The fate of President Obama's health care reforms depends as much on the outcomes of a handful of U.S. Senate races as the fight for the White House.
Nowhere is that clearer than in Virginia, where Republican Senate nominee George Allen has vowed to be the 51st vote to repeal the Affordable Care Act and his Democratic opponent, Tim Kaine, remains a steadfast supporter of the law.
While the campaign's rhetoric and political advertising have emphasized the candidates' divergent views on Obama's signature legislative achievement, Kaine and Allen have staked out equally polarizing positions on where to next take the debate over health care.
Kaine became an ardent defender of the president's reforms while he was chairman of the Democratic National Committee and he continues to tout the law's more popular provisions, like rules that ban insurance companies from dropping people with pre-existing conditions. But he's also quick to admit the law isn't perfect.
"There have already been 33 votes to repeal it, and I don't think Virginians want to spend all their time in the rearview mirror," Kaine said. "The improvements that I think are important are the improvements that enable regular people to better afford health care."
Doctors in the U.S. too often order redundant procedures that drive up the cost of care, he said. Kaine called for payment reforms that give doctors an incentive to put results ahead of profits.
He also said insurance companies could promote healthier living by rewarding those who make positive life choices, much as they do already for nonsmokers.
Allen offers a different prescription for Obama's health care plan: "repeal and replace."
Under Obama's law "some employers are going to drop their insurance and some employees will lose it," Allen said.
He said he would keep a provision in the Affordable Care Act that allows children to remain on their parents' insurance until age 26, but not much else.
Instead, Allen advocates that people be allowed to create health savings accounts that would receive favorable tax treatment. He also would allow small businesses to band together to buy health insurance across state lines.
One in five Virginians ranks health care as one of their top concerns in the fall election, second only to the economy, polls show. While voters generally believe Democrats are better suited to handle health care, 51 percent say the current reforms are bad for Virginia while only 38 percent think they are good.