SAN ANTONIO — Sen. Ted Cruz Rafael (Ted) Edward CruzThe Hill's Morning Report - Sponsored by Facebook - Trump previews SCOTUS nominee as 'totally brilliant' Cruz blocks amended resolution honoring Ginsburg over language about her dying wish Trump argues full Supreme Court needed to settle potential election disputes MORE (R-Texas) and Rep. Beto O’Rourke (D-Texas) clashed in a heated second debate on a cold and bitter night in San Antonio, less than three weeks out from the midterm elections.

O’Rourke went on the attack right at the start of the debate, framing Cruz as “dishonest” and someone who abandoned Texas to run for president. But Cruz continued to aggressively go after the Democratic congressman’s record, which he says doesn’t line up with deep-red Texas.

The contentious showdown again highlighted the starkest differences between the candidates, particularly on immigration and health care.

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Here are the five takeaways from the fiery — and likely final — Senate debate in the Lone Star State.

O’Rourke goes on offense

O’Rourke didn’t pull any punches in this debate, especially with polls consistently showing him trailing Cruz.

Unlike in the first debate, the Democratic congressman came out swinging from the beginning and repeatedly hammered Cruz throughout the hourlong debate.

Right out the gate, O’Rourke sought to highlight the major differences between them, starting with election security. O’Rourke accused Cruz of being incapable of standing up to the president on both this issue and also on tariffs.

“He voted against safeguarding the integrity of our ballot box,” O’Rourke said. “Our junior senator won’t stand up to President Trump Donald John TrumpSteele Dossier sub-source was subject of FBI counterintelligence probe Pelosi slams Trump executive order on pre-existing conditions: It 'isn't worth the paper it's signed on' Trump 'no longer angry' at Romney because of Supreme Court stance MORE.”

The attacks only got more heated throughout the night. O’Rourke brought back President Trump’s past pejorative nickname for Cruz from the 2016 Republican primary race, arguing that the GOP senator fits the name “Lyin’ Ted.”

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"This is what you can expect over the course of debate," O'Rourke said. "Sen. Cruz isn’t going to be honest. He’s dishonest."

"That’s why [Trump's] nickname stuck — because it’s true."

But Cruz, a seasoned debater, countered each of O’Rourke’s attacks. In a familiar line of attack, Cruz continued to cast the Democrat’s voting record in Congress as “out of step in Texas.”

The GOP senator even noted the change in tone since their last debate in Dallas.

"Well it’s clear Congressman O'Rourke's pollsters told him to come out on the attack," Cruz said.

Cruz on defense over GOP tax law

Republicans are hoping that the GOP’s tax law passed last year will be a boon for them in the midterms. But Cruz was left explaining his support for the GOP’s biggest legislative achievement since Trump took office.

Cruz trumpeted his support for the tax cuts, while talking about the need for paying down the deficit and debt.

He called the growing deficit and debt “immoral,” but argued that it wasn’t due to the tax cuts passed late last year.

But in a notable moment of the debate, one of the moderators interrupted Cruz’s answer to mention past comments he made while running for the GOP presidential nomination in 2016.

“Respectfully, Sen. Cruz, in Iowa, you talked about how bad the deficit is.”

When asked if the tax law increases the deficit and debt, Cruz responded, “No, it wouldn’t. That projection is wrong.”

Cruz continued that measures that spur economic growth — like the tax law — don’t contribute to that. He said that the government can fix the “out-of-control spending” in Congress by imposing things like congressional term limits and passing a balanced budget amendment.

For his part, O’Rourke decried that tax cuts as "disproportionately” benefiting corporations.

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Cruz gets upper hand in health-care exchange

Health care has been a prominent issue this election cycle — and one that Democrats believe is a winning issue, especially when it comes to protections for those with pre-existing conditions.

But there was no mention of the popular ObamaCare provision in this debate. Instead, moderators focused more on “Medicare for all,” which gave Cruz an opening to tie O’Rourke to a democratic socialist.

Cruz accused the Democratic congressman of wanting “socialized medicine” and Sen. Bernie Sanders Bernie SandersThe Hill's Campaign Report: Trump faces backlash after not committing to peaceful transition of power Bernie Sanders: 'This is an election between Donald Trump and democracy' The Hill's 12:30 Report: Trump stokes fears over November election outcome MORE’s (I-Vt.) Medicare for all proposal.

“O’Rourke supports Bernie Sanders’s socialized medicine,” Cruz said, adding that it would “triple your taxes.” The GOP senator pointed to examples of other countries who use that system, arguing that it would lead to long wait times and that the costs would be “immense.”

But O’Rourke stood his ground for wanting affordable and quality universal health care, especially for working families. He said that there are different approaches to achieving that goal, noting Medicare for all, expanded Medicaid and “the ability for people to pay into Medicare.”

“All you hear from Sen. Cruz is what we should be afraid of,” O’Rourke said, pointing to Cruz previously shutting down the government “perhaps because too many people had health care.”

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Immigration still the biggest wedge issue

Like the last debate, immigration continues to be the biggest separator between the two candidates running to be a senator of a border state.

Republicans running across the country have seized on this issue as a way to draw contrasts with their Democratic opponents. And in Texas, a Tuesday poll from CNN found that immigration is a top priority for voters in the Senate race. That same poll found Cruz leading O’Rourke by 7 points among likely voters.

Trump’s signature campaign promise of a wall along the U.S.-Mexico border yet again highlighted the differences between them.

O'Rourke said building a border wall won’t resolve the country’s immigration issues.

"No wall is going to solve legitimate security issues, but smart policy will," he said, noting that he introduced a bill with Sen. John Cornyn John CornynQuinnipiac polls show Trump leading Biden in Texas, deadlocked race in Ohio The Hill's Campaign Report: GOP set to ask SCOTUS to limit mail-in voting Liberal super PAC launches ads targeting vulnerable GOP senators over SCOTUS fight MORE (R-Texas) that would invest more money in ports of entry in the U.S.

Cruz said he's "led the fight to secure the border and building the wall." Cruz continued to make the case that O’Rourke’s liberal record is out of touch with what Texans want.

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"Let me say there's no race in this country where there is a starker divide on immigration," Cruz said.

Candidates make their final pitch

In a bitter debate from start to finish, both candidates laid out distinct visions for why they should be elected in their closing statements. Those respective visions essentially boiled down to "hope and change" versus continued progress.

O’Rourke said the country and Texans need "inspiration" and hope when Americans and their government are more divided than ever.

"Whether we remain the inspiration of the world is an open question right now," O’Rourke said, saying he’s been inspired to "transcend the obstacles" and fight for so-called Dreamers and universal health care.

Meanwhile, Cruz made the case for familiarity, arguing that electing O’Rourke would disrupt the economic growth in Texas that’s been made over his past six years in office.

"This is a choice about keeping the boom going," Cruz said. "We have the lowest Hispanic unemployment, the lowest African-American unemployment. Why would we want to screw that up?"

While there was visible tension, both candidates bemoaned the hyperpartisanship gripping the country. And there was a moment of emotion — and agreement — when it came to parenting while campaigning.

Cruz gave an emotional answer about the difficulty of being away from his children. O’Rourke, who is also the father of young children, said Cruz’s answer resonated with him.

Jessie Hellmann and Tess Bonn contributed.