Jeff Johnson and Tim Walz know where to focus their attention in the closing days of their 2018 campaign.

Thanks to polling results — and their own conversations with voters throughout the state — the two governor candidates are well aware that health care is the top issue on voters’ minds.

“This is the most-important issue in this election,” said Republican Johnson during a recent press conference on the issue. “No matter where we travel, it is the No. 1 issue that comes up. Nothing is even close. People are scared to death about their insurance in this state.”

“This should be the issue that unites us,” DFL nominee Walz said at a health-care focused event at which he joined 2nd Congressional District candidate Angie Craig. “I want to say it until I’m blue in the face; it’s always about people. If we bring it back to people and their lives then we’re gonna find solutions.”

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Polling has shown that the issue has remained important throughout the election. An August poll by Suffolk University of 500 likely voters in Minnesota put health care as the top issue in the U.S. Senate and governor races, while a September Star Tribune/MPR poll of 800 voters found that health care was mentioned as a priority by 25 percent of voters, more than any other issue. More importantly, 20 percent of undecided voters list it as their No. 1 issue.

The latter poll asked two questions on some specifics related to the issue. Some 52 percent of likely voters polled in the MPR/Star Tribune survey said they thought the federal government had a responsibility to make sure all Americans have health insurance, though there was a pronounced partisan split on the question: 84 percent of Democrats agreed with the sentiment, but only 23 percent of Republicans did. Voters identifying themselves as independent were divided evenly on the issue, with 43 percent saying yes and 45 percent saying no.

There was far less of a gap — partisan or otherwise — on a second question related to health care: did voters support letting residents buy their insurance through a public insurance program such as Medicare or MinnesotaCare, an option advocated by some DFLers? Of those polled, 70 percent supported the concept while 11 percent opposed, and there were supermajorities among Democrats, Republicans and independents, as well as among all age groups and all regions of the state.

Medicare for all or Medicare for some?

The polling explains why health care is showing up in so much campaign advertising. An analysis of political ads by the Wesleyan Media Project (based on data gathered by Kantar Media) found that 46 percent of ads aired between Sept. 18 and October 15 for federal races throughout the country mentioned health care. During the same time period, just over 30 percent of ads in governor races were on that issue.

The themes that run through the advertising are simple, and sometimes simplistic. Democrats say Republicans want to complete the repeal of the Affordable Care Act, including its protections for pre-existing conditions, and their ads often feature testimonials from people who describe the financial and health impacts of losing coverage.

Republicans, meanwhile, say “Medicare for all” equates to a government takeover of health care. One mailer, targeted against a DFL state House candidate, pictures a mother on the phone with a sick child in the bed next to her, and claims the DFL candidate “thinks you should call bureaucrats — not your doctor — when your child is sick.”

Those campaigns have required both Johnson and Walz to respond. At their debate in Willmar Oct. 9, for example, Walz was asked about his support for a single-payer system. “I have said I think it is probably inevitable, because in every other industrialized nation, that’s what they have,” he said. “But I’m open to what that looks like.”

When pressed as to whether he supports such a system, which has taken off among some Democrats after it was a centerpiece of the Bernie Sanders campaign in 2016, Walz responded with a lengthy answer. “This nation spends twice as much on health care as any other nation, and we rank about 37th in results,” he said. “I simply believe we can achieve outcomes better than anyone else.”

He praised the concepts behind the Affordable Care Act to spread the risk pool over as many people as possible. “Don’t pretend that prior to 2009 that rates were going down,” he said of the year the ACA passed. “They were skyrocketing.”

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When pressed by Johnson to give his views on single payer, Walz said, “I don’t care what that payer looks like as long as we’re getting value for our dollars, we are improving that care receiver’s health and adequately compensating those care providers. There are many different models that have been tried. Most of the countries that get better outcomes with cheaper price have ended up cutting the payer out of that.”

More than 120 members of Congress are co-sponsors of the Expanded and Improved Medicare for All Act, which would open Medicare — a program created to provide health care for Americans over the age of 65 — to every resident. There is a 70-person Medicare for All Caucus, of which U.S. Rep. Keith Ellison, the DFL nominee for attorney general, is a co-chair. Walz is neither a sponsor of the bill nor a member of the caucus.

But he did answer a questionnaire for a group called Main Street Alliance, which advocates on issues important to “socially responsible” small businesses.“We need to enact a single-payer system, and as governor I will put us on a path toward single payer,” he told the group.

Johnson accuses Walz of shifting his support on single-payer to something short of that for political reasons, since single-payer was more popular among DFL primary voters than it might be in a general election, Johnson said.

A national debate

Democrats nationally are having their own debate on the issue. Some support enhancements of the ACA, including providing a public insurance option, such as Gov. Mark Dayton’s MinnesotaCare buy-in proposal. Others fully embrace single payer through Medicare for all. There also are differences in what candidates — and voters — mean when they speak about “single payer” and “Medicare for all.”

A recent national poll by Reuters-Ipsos found that 70 percent said they supported “Medicare for all.” But when the question was rephrased to gauge opinions about “single payer” health care, support dropped to 41 percent. Other polls have seen support drop when respondents are told taxes