MARMET, W.Va. — There were the beauty queens, ages 6 to 60, riding in style in the Labor Day Parade, including Teen Miss West Virginia Coal. There was the man driving a pickup truck memorial to 29 workers killed in a 2010 mine disaster, each victim’s portrait airbrushed on metal.
And there was Senator Joe Manchin, in a sky-blue shirt with the state’s craggy outline on its crest, walking the route and greeting voters who brought up his favorite issue themselves.
“Save our health care!” Barbara Miller shouted.
Mr. Manchin stopped to give her a hug. After he passed, she said she feared that Republicans in Washington will continue to try to repeal President Barack Obama’s health care law. “If they can’t overturn that, then they hope they can at least favor their big-insurance buddies by allowing them to block pre-existing conditions,” said Ms. Miller, a nurse educator. “I have a pre-existing condition.”
“We all do,” chimed in four other women seated with her on a porch.
In a state where approval of President Trump is near the country’s highest, Mr. Manchin, a Democrat, was once thought to be deeply endangered in his re-election this year. But the 71-year-old incumbent, who likes to say “Washington sucks,” has a 7- to 10-point polling edge over his Republican opponent, Patrick Morrisey. A lot can happen before Election Day, but for now, he is the envy of other red-state Democrats as the parties wrestle over control of the Senate.
For an explanation, look no further than the issue Mr. Manchin has made No. 1 in his campaign: health care, specifically protections enshrined in the Affordable Care Act, a once-vilified law that has grown increasingly popular now that its benefits are woven deeply into a state with high poverty and poor health. West Virginia has the highest share of its population covered by Medicaid, 29 percent, including about 160,000 who became eligible in the Medicaid expansion under the law.
Mr. Manchin, a former governor and the state’s dominant politician for more than a decade, rarely cites the law’s formal name, much less its toxic-for-West Virginia nickname, “Obamacare.”
But he has relentlessly raised the alarm over the potential loss of coverage for people with pre-existing conditions, about one in three West Virginians.
Mr. Morrisey, the state attorney general, practically handed him the issue by joining a new lawsuit seeking to repeal the health care law, which Mr. Morrisey calls “devastating” because of rising premiums in the individual market.
A federal judge in Texas heard arguments Wednesday in the case, which was brought by Republican state officials from around the country. If they win and the Affordable Care Act, or pieces of it, falls, an estimated 17 million Americans will lose coverage. And in a change that would affect far more people, insurers would once again be able to deny coverage to those with pre-existing conditions or charge them more.
Democrats have seized on the lawsuit to defend endangered senators in red states, including North Dakota, Montana and Missouri.
But few are using it to galvanize votes as aggressively as Mr. Manchin, whose state has epidemic levels of diabetes, heart disease and opioid addiction. His TV ads star West Virginians with pre-existing conditions. He hosts round tables on the topic. And in the Senate, he introduced a resolution to fight the Republican lawsuit.
Running on health care is designed to overcome his chief vulnerability: Mr. Trump’s 60 percent job approval here.
Jimmy Ulbrich, from nearby Dawes, is a prime target. “He is bringing America back the way it should be,” Mr. Ulbrich, 48, said of Mr. Trump. But Mr. Ulbrich, who is disabled, does not like the idea of overturning the Affordable Care Act. “I guess Joe Manchin gets my vote,” he said.
Mr. Morrisey accuses his opponent of engaging in “scare tactics.” He says he supports protecting people from losing coverage because of pre-existing conditions. “But to say you shouldn’t knock out a law that’s been utterly devastating West Virginia families with double-digit premium increases is ridiculous,” he recently said on West Virginia talk radio.
The Affordable Care Act, signed into law by Mr. Obama in 2010, barred insurance companies from denying coverage to those with pre-existing conditions, required all Americans to get health insurance, offered subsidies for many plans and allowed states to expand their Medicaid programs.
West Virginia benefited more than almost any state. The uninsured adult population dropped to 9 percent in 2015, down from 21 percent before the law’s enactment. “It’s probably the most important piece of legislation for West Virginians since the Great Society,” said Simon F. Haeder, a political scientist at West Virginia University.
