Since President Trump took office just under two years ago, the Affordable Care Act (ACA) has been the center of debate and, more often, confusion. Though the proposed repeals and modifications to the American health care system have died down in recent months, health care is still a hot-button issue in this year's midterm elections.

Here's a look at where the ACA stands leading up to midterm elections, and how the polarizing issue is affecting both Republican and Democrat candidates.

Republicans: The push for further repeal

Even though the Republican-controlled Congress failed to completely repeal the ACA in 2017, the GOP hasn't given up. Many Republican candidates, led by President Trump, are continuing to push for an ACA repeal, including protections for people with pre-existing conditions, and are highlighting rising premiums as proof of the ACA's failure.

Meanwhile, some moderate Republicans are distancing themselves from the party line. In North Dakota's Senate race, Rep. Kevin Cramer committed to ensuring protection for people with pre-existing conditions, despite previously voting for legislation that would weaken the ACA. Republican Senator Susan Collins (ME) is also opposed to the party's push to remove these protections, consistent with her voting record against GOP repeal bills.

In the 29 swing districts with elections this November, Republicans running for re-election will likely be pressed on the issue, and forced to acknowledge their party's push for total repeal. With more than 20 million Americans at risk of losing healthcare coverage, it's no wonder some candidates are trying to distance themselves from the ACA on the campaign trail.

If the special election results are any indication, Republicans could struggle to maintain control of Congress come November. Earlier this year, Democrat Conor Lamb beat out Republican candidate Rick Saccone in a special election in the state's deeply conservative 18th Congressional District, a district Trump won by 20 points in 2016. And this month, GOP candidate Troy Balderson narrowly won in a tight race with Democratic candidate Danny O'Connor in Ohio's 12th Congressional District special election, a state that President Trump won by 11 points two years ago.

Democrats: The hope for status quo

Democratic candidates, meanwhile, are campaigning on the ACA's success — namely how it has granted millions of Americans access to health care — and on the general public's desire for Congress to give up on health care reform and focus on other initiatives. Additionally, in several congressional races, Democrats are criticizing Republican-leading states like Florida, Georgia, North Carolina, South Carolina, Texas and Wisconsin for not adopting the Medicaid expansion of the ACA.

Democratic candidates are also highlighting President Trump's failure to fulfill his promise to eliminate the ACA completely and replace it with a new, less expensive plan. They're taking a different approach from Republicans on rising premiums and blaming it on the repeal of the individual mandate in 2017. Since then, ACA premiums have increased 34 percent, and they're predicted to increase by another 3.6 percent in 2019. Democrats maintain rising costs are undermining the efficacy of the ACA and ultimately making it harder for Americans to afford health insurance.

The verdict: Health care is on the hot seat

Health care has never been seamless, but the spiraling ACA debate is the focal point for both parties in the midterm elections. Republicans continue arguing the ACA was repealed and will have to answer to the millions of Americans at risk of losing coverage, and Democrats keep championing the remaining requirements of the ACA to protect those Americans' access to health care.

In order for Democrats to take back the House in November, they'll need to reclaim 23 Republican seats. With 29 districts deemed competitive between the parties, control of the House is definitely up for grabs at the midterm elections. Should Democrats win control of the House, any bills aimed at dismantling the ACA will be taken off the table. If Republicans maintain their majority, it wouldn't be surprising to see them launch another ACA repeal effort.

There are also six Senate seats up for grabs from Republicans. If Democrats gain two of these seats (and defend their existing seats) they will have the Senate majority, and the likelihood of a successful ACA repeal attempt will decrease significantly.

With the future of both the Senate and the House in murky waters, the heated health care debates from state to state hold a lot of power in the future of the ACA, and for the millions of Americans on the border of losing their coverage this fall.

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Arthur Tacchino is principal and the chief innovation officer at SyncStream Solutions, a reporting and compliance company with solutions for everything from health care reform to EEO-1. He presents frequently to the National Association of Insurance and Financial Advisors (NAIFA), the National Association of Health Underwriters (NAHU), the Financial Planning Association (FPA), and other organizations.

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Why the future of the ACA could be decided at the midterm elections

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