Perhaps nothing illustrates this profound shift better than this new ad from West Virginia’s Joe Manchin III:

This ad references one Manchin aired in 2010, in which he fired a bullet through a copy of a cap-and-trade bill, a failed effort to reduce carbon emissions. Manchin was joining a long list of candidates, mostly but not entirely Republicans, who took out their rifles in ads to shoot at whatever had aroused their ire, a genre of political advertisement that has all the subtlety and complex deliberation we’ve come to expect from American politics, poured into a pull of the trigger.

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But instead of blasting away at a bill that might threaten the coal industry, Manchin is now shooting a lawsuit being heard in federal court that seeks to strike down the entire Affordable Care Act, brought by 20 Republican attorneys general and governors. And guess what: One of the plaintiffs in the suit just happens to be Manchin’s opponent, the West Virginia attorney general.

This confirms once again that this lawsuit is a political nightmare for Republicans. If it succeeds, not only would an estimated 17 million Americans lose health coverage; the tens of millions with preexisting conditions would lose the protection they got from the ACA (about half of all non-elderly Americans have a preexisting condition). A recent poll found that 75 percent of Americans said it’s “very important” to them that those protections remain in place.

One of the most vulnerable Democrats in the country — one that represents a state where Trump is still enormously popular — is going on the attack against his opponent for supporting this effort to destroy Obamacare. This shows how much the politics have shifted against repeal.

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Still, this ad also reveals the complexity of the politics around defending the health law. In many places dominated by Republicans, saying you support “Obamacare” is like calling yourself a Satanist. Trump won West Virginia by a 42-point margin, while promising to take West Virginians’ health care away.

Yet in few places has Obamacare transformed people’s lives for the better more dramatically than in West Virginia. The number of uninsured was cut by more than half after the ACA took effect. The number of West Virginians getting coverage through Medicaid increased by more than 50 percent because of the law; only New Mexico has a larger proportion of its citizens on Medicaid.

Manchin’s political survival depends on winning significant numbers of Republicans, as well as old-style ancestral Democrats-in-registration-only who backed Trump. But now it turns out that the way to do that is to attack what the Republican Party is doing on health care, even if he does it without mentioning Obamacare by name.

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This is working in many parts of the country, including more conservative and Trump-friendly ones. According to the Wesleyan Media Project, 52 percent of pro-Democrat ads for federal offices in August mentioned health care.

It’s also resonating across the Senate map. Democrats have an outside chance to take back the Senate this year, despite the fact that they’re defending many more seats than Republicans are. One of the key reasons that’s possible is that Democrats’ most vulnerable seats are held by people such as Manchin, Heidi Heitkamp of North Dakota, and Claire McCaskill of Missouri — skilled politicians who have long experience in the delicate enterprise of running as Democrats in red states. Wherever you find a potentially vulnerable Democrat, you’ll probably find them talking about preexisting conditions (see here or here or here).

And these Democrats have a good shot at survival in no small part because, while they are still to the right of the typical Democrat, they are now passionate defenders of the ACA.

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Obviously, the health-care debate has shifted leftward. But the nature and extent of that shift are truly remarkable. In 2010, Democrats got absolutely destroyed in the midterm elections, losing a net of 63 seats in the House and costing them the lower chamber, in large part because Republicans successfully got their base angry about the ACA, and in 2014, that helped cost Democrats the Senate, too.