Republicans campaigning in swing districts are running ads about healthcare after facing criticism of the cuts in the One Big Beautiful Bill Act. Many of these ads target voters over 35 years old and focus on three topics: Medicaid fraud, rural hospitals and affordability.

An NPR analysis looked at video ads on YouTube that ran this midterm cycle, many of which mirror ads on other digital platforms and on television. The analysis includes advertising for candidates in races that are toss-ups or leaning toward one party or the other, as rated by the Cook Political Report.

This is a shift for the Republican Party. Jonathan Oberlander, a healthcare policy expert at the University of North Carolina, said repealing the Affordable Care Act (ACA), commonly called Obamacare, was “target No. 1” for Republican lawmakers after Trump was first elected in 2016. When the Senate failed to repeal the legislation, there was still major backlash against Republicans for attempting to do so in the midterms.

“[The repeal is] probably one of the factors that led them to lose their majority in the House,” he said of the 2018 midterm election, where Democrats won a decisive majority. “It was extraordinarily unpopular, the least popular major legislation of the past 40 years.”

With the passing of the One Big Beautiful Bill Act last year, there are now stiffer requirements for insurance and reduced funding for state programs. About 10 million fewer people are expected to have health insurance in 2034, according to a report by the Congressional Budget Office.

There were about 3 million fewer people enrolled through the health insurance exchanges in early 2026 than when the bill passed, according to the Centers for Medicare & Medicaid.

Since then, Republicans have failed to recover on the issue, with only a third of total voters approving of the Trump administration’s handling of the cost of healthcare, according to KFF’s most recent poll on the issue from April.

Republican candidates are addressing the unpopular reforms early, according to Daniel Hopkins, a professor of political science at the University of Pennsylvania.

“[Congressional Republicans] know that that’s going to be a potent line of attack from their challengers and they have to get in front of it and defend it,” he said.

Reforming Medicaid as a strength 

Rep. Mike Lawler, a Republican running for reelection in a toss-up seat in New York, ran ads on reforming Medicaid, saying the law — which he voted for — reduced the number of able-bodied individuals in the program. He’s also raised the false claim that undocumented immigrants can no longer receive benefits (they are not under a “qualified status” to receive benefits), a topic that plays well with the Republican base.

Focusing on reform plays into a strength of the Republican Party. According to KFF, Republicans outperform Democrats on “addressing fraud and waste in government health care programs” when respondents rated which party they trust more in different areas of healthcare policy.

“What Republican voters want to see from their lawmakers is changes to the Medicaid program,” Ashley Kirzinger, the director of survey methodology at KFF, said.

“They don’t want the program to go away, but they want it to reduce fraud so that the program is more sustainable.”

Notably, around a third of independent voters consistently said they don’t trust either party on addressing costs of healthcare, prescription drugs, keeping corporate interests out of medical care or addressing fraud and waste.

Funds into rural hospitals

Rural hospitals have the highest risk, because they rely on funding that was part of Medicaid expansion in the ACA. Many counties in Lawler’s home state are already in a healthcare crisis, according to a report from the New York State Comptroller last year.

In response to criticism over cuts to rural hospitals, Congress included the Rural Healthcare Transformation Act (RHTA), co-sponsored by Lawler, in the One Big Beautiful Bill Act. The $50 billion in funding from the RHTA doesn’t offset the $137 billion in Medicaid cuts that would directly affect rural areas, though, according to an analysis by KFF.

There’s also an expected gap in implementation, with the threat of “clawbacks,” where money is taken back if states don’t meet outcomes. This is causing states to take a cautious approach to rolling out the programs. Lara Kassel, coordinator for Medicaid Matters in New York, sees a waiting period in coverage for those removed from Medicaid who are waiting for funding from the RHTA.

“It’s an undertaking similar to [other programs] where you have to set up a program, rules, have people apply, and then allocate the money,” she said.

Republicans are trying to take control of the narrative. Maine Sen. Susan Collins has released a series of ads mentioning that she directed $190 million in funds for rural hospitals in Maine.

More than 60% of Maine’s hospitals are in rural areas, one of the highest rates in the country. Medicaid is crucial in keeping rural hospitals operating, covering essential services such as discharges and births. With more than 4 in 10 hospitals in debt, cuts would have major consequences for these facilities.

“They’re sources of safety, economic prosperity and jobs,” KFF’s Kirzinger said. “People in rural areas have a really strong connection to their hospital.”

Making healthcare affordable 

More than half of Americans say that healthcare costs are a high worry for them when voting, according to KFF, and Republican candidates are positioning themselves as fixers.

“Democratic lawmakers were more trusted on healthcare, and Republican lawmakers were more trusted on the economy, so what happens when it’s an economic healthcare issue?” Kirzinger said. “There is an opportunity to gain that lane and be the party that people trust.”

Three Republicans, Rep. Ashley Hinson, who is running for U.S. Senate in Iowa, and Reps. Mariannette Miller-Meeks, also of Iowa, and David Valadao, of California, who are both running for reelection in their districts, have made healthcare affordability part of their campaign messaging. All three are running in states or districts that have shifted away from Republicans in the past year (though Valadao’s district was also redrawn in California’s redistricting last year), according to the Cook Political Report. Miller-Meeks and Valadao are running in districts now seen as toss-ups.

Hinson and Miller-Meeks directed blame for medical costs toward insurance and pharmaceutical companies, organizations with historically low approval ratings. Hinson pointed to working with Trump to lower healthcare costs, while Miller-Meeks, a medical doctor, highlighted her expertise in challenging pharmaceutical companies.

In California, Rep. Valadao ran ads promising to lower costs and protect Medicare and Medicaid. Valadao voted for the OBBBA.

A report by the Urban Institute shows that ACA premiums have risen nationwide 21.7% between 2025 and 2026. Healthcare policy expert Jonathan Oberlander says this is linked to the Trump administration’s hands-off approach toward the healthcare industry.

“[Republican] policy, both on the One Big Beautiful Bill and not renewing the enhanced subsidies and rules and regulations, has been to make it harder for people to get health insurance coverage through the Affordable Care Act and through Medicaid,” he said. “When you take Medicaid away from people, when you take those enhanced subsidies away, it really increases the costs that they face.”

Looking forward

The majority of the changes and cuts enacted in the One Big Beautiful Bill are expected to go into effect after the midterm elections. While some healthcare cuts have already gone into effect, such as the removal of ACA premium tax credits, many other requirements will begin next year, such as frequent redeterminations of eligibility and work requirements, according to Medicaid Matters’ Lara Kassel.

Key changes, like the reduction of Medicaid funding, don’t occur until after this year’s midterms, so candidates see this as an opportunity to emphasize other, popular parts of the law, like tax cuts. Still, Republican lawmakers are laying the groundwork for blame if the opposing party gains power in the future, according to political scientist Daniel Hopkins.

“Some of the key changes, for instance, [like] the reductions in Medicaid funding, are scheduled to kick in years down the road,” he said. “That time disconnect makes it really hard for voters to tangibly feel and react to changes that are in the future.”

That delay will likely set up healthcare to be a top issue for the 2028 election, where Democrats are expected to attack Republicans on the fallout and both parties will have open primaries for the presidency.

“That phasing provides a bit of a buffer for Republicans from the political pain of these cuts,” Oberlander predicted. “[The healthcare cuts will] be fully exposed in 2028.”