Mail bombs, a military response to a migrant caravan and the massacre at a Pittsburgh synagogue have injected a roller coaster of fear and anger to the homestretch of midterm campaigning. But the stakes of Tuesday’s election, analysts say, are two very different paths on key issues.

If Democrats wrestle control of the House of Representatives, Americans can expect a push to expand health care access, increase taxes on the wealthy and corporations, and hold industries — and the Trump administration — accountable with more stringent regulations and oversight.

If Republicans manage to retain both chambers of Congress, the country is likely to see new attempts to gut the Affordable Care Act — despite claims by GOP candidates that they would protect patients with preexisting medical conditions, a move to expand tax cuts and continued loosening of regulations.

The possibilities could be sharply curtailed depending on the returns: The most likely scenario, which has Democrats controlling the House and Republicans holding the Senate, is apt to lead to gridlock as both sides immediately pivot to messaging for the 2020 presidential campaign.

Health care ranks as highly important to voters, polls this year have shown.

“Regardless of why people are voting, the outcome of the election will have huge consequences for the direction of the debate over health care,” said Larry Levitt, senior vice president of the Henry J. Kaiser Family Foundation, a nonpartisan nonprofit headquartered in San Francisco.

In states and districts won narrowly by President Trump, Democrats have watched Republicans repackage themselves as defenders of Medicare and of the most popular parts of the ACA.

Just a handful of Republican campaigns have run ads about the migrant caravan that has captured the White House’s attention. By contrast, dozens are running ads that promise to keep the ACA’s rules preventing insurers from discriminating against customers with preexisting conditions — even as party leaders push a lawsuit to repeal the measure protecting such coverage.

“I support forcing insurance companies to cover preexisting conditions,” Florida Gov. Rick Scott, the Republican nominee for a U.S. Senate seat, says in one of his closing ads.

“I’m leading the fight to secure our border [and] force insurance companies to cover preexisting conditions,” Rep. Martha McSally of Arizona, a Republican Senate nominee who voted to repeal Obamacare, says in another one.

Details on how Republicans would protect coverage of preexisting conditions remain vague. Health policy analysts have pointed out that it would be financially unfeasible to force insurers to cover preexisting conditions without mandating that people, including those who are healthy, buy insurance — a provision of the ACA that Republicans repealed in last year’s tax bill.


Republicans also have not come to any agreement over how to handle the broader issue of health care, said Doug Heye, a Republican strategist and former spokesman for the Republican National Committee.

“On the House Republican side, I worked on [ACA replacement language] every day for six months in 2014, and we couldn’t even produce a white paper,” Heye said.

Another ACA provision, expanding Medicaid for low-income Americans, got a boost during the campaign from Democrats and in typically conservative states — with ballot measures to do so in Utah, Idaho, Nebraska and Montana. The measures are expected to pass in Utah and Idaho, with Republican support.

“The closing argument for many Democrats has been protecting the gains made under the ACA,” said Steve McMahon, a Democratic strategist, “and they will be taking measures to reinforce, strengthen or fix things Republicans have been trying to undo, overturn or ignore.”

But divisions over health care also hover over Democrats, who analysts say will face pressure, if they gain a majority, to move toward universal health coverage, given that a number of Democratic gubernatorial candidates and potential presidential contenders have endorsed “Medicare-for-all.”

That debate would raise questions about a critical facet: how to pay for it.

On the fiscal front, Republicans contend that Democrats would unwind last year’s tax cut. But neither Democratic leaders nor most of the party’s candidates have said they would repeal the tax cut. As they did after two rounds of tax cuts in 2001 and 2003, Democrats instead have promised to revisit the tax law to make the wealthy pay more, sparing middle-class voters from changes.

If Democrats win the House, their committee leaders are expected to introduce oversight into Trump administration activities.

“We will begin to see checks and balances that haven’t existed,” said Norman Ornstein, a political scientist and resident scholar at the American Enterprise Institute.

The regulatory environment and dynamics of the fight over the Consumer Financial Protection Bureau, gutted under Trump, would also change with a substantial Democratic House majority, said Kevin Madden, a Republican strategist.

“And the I word — both investigations and impeachment — would certainly be on the table,” Madden said.

Democratic strategist McMahon said he hopes Democrats, if they are put back in charge, will remember to focus on the concerns of “ordinary Americans” — health care, the environment and climate change, income inequality and tax fairness — and not just “an endless stream of subpoenas.”

Some even see an opportunity, however slim, for dealmaking with Trump on guns, immigration and infrastructure if a realignment in Congress occurs.

Trump has occasionally suggested that Democrats could work with him on infrastructure spending, though the Democratic Party’s own bills — it introduced a $1 trillion package in 2017, to preempt a Trump plan that never came — differ wildly on how much federal versus private investment would be required up front.

With much of Washington at an impasse and poised to stay that way, many of the issues most concerning voters, from gun control to abortion access and infrastructure to education, will play out instead in the states.

“Governors are becoming less and less reticent to act on policy that in the past has been left to Congress,” said Jennifer Duffy, senior editor of the independent Cook Political Report. She cited gun safety legislation tracked by the Giffords Law Center to Prevent Gun Violence as an example, noting that since 17 people were killed in February at a high school in Parkland, Fla., 27 governors, including 14 Republicans, have signed gun laws.

Abortion rights have motivated Democrats this election cycle more than at any time in the past decade, according to a September Pew poll showing that 61 percent of Democrats view the issue as “very important” to their vote compared with 44 percent of Republicans. Among Democrats, that figure rose 23 points since 2008 while it remained constant for Republicans.

The political environment shifted at about the same time the poll was taken, as the Senate considered Justice Brett M. Kavanaugh’s nomination to the Supreme Court. His confirmation has heightened fears among Democratic women, in particular, that their right to abortion could be in jeopardy if the high court reverses its 1973 Roe v. Wade ruling that decriminalized abortion and sends the matter back to the states. Several conservative states have already restricted access to abortions.

In Michigan, where Democrats have taken the lead in statewide races, the party’s nominee for governor, Gretchen Whitmer, has released a plan to protect abortion rights regardless of future Supreme Court rulings. Michigan has yet to repeal a 1931 state law banning most abortions despite the Roe v. Wade decision.

Whitmer has been helped by the struggles of the Republican nominee, Bill Schuette, the state’s two-term attorney general, who had repeatedly sued to repeal the ACA. Schuette also has said that as governor, he would enforce the state law banning abortion should the Supreme Court overturn Roe v. Wade. While Schuette has pledged to keep the state’s Medicaid expansion if elected, Whitmer has pointed out that the expansion would vanish overnight if Schuette’s legal battle paid off.

But on the campaign trail, voters leaning toward Whitmer are sometimes less focused on her individual policies than on the possibility of building a resistance to the Trump administration. At a recent get-out-the-vote stop in the Detroit suburb of Royal Oak, Whitmer told voters that people and communities who felt threatened would be protected if she won.

“When we win, LGBT people go into the governor’s office,” Whitmer said. “When we win, clean water is on the agenda.”

Marissa Bassan, 19, signed up on the spot to help encourage voting. This election, she said, is about putting up blockades against a Republican agenda that isn’t slowing down.

“People need a shield from what’s going on in Washington,” Bassan said. “I want to have actual laws, not anarchy.”