An image from a Tom Perriello for Governor viral video ad that featured a crushed ambulance

An hour after House Republicans voted to gut the Affordable Care Act last week, Tom Perriello released a viral ad that showed him in front of an ambulance being compacted in a scrapyard, shouting above the din that he’d stop Republicans from crushing health care in Virginia if he is elected governor.

Never mind that Perriello is competing for the Democratic gubernatorial nomination against a pediatric neurologist, Lt. Gov. Ralph Northam, who supports Obamacare as much as he does. Or that the GOP House bill may never become law after the Senate gets to work on its version.

In a boomerang of politics and timing, Perriello — who lost his congressional seat in 2010 after he voted for the Affordable Care Act — is now using the same issue to mount a political comeback. He is counting on anger at Republican control of Washington — currently zeroed in on health care — to propel him into the governor’s mansion in Richmond.

As one of just two governor’s races this year — the other is in New Jersey — the Virginia contest will demonstrate whether the federal war over health care is affecting state-level races and reshaping the electoral landscape as it did after the Affordable Care Act passed in 2010.

The bill approved last week would allow states to seek a waiver to enable insurers to charge more for people with preexisting conditions — something prohibited under Obamacare. Democrats are pressuring GOP governors to answer whether they would seek a waiver.

Tom Perriello, left, shakes hands with Lt. Gov. Ralph Northam at the first debate of Virginia's Democratic candidates for governor last month. (Sarah L. Voisin/AP)

“Democrats are going to beat this down as long as they can because it’s doing good for them,” said Jennifer Duffy, who tracks gubernatorial and Senate races for the nonpartisan Cook Political Report. “You are going to see a lot of challenging Republicans and gubernatorial candidates on would they ask for this waiver or not. They’ve had this issue for six years and now the tables are turned.”

In Virginia, the health-care debate is playing out between two Democrats ahead of the June 13 primary.

“The fact that Northam is a physician and that this is the one issue he’s been visible on gives him an initial advantage on this matter,” said Bob Holsworth, a longtime political analyst. “If Perriello was successful in taking this issue from Northam, his chances would be thoroughly enhanced.”

In an interview, Perriello said he thinks voters are rewarding him for backing the Affordable Care Act while representing a Republican-leaning stretch of central and southside Virginia. He was hit with attack ads for that vote, including one that decried Perriello as a rubber stamp for the “Obama-Pelosi health-care plan.”

“When it was really crunchtime, it was clear to folks who was willing to stand up to the insurance companies and the drug companies at great political risk to put Virginians and patients first,” said Perriello. “That’s my track record. I was willing to take millions of dollars in attack ads.”

On the morning of last week’s vote, Perriello sent instructions to people on his campaign email list about how to call their members of Congress to oppose the health-care bill.

The hour after the bill passed, Perriello launched the ambulance-crushing ad. It has racked up 400,000 views on YouTube and been played repeatedly on CNN and MSNBC, even before it hits Virginia airwaves this week.

Northam, by contrast, put out statements after the vote decrying Republicans’ “spineless, unprincipled cruelty” in passing the legislation. He met with medical providers in rural Virginia the next day to hear stories about how health-care access in their communities would be affected.

On Sunday, Northam’s campaign rolled out a digital advertisement featuring him in his white coat caring for children while text says he’s “ready to fight Trumpcare.”

At a primary debate just hours after the House vote, Perriello mentioned his proud vote for Obamacare almost as often as Northam mentioned being a doctor.

Perriello talked about health care as if he just stepped out of a time machine from a 2009 congressional committee meeting, firing off statistics and policy details. Northam, who spoke of the general need for equal access to health care, was more cautious about specifics and noted problems that need to be fixed.

Stephen Farnsworth, a political scientist at the University of Mary Washington, said Perriello has done the better job appealing to Democratic activists.

“Over the last several days, it seems like Northam has been playing catch-up on the health-care debate,” Farnsworth said. “Powerful images can really trump substance as we’ve learned in politics, and the arresting image of a crushed ambulance is going to resonate with a number of voters a lot more than a quietly successful career in health care.”

Political analysts warn that embracing the health-care status quo may not play as well with moderates in a general election.

Last week, Aetna announced that it will withdraw from selling insurance plans on the individual market in Virginia because of financial losses, while CareFirst Blue Cross Blue Shield is seeking a 35 percent rate increase in Northern Virginia.

Republicans are prepared with their own litany of horror stories under the Democratic overhaul — and welcomed Perriello’s full-throated embrace of the Affordable Care Act.

“I don’t think there’s any singular issue in all of American politics that has done more damage to the electoral success of the Democratic Party than Obamacare,” said John Whitbeck, chairman of the Republican Party of Virginia. “I hope he continues to campaign on Obamacare, and he’ll lose two elections.”

Ed Gillespie, the front-runner in the Republican gubernatorial primary, called the House vote an “important first step” to repeal Obamacare but said he wanted to see what legislation emerges from the Senate. He faces state Sen. Frank Wagner (Virginia Beach) and the chairman of the Prince William Board of County Supervisors, Corey A. Stewart, in the primary.

Perriello’s role in the Affordable Care Act debate has hurt his standing among some Democratic voters.

He voted for the unsuccessful Stupak amendment to the law, which would have prevented insurers that cover abortion from receiving federal subsidies through the ACA. He also repeatedly said barring federal funding for abortion was his priority for any health-care overhaul. Later, during the debate over the bill, he switched gears and opposed an attempt by Republicans to revive a version of the Stupak amendment. And he apologized for his support for the amendment the day after he launched his gubernatorial bid. Still, it continues to infuriate abortion rights activists.

“Him trumpeting himself up as a poster boy for the Affordable Care Act is incredibly disingenuous,” said Erin Matson, a reproductive rights activist and one of Perriello’s fiercest critics. “What he did with women in Virginia and across the country with that Stupak vote was set the stage for the broader removal of abortion from the health insurance market.”It almost killed the entire Affordable Care Act.”

A spokesman for Perriello said Northam also has a blemished record when it comes to the health-care overhaul.

While seeking reelection to the state Senate in 2011, Northam offered tempered support for the law, expressing concerns with the tactics Democrats used to pass it and questioning whether it went far enough to bring down the cost of health care.

A spokesman for Northam noted that he helped create a state health insurance exchange and has been a steady advocate for the expansion of Medicaid to low-
income Virginians — ideas the Republican-controlled legislature has repeatedly rejected.

“Ralph Northam spent his life seeing patients as an Army doctor and a pediatrician, and he knows firsthand how important [it is] for people to be able to get the health care they need, when they need it,” said Northam spokesman David Turner. “He firmly believes that every American and Virginian has a right to affordable health care, and he believes it is the responsibility of government to make sure they do.”

Political observers have cautioned that the electoral landscape could change rapidly by the 2018 midterm elections, and the House bill could be long forgotten if it fails to become law.

But with just five weeks to go until the gubernatorial primary, Virginia remains closely watched for signs of potential electoral fallout.

“This is more evidence of a new chapter of the fight over health care in this country,” said Nathan Gonzales, editor and publisher of the nonpartisan Inside Elections.

“I know Democrats in that House chamber felt like that vote (Thursday) gave them that House majority, but there’s a long time between now and November 2018. But for Perriello, there’s a lot less time between now and the June primary.”

An earlier version of this story incorrectly said Perriello had been a co-sponsor of the Stupak amendment; he voted for it but was not a co-sponsor. This story has been corrected.

Gregory S. Schneider contributed to this report.