U.S. Sen. Dean Heller (R-NV), representing a state that has benefited tremendously from Medicaid expansion under the Affordable Care Act (ACA), had to choose between maintaining health-care gains for Nevadans or satisfying a president hellbent on eviscerating the health-care reform law.

Heller last year sided with Trump in voting for a “skinny repeal” bill that would have slashed Medicaid funding and eliminated critical planks of the ACA, also known as Obamacare.

That decision could determine Heller’s neck-and-neck race for re-election against Rep. Jacky Rosen (D-NV), a moderate who supports the Affordable Care Act (ACA) and talks often about compromising with Republicans. Nearly seven in ten Nevada voters said in a recent Kaiser Family Foundation survey that they’re more likely to support a candidate who supports keeping the ACA’s pre-existing conditions protections. Forty-seven percent said they’d be more likely to vote for a candidate who wanted to protect the ACA, while 34 percent said they wanted a candidate who would help repeal the health-care reform law. Half of Nevadans said they have a family member with a pre-existing medical condition. 

And 53 percent of Nevada respondents said they’d back a candidate who would expand reproductive health-care services, compared to 18 percent who said the opposite. Rosen has been endorsed by a range of pro-choice groups; Heller, meanwhile, has joined his Senate GOP colleagues in attacking funding for reproductive health care at every turn.

Nevadans are hardly the only U.S. voters to name health care as their top issue—Republicans’ myriad attempts to destroy Obamacare have played a central role in midterm contests—but the large Nevada majorities that support key planks of the ACA could be unwelcome news for Heller, who was one of 48 Republican senators who voted for “skinny repeal” of the health-care law. That repeal effort would have left 15 million people uninsured while ballooning health-care premiums, according to the nonpartisan Congressional Budget Office.

Republicans’ “skinny repeal” effort, killed in dramatic fashion by the late Sen. John McCain (R-AZ), also included defunding Planned Parenthood. While it did not end protections for those with pre-existing medical conditions, the Heller-supported “skinny repeal” effort would have imposed massive cuts to Medicaid spending, “effectively ending the ACA’s Medicaid expansion,” according to an analysis by the Center of Budget and Policy Priorities. The bill would have imposed a “cap that would fundamentally alter Medicaid’s financing structure and fuel hundreds of billions of dollars in Medicaid cuts and cost shifts to the states, with the cuts growing deeper with each passing year.”

Nevadans’ support for the ACA may stem in part from the actions of Nevada Gov. Brian Sandoval (R), one of the most popular governors in the United States and an unabashed ACA supporter. Sandoval, who enthusiastically expanded Medicaid accessibility under Obamacare, launched a campaign for Nevada residents to sign up for health-care plans through the ACA’s marketplace. The Medicaid expansion brought down the state’s uninsured rate from 22 percent in 2013 to 10 percent in 2016. Sandoval did not give his blessing to the GOP’s “skinny repeal” plan. While it initially seemed that Heller would remain in lockstep with Sandoval—voting against Republicans’ initial two attempts to repeal Obamacare—he ultimately gave into pressure from the Trump administration.

Heller says today that he’s a supporter of protections for those with pre-existing conditions—an argument many GOP candidates have turned to as the deeply unpopular efforts to make health care less affordable and accessible have endangered their electoral chances.

This move has given his Democratic opponent a chance to paint him as a Trump-aligned Republican who is now scrambling to moderate his hardline position against Obamacare protections and benefits, says David Damore, chair of the Department of Political Science at the University of Nevada, Las Vegas.

“The ACA and Heller’s handling of it has provided the Rosen campaign with a ‘twofer,'” Damore told Rewire.News. “Nevada is a bigger winner under the ACA and the issue highlights how Heller is working against the interests of Nevada in service of partisan interests. The campaign also is using the issue to frame Heller as a disingenuous and willing to do and say anything to stay in office.”

Heller has made it easy for his opponents to go after him as a congressional foot soldier for President Trump: He’s voted in line with the president’s policy position 92.4 percent of the time, according to FiveThirtyEight. Heller’s “Trump score” is far higher than his predicted score, as projected by FiveThirtyEight. This means Heller has been much more closely aligned with Trump’s unpopular agenda than one would expect from a senator from Nevada—a so-called purple state with 100,000 more registered Democratic voters than Republicans.

Heller has done damage control since casting his vote for the “skinny repeal” of Obamacare: He was one of ten Senate Republicans who in August introduced a bill that would attempt to uphold pre-existing conditions protections if the lingering Republican lawsuit against the ACA is successful in federal court. Health-care policy analysts have chided the GOP bill for falling well short of the protections provided under Obamacare, including a prohibition on insurance companies excluding coverage of a person’s pre-existing condition. An insurance company couldn’t legally deny a person from signing up for coverage, but it could choose not to cover the person’s medical expenses.

“If you’ve got a serious condition, it’s kind of like throwing a ten-foot rope to somebody in a 20-foot hole. It’s not going to help them. It’s really not,” Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told the Nevada Independent. “What you would pay for the insurance and the little you would get, I think most people would say no that’s not meaningfully better for me.”