In 2012, before the major provisions of the law kicked in, a poll of the state found 55 percent favored repeal. Five years later, a survey for the American Medical Association found West Virginians opposed by a 2-to-1 margin letting insurance companies charge higher rates to people with pre-existing conditions.
“Time heals and changes views when people see they have health insurance,” said Natalie Tennant, a Democrat who lost a race for the seat of retiring Senator Jay Rockefeller in 2014. In her campaign, she highlighted the issue of pre-existing conditions. “People pushed me aside and laughed,” she said. “‘Aww, you’re just talking about Obamacare.’”
Mr. Morrisey regularly attacks Mr. Manchin for voting against the Republican tax cut and its economic benefits. It is Mr. Manchin’s most vulnerable vote, and when pressed, he returns to health care. He says he opposed the tax cut bill, Mr. Trump’s major legislative achievement, because it zeroed out the penalty for not buying health insurance. That effectively kills the individual mandate, which experts say shakes the foundation of the health law.
In recent years, as other West Virginia Democrats switched to the Republican Party, Mr. Manchin has held out, a social conservative who believes in using government’s money and might to protect the needy. He won 60 percent of the vote in his last election, even as the Republican presidential nominee, Mitt Romney, carried every county.
But this year he will not have nearly as easy a time. That is why, at a rally for the United Mine Workers of America later on Labor Day, he invoked a biography many knew well. How he was raised in the tiny coal mining town of Farmington. How an uncle died in a mine disaster in 1968. He combined that with attacks that Mr. Morrisey, 50, despite two terms as attorney general, is an outsider, who once ran for office in New Jersey.
“I know what it’s like,” Mr. Manchin told the miners, most of them retired. “I’ve been there, I’m never going to leave y’all.”
“Pick the person you believe in,” he said. “Who’s going to be there for you, who’s going to fight for you, who understands how we were raised. Who understands the hardships we have.”
The challenge for a candidate running on health care in a red state is that Democrats long ago lost the messaging fight on Obamacare, which became an all-purpose epithet for the myriad deficiencies of American health care.
In fact, West Virginians covered under the Medicaid expansion don’t always believe they are benefiting from the law. They simply know they became eligible for a “medical card” entitling them to government benefits, which many neighbors and family members already had under more restricted programs.
David Johnson, 57, worked in a sawmill for decades, with two mangled fingers to show for it. In 2009, his employer canceled his insurance benefits, he said, and when he sought a policy on the open market the premiums were $1,700. He blames the Affordable Care Act, even though the law was not yet enacted.
At the Cabin Creek Health Center in Dawes, Mr. Johnson brought a letter from the state on Wednesday entitling him and his wife to Medicaid under the expansion, which they qualified for as low-income adults without dependent children. But he did not connect his benefits to the Affordable Care Act.
He plans to vote for Mr. Morrisey. “My dad would roll over in his grave to think I’d vote Republican,” he said.
The Cabin Creek clinic is part of a network of rural health care providers treating patients regardless of ability to pay. The health care law provided easier access to specialists and medications, and it pays for opioid addiction treatment in the state with the highest overdose death rate in the country.
One patient, Erica Honaker, 37, said the program saved her life. She had lost a job, her home and custody of a son after years of being a “textbook junkie.’’
She said she used the “medical card” she had as a low-income mother to enter Cabin Creek’s treatment program. It included group therapy and the anti-craving drug Suboxone. Ms. Honaker found a part-time factory job and was recently offered full-time work with health insurance. She has a court date this month to win back custody of her son, now five.
“I’m a functioning member of society again,” Ms. Honaker said. “I paid my taxes this year so the next person can get a medical card and get taken care of.”
Ms. Honaker plans to vote for the first time in many years. She has not yet tuned into the race. But she recalls paying close attention last year to the debate in Washington when Republicans tried, and failed, to repeal Obamacare. “Thank God that didn’t happen,” she said.