisions in the One Big Beautiful Bill so I’m expecting that will be a very prominent feature of the Democratic advertisements this year. I can imagine it being pretty effective.”
Celinda Lake, president of Lake Research Partners, a national public opinion and political strategy research firm, said the massive healthcare changes will hurt Republicans’ messaging on affordability and whether that is enough to significantly impact vulnerable Republicans’ races depends on how much those districts still support Trump.
“You can not just take away, in this economy, people’s healthcare unless you have the ability to say, ‘This is part of the MAGA agenda, I’m with Trump,’ and in some districts that still works, but in a lot of districts it doesn’t and his support has eroded, particularly with women,” Lake said.
A November KFF poll shows that 74% of the public support extending the ACA tax credits but 50% of Republicans said they supported it. Only 44% of MAGA supporters among Republicans and Republican-leaning independents agreed. A November Pew Research poll showed the majority of Republicans said the federal government is not responsible for ensuring healthcare coverage for all, the share of Republicans who say it is has increased 9 percentage points since 2021.
Matt Foster, professorial lecturer at American University in Washington, D.C., said it’s clear that this issue will remain in voters’ minds, not just because they may feel it personally and see it reverberate across the healthcare system or because Democrats make sure it’s discussed in campaigns but because it’s clear the media will continue to cover it. Although Republicans are expected to hold these positions against the subsidies, it’s a tough issue for Republicans as they navigate disagreements in their own party over the issue, Foster said.
“For many Americans in today’s world, healthcare is a right like public education, and clearly with work requirements and all this we’re seeing fractures in the Republican caucus,” he said.
Christopher Jorde, who teaches classes on U.S. campaigns and elections and political psychology at the University of Colorado, Boulder, said he was surprised to see such cohesion among Republicans in Congress earlier last year but he has begun to see that change.
“Increasingly, it seems like there are some issues with which Republicans are willing to break,” he said, including healthcare.
Kondik said that he’s not sure the vote to extend the ACA subsidies will insulate Republicans in vulnerable districts because they ultimately can’t change the larger environment that is hurting all Republicans in the midterms.
Other election experts say that it’s harder for House Republicans to build a personal brand on opposing Trump like Republican senators, such as Maine Senator Susan Collins, whose political office has clearly survived those positions, which is why the vote was significant.
“It’s harder for House members to define their own brand so they really are tied to the leader of their party, whoever the current president of their party is. For Republicans in Congress, I think this ACA vote was the first big test of whether Republicans would break with him, and I think it’s significant that we saw 17 Republicans vote for the subsidy extension,” Covey said.
It may be hard to sell a nuanced message on why they voted this way, both in the primary and the general election; however, this may be the reason some vulnerable Republicans, such as Evans, chose to vote against it anyway.
When looking at the Republicans who voted against the subsidies, Covey said Issa and Higgins may be particularly vulnerable in the midterms due to Democratic redistricting efforts to flip Republican seats. But Issa may have a spending advantage in the race due to the fact that he is incredibly wealthy. Covey said Miller-Meeks has sometimes been seen as moderate in her district and ran what she saw as a close primary in 2024, which may explain why she stuck to her party during the vote last week.
She added that Democrats have effectively used Perry’s votes against him in previous election cycles, which may make him more vulnerable during the midterms. Evans’ and Kiggans’ districts did not go as strongly for Trump in 2024 as others, which puts a lot of pressure on their races.
Time will only tell as to whether their votes on a major healthcare issue will impact their races at all during what is expected to be a tough year for House Republicans.
“The members themselves can’t control what the environment is,” Kondik said. “They can only control what kind of campaign they try to run and what their voting record is and it may be that all of these things they try to control can’t change the environment.”
