More than a dozen DFLers and Republicans are running for governor next year, and nearly all of them agree on at least one thing after months on the campaign trail: Health care is the issue that voters throughout Minnesota want to talk about most.
"It's absolutely the No. 1 issue I hear about, far and away," said DFL candidate Rep. Paul Thissen.
"Health care costs, specifically, are if not the No. 1 issue, one of the dominant issues in the campaign," said GOP candidate Keith Downey.
With nearly a year until the election, few candidates have issued detailed health care plans. But most are ready to offer strong opinions about slowing the rise of insurance premiums, expanding coverage in greater Minnesota and stabilizing the state's health care market amid uncertainty in Washington, D.C.
On the campaign trail, Republicans have pushed for the dissolution of MNsure, Minnesota's individual health insurance market, and a shift to health care policies where customers can pick and choose what's covered. DFLers have lined up behind single-payer health care, in which the state would take the lead in providing more expansive coverage.
Across the political spectrum, candidates want to build on short-term fixes the Legislature passed earlier this year.
Between a premium subsidy and a "reinsurance" program that funnels money to insurance companies to help with major claims, lawmakers approved $868 million to prop up the state's individual insurance market over the next two years.
Republican state Sen. David Osmek said lawmakers did right by approving reinsurance and other changes like allowing for-profit insurance companies to operate in Minnesota for the first time.
Now, Osmek wants to trim the number of people who get health coverage through Medicaid; eliminate MNsure and replace it with a high-risk insurance pool; and allow all insurance plans to shift to a "cafeteria-style" approach, in which some conditions wouldn't have to be covered. He said people should select health plans based on "risks you believe you have in your life."
Hennepin County Commissioner Jeff Johnson also wants to see an end to federal mandates requiring everyone to buy health coverage, and for all plans to offer a list of essential services.
He's championing a reboot of Minnesota's high-risk pool, which provided coverage for people with pre-existing conditions who had a hard time finding health insurance before the passage of the Affordable Care Act.
"It was expensive, but Minnesotans were willing to pay that expense," Johnson said. "And it worked really well."
Downey and Rep. Matt Dean, another GOP candidate, have sparred publicly over health care. Dean, the chairman of the House Health and Human Services Finance Committee, has been outspoken in favor of abandoning MNsure. He wants to replace the individual market with a system in which people who buy their own insurance could do so independently but still receive subsidies. People on public programs would sign up through counties rather than the state marketplace.
"I think people are going to make better decisions on their own," Dean said.
Downey, a former chairman of the Minnesota Republican Party, says Dean's plan doesn't go far enough to get government out of health care. He wants to scrap MNsure and other programs and instead give Minnesotans "income-adjusted" vouchers with which they'd purchase health care. The vouchers and income verification would be provided by the state.
Meanwhile, all six DFL candidates say cutting the state out of the picture won't solve persistent cost problems and won't ensure access to insurance and quality care for rural residents.
Every DFLer favors an eventual shift to a single-payer system, though some use other terms like "Medicare for all" or "universal" health care.
Rep. Tina Liebling said cutting out insurance companies and having the state work directly with clinics and hospitals is a more specific move toward a single-payer system than some of her DFL challengers are ready to make. She said DFL voters tend to see the Affordable Care Act as the start of a remade health care system, not the end of it.
"They realize the ACA made things a little better, but it's still an insurance-based system," Liebling said. "And people are ready to move beyond that."
Most DFL candidates say the first step should be a plan DFL Gov. Mark Dayton has been pushing. The idea: open up MinnesotaCare, the subsidized insurance program for low-income people, to anyone who buys their own insurance. People who make more money than the program's income threshold would pay full premiums but sign up through the state.
Republican majorities in the Legislature rejected that this year, but Thissen said he expects it could pick up traction in 2018. Lawmakers may be wary of doling out hundreds of millions more to insurance companies to extend the reinsurance program, he said.
Rep. Erin Murphy, a nurse who frequently references her work in health care, said the MinnesotaCare "buy-in" approach would help sidestep a private insurance industry she believes has become more focused on its own success than serving people.
"I think there's a lot of evidence that the private market … is first and foremost interested in their bottom line," Murphy said.
State Auditor Rebecca Otto has released a 28-page health care plan. She said the state should set up a system in which all state and federal health care money would be funneled into a single fund managed by the state and potentially supplemented with a payroll tax. She's less interested than some other candidates in starting that process by expanding MinnesotaCare.
"We need to move on to something that's much better," Otto said.
U.S. Rep. Tim Walz and St. Paul Mayor Chris Coleman say they support a switch to a single-payer system but believe it's a long-term shift. Both back the MinnesotaCare buy-in as a starting point.
"I hear a lot of support for a single-payer system of some sort and the reality is that it may be the long-term solution, but it's not something we can pivot to immediately," Coleman said.
Walz said he'd also focus more attention on preventive measures that could help drive down health care costs, like reducing obesity rates in young people.
"As governor, I'd be talking more holistically about this," Walz said.