ST. PAUL - In the midst of the divide and confusion over health insurance's future, Minnesota Democrats who would be governor are near united in their prescriptions: Universal and single-payer is the way forward.

In a recent debate before a union-member crowd, the half-dozen Democratic-Farmer-Labor candidates gave nods to supporting universal health care, meaning everyone would be covered by health insurance. Four of the six proudly said they supported a single-payer health care model, meaning a publicly financed system. Last week, Democrat Rebecca Otto, the state's auditor, came out with a lengthy Minnesota-based plan to finance health care.

The leading Democrats to replace DFL Gov. Mark Dayton would give the state a radically different debate than it has ever had on health insurance. The politics of health care have changed dramatically since 2010, when Minnesota had its last gubernatorial election with no incumbent.

Since then, the country and state have grappled with the rocky rollout of the ACA, known as Obamacare, seen health insurance costs leap and the number of uninsured decrease. Now, in Washington, D.C., with a new president and Republican-controlled Congress, the debate is how and whether the GOP can repeal the federal health care law. So far, repeal attempts have failed.

Dayton has long said he supports single-payer health care but on a national level and this year came out with a public option to allow all Minnesotans to buy into a state system. The Republican Legislature rejected Dayton's proposal.

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If a Democrat wins the 2018 election, he or she may struggle with similar political realities. Earlier this year, deep blue California tabled a measure to bring single-payer health care to that state.

Republican waging different fight

Minnesota Republicans are having a debate of their own on their equally crowded side of the governor's race. Among Republicans, the theme is getting distance from MNsure, the health exchange created after the federal government rolled out the Affordable Care Act.

In a flare-up among Republicans last month, former party chair-turned-candidate Keith Downey accused fellow candidate Matt Dean of not working hard enough to rescind MNsure at the Capitol. Dean, a state representative from Dellwood, hit back that he has "devoted my legislative priorities to killing" MNsure and called Downey's attacks "embarrassing and tragic."

The GOP Legislature earlier this year approved millions in state spending to subsidize those with skyrocketing increases in their health insurance costs and to fund a multimillion dollar reinsurance plan to keep costs down.

Meanwhile, through executive actions, President Donald Trump has opened the health insurance market to plans that do not meet Obamacare standards and ended certain federal subsidies for health insurance. Minnesota is suing over the latter.

"ObamaCare is a broken mess," the president said on Twitter. "Piece by piece we will now begin the process of giving America the great HealthCare it deserves."

National and state Republicans have dismissed Democratic support for single-payer health care as a doomed, budget-busting, big-government takeover of patients' most crucial rights.

Growing single-payer support

For most Democrats running for governor, however, fighting to keep and improve Obamacare is not enough. That's a reflection of the growing support for government-paid health care.

"A majority of Americans say it is the federal government's responsibility to make sure all Americans have health care coverage. And a growing share now supports a 'single-payer' approach to health insurance," a Pew Research survey found this summer.

More than half of Democrats in the national survey said they supported health care coverage through "a single national government program." That support is likely stronger among the Minnesota DFL activists who will winnow the gubernatorial field before next November.

The idea of single-payer health care is not new. More than 40 years ago, a health care prognosticator predicted in the Atlantic Magazine that "national health care," presumably financed by the federal government, was just a few years away.

But it is getting new life.

"I'd argue on health care, we've exhausted every other alternative," said longtime state Sen. John Marty, DFL-Roseville. Marty, who has run for governor twice, has long pushed for a universal, Minnesota-based health-coverage system. He has introduced measures in the Legislature to make it happen and written a book about what he calls the "Minnesota Health Plan."

At the DFL candidates forum in Duluth this past week, Otto and state Reps. Erin Murphy and Tina Liebling said pointedly that they supported single-payer health care.

"I'm a single-payer supporter," said Murphy, a nurse who has long represented St. Paul in the Minnesota House. "I don't want to wait for Congress. I don't have a lot of faith in Congress."

State Rep. Paul Thissen, of Minneapolis, said he supported "Medicare for all," a single-payer system being pitched by U.S. Sen. Bernie Sanders, I-VT, and others in Washington.

St. Paul Mayor Chris Coleman said health care should be universal, comprehensive and affordable, and U.S. Rep. Tim Walz of Mankato said he backed "universal access to health care."

'A path'

Otto, the three-term state auditor now running for governor, has given the most detail on her plan. She proposes to funnel all the current state and federal health care dollars into a single trust fund, bolstered with cash from new taxes, and deliver health care coverage to all Minnesotans.

'If you are a Minnesota resident, you are covered, and that's it," she said.

Her proposal would do away with co-pays and deductibles - and much of the role insurance companies play now. Instead, health care providers would be paid quarterly per patient, with incentives to keep people healthy. She said the state would come up with a set of minimum benefits that all residents would receive, and businesses or individuals could supplement those if they wished.

The plan still has some blank spaces in it. She said she would work with lawmakers and others to figure out how and on whom to raise taxes. Otto acknowledged that the federal funds Minnesota got for health care in the past may not be there in the future and that political realities at the Minnesota Capitol and in Washington, D.C., might make approval of her plan difficult or impossible.

"What I'm creating here is a path," she said. "Somebody has to talk about this, and I am willing to talk about this."

Among Democrats, she is not alone in that willingness.

The Pioneer Press is a Forum News Service media partner.