When President Donald Trump went to West Virginia this month to tout the Republican tax plan, his main political target in the state prodded the president on two major issues.
Sen. Joe Manchin, a Democrat running for re-election in a state Trump won easily in 2016, asked what would happen to West Virginia residents who choose not to get health care because of a provision in the GOP tax overhaul. He also questioned whether Republicans would cut funds from Social Security and Medicare to help offset projected budget deficits generated by tax cuts.
"I won't stop fighting to protect Medicare and Social Security for our seniors, the 200,000 West Virginians at risk of losing coverage, and to secure coal miner pensions," Manchin said in a statement earlier this month.
Health care and Social Security are always important issues for voters, and Democrats have often made them keystones of political campaigns. But with midterm congressional elections approaching, the issues have taken on more political importance for the party following Republican efforts to repeal the Affordable Care Act and GOP musings about shrinking social programs.
While Republican moves to overhaul Social Security, Medicare or Medicaid appear unlikely — at least for this year — Democrats are increasingly warning about the prospect because of the deficit concerns created by the tax plan. The GOP argues Democrats want to distract from the fact that they did not support the tax overhaul, the signature Republican achievement of Trump's first year in office.
Democrats' ability to sell voters on their vision for health care and warn about the possibility of cuts to Social Security and Medicare could prove crucial for candidates, such as Manchin, who are trying to win in red areas.
Democrats already heavily argued for protecting social programs in one key House election. Rep. Conor Lamb, D-Pa., won a March special election in a district Trump carried by 20 points. Former Vice President Joe Biden made campaign stops for Lamb and repeatedly argued the region's voters needed to elect Lamb to protect Social Security and Medicare.
"If we do nothing in terms of cutting programs, if we just keep things as they are, America's gonna go flat bankrupt over the next 10 years. Not a joke," Biden said at the time. "It's because this tax cut is not paid for. But they have a way to pay for it. And [Lamb is] gonna get in their way, they're afraid."
Biden, who has not ruled out running for president in 2020, is expected to campaign for House Democrats throughout the year and will likely make similar arguments.
Health care and Social Security: More important than the economy
Recent polling has shown the importance of those issues. In an Economist/YouGov poll taken in early April, 15 percent of surveyed U.S. adults listed health care as the most important issue to them, while another 15 percent chose Social Security. Those were the most frequently chosen topics, ahead of even the economy at 11 percent.
Twenty-three percent of responding voters in a March Quinnipiac poll listed health care as the most important midterm issue for them, ahead of every other topic including the economy.
Polling suggests Trump and the GOP's efforts to reshape the American health-care system have not resonated with voters. Thirty-six percent of respondents to the Economist/YouGov poll said they strongly disapprove of how the president has handled health care, compared with only 15 percent who said they strongly approve.
Among independents, 32 percent said they strongly disapprove, while 13 percent said they strongly approve.
Taking a back seat to tax cuts
Last year, congressional Republicans tried to repeal and replace major parts of the Affordable Care Act. The proposals throughout the year varied, but the GOP broadly argued it aimed to increase consumer choices and bring down health-care costs. Some repeal proposals would have scaled back future increases in spending on Medicaid, the federal and state health program for low-income Americans.
Every GOP proposal to overhaul the health-care system was expected to lead to higher average premiums and millions more Americans without insurance. Those estimates were partly due to the proposal to scrap the individual mandate, which required most Americans to buy insurance or pay a penalty. It is designed in part to keep healthy individuals in the marketplace and bring down costs.
While the House passed a repeal bill, Senate Republicans failed to pass multiple repeal plans. However, the party voted to repeal the individual mandate starting next year as part of the tax overhaul.
Despite concerns about premium costs, Congress has not approved any of the recent bipartisan proposals to stabilize the individual insurance markets.
Meanwhile, some Republicans started discussing the prospect of reforming major social programs after the tax bill's passage in December. Observers considered possible action on Social Security, Medicare or Medicaid realistic partly because of House Speaker Paul Ryan, a self-professed deficit hawk who has talked about changing the programs in the past.
However, Ryan said earlier this year that he does not think the House will pass Social Security or Medicare reform in 2018. The speaker announced last week that he would retire when his current term ends in January, creating questions about whether the GOP would still make reforming the programs a priority.
But the issue will likely still feature prominently in November's elections, as Ryan plans to campaign and raise money for Republican candidates for the House. Democrats will likely use Ryan's desire to cut the programs against him and the GOP.
"Even if Republicans aren't pushing it, they can raise the specter," said Robert Shapiro, a political science professor at Columbia University. "It won't go away for Paul Ryan and Congress until he leaves Congress."
'It is disgusting, and we deserve better'
Lauren Underwood, a registered nurse who worked in the Department of Health and Human Services during the Obama administration, is one of numerous Democrats running for the House this year with health care as their signature issue. Underwood, who aims to unseat GOP Rep. Randy Hultgren in Illinois' 14th District, has criticized the congressman for backing Obamacare repeal efforts.
Underwood told CNBC she would first push to stabilize the Affordable Care Act. She also wants to seek solutions to reduce prescription drug prices, fight the opioid crisis and reform mental health care.
Like other Democrats around the country, she has seized on the possibility of the GOP cutting funding from Social Security, Medicare and Medicaid.
"It is unacceptable, it is disgusting, and we deserve better," Underwood said.
The campaign trail conversation on health care and social programs flips the script from recent election cycles, which were defined by Republican attacks on Obamacare and pledges to repeal the law. After the passage of the tax law and repeal of the individual mandate, the GOP political base appears not to be "clamoring on Obamacare," Columbia's Shapiro said.
Republicans argue Obamacare is fundamentally broken and warn of potential Democratic efforts to pass a public single-payer system. Arguments about possible cuts to Social Security or government-funded care are an "effort to distract from what was an unconscionable step" to oppose the GOP tax law, said Jesse Hunt, a spokesman for the National Republican Congressional Committee.
During his stop in West Virginia, Trump made similar points about Manchin, whom Republicans hope to unseat as they try to keep a narrow majority in the Senate.
"He votes against everything. And he voted against our tax cuts. ... He also voted against medical help and health care, and that's bad. And we can't have that," Trump said.