WASHINGTON – Republican Sen. Shelley Moore Capito is between a rock and a hard place on her party’s determination to scrap the Affordable Care Act or Obamacare.

President Donald Trump won 75 percent of the vote in her state of West Virginia campaigning against the health care law, and Republican leaders have been promising for seven years to get rid of it.

But Capito has misgivings, fearing GOP bills to date would harm West Virginia’s efforts to combat its opioid addiction epidemic and also result in thousands of uninsured constituents.

She is getting pressure from Trump, Republican leaders and social conservatives to support this week’s anticipated Senate vote to debate legislation to replace and/or repeal Obamacare, then act on whatever results from the debate.

David McIntosh, president of the conservative political action committee Club for Growth, defined the quandary Capito and other Republican moderates face during a call with reporters last week.

“They have to choose, do they want to be traitors?” he said. “Because that’s what they would be doing by siding with the Democrats to keep Obamacare.”

The pressure continued Monday as Republicans appeared short of the 50 votes needed to pass a motion to even consider either a bill replacing the nation’s health care law, or one to simply repeal it.

Trump headed for West Virginia to appear with Capito before 40,000 scouts, leaders and volunteers at the National Boy Scout Jamboree in Fayette County.

Before he left Washington he repeated his disparagement of the current law, saying: “Obamacare has wreaked havoc on the lives of innocent, hard-working Americans.”

Capito has been a target of the president’s and GOP leadership for joining moderates and conservatives in shooting down a proposal to repeal many provisions of the law. She has also opposed a fallback proposal to simple repeal the law after a two-year transition to figure out what to do instead.

Yet Capito voted for a repeal bill two years ago, a largely symbolic vote because then President Barack Obama vowed to veto it. This time there would be actual consequences, she noted on a radio talk show last Thursday, as Trump has said he will sign replace and/or repeal legislation into law.

Republican moderates have opposed cuts in federal funds for states like West Virginia that expanded Medicaid to thousands of lower-income individuals who make too much to qualify for traditional assistance but not enough to afford comprehensive health insurance. Repealing Obamacare would eliminate the funding entirely.

Observers like Simon Haeder, a West Virginia University political science professor, and lobbyists in the state contend support for Medicaid cuts would run counter to Capito’s long support for health coverage to low-income people, particularly children.

Nearly two decades ago, many state lawmakers balked at spending state money to expand government health insurance to low-income children — even if it brought the state three times as much in federal Children’s Health Insurance Program (CHIP) matching grants.

Capito, then a 42-year-old state representative, co-sponsored the bill that eventually led to 60,000 children getting CHIP insurance.

“She has a genuine concern for kids and vulnerable people,” said Renate Pote, who lobbied for the children’s insurance on behalf of a state coalition of churches and is now fighting the GOP national health care effort as chairwoman of the West Virginia Medicaid Coalition.

Matt Walker, lobbyist for the West Virginia Primary Care Association, said Capito has visited several community health clinics he represents to get a first-hand look at the issue.

“She has a real understanding of what Medicaid does,” said Walker. “She’s seen with her own eyes what the impacts are” for a state battling obesity, opioid abuse and other health problems.

There’s little doubt Capito understands the importance of federal health care money to a state where a third of the people are on Medicaid, the largest percentage of any state. She is the daughter of former Gov. Arch Moore Jr., and has served as a state legislator, U.S. House representative and a U.S. Senator since 1986.

Haeder said she could be influenced by her late father’s commitment as governor to bring federal dollars to West Virginia for highway projects and Medicaid.

He could get creative in doing it.

In the midst of a recession in the 1980s, a state budget shortfall meant the state had less matching funds to spend on Medicaid, which in turn reduced the amount of federal funds available to West Virginia.

So Moore gathered together the heads of the state’s hospitals, according to the 1970 book, Financing Medicaid, by New York University political scientist Shanna Rose.

He asked them to contribute money to the state’s treasury, promising, “I will return it to you the next day,” wrote Rose. Additional state funds begot a bigger federal match,

“Capito is one of the most interesting people to watch in this debate,”  said Haeder. “She’s pragmatic. She understands very well the importance for very poor states like West Virginia of getting money from the federal government to make things work.”

Contact Washington reporter Kery Murakami at kmurakami@cnhi.com.