Health care affordability is a significant issue heading into the midterm elections, but many Republicans are hesitant to enact major policy changes before facing voters, fearing division and political risk. Despite widespread agreement that costs are too high, conventional wisdom suggests avoiding substantial action this close to an election. While the White House highlights drug pricing deals and efforts against waste and fraud as victories, these have done little to reduce patient premiums or out-of-pocket expenses. Republicans face pressure to address underlying costs, with hospital and insurer business practices as frequent targets, though targeting hospitals is politically complex. Less controversial options like price transparency and PBM reform are potential paths forward, with some arguing it would be a mistake not to address affordability before the midterms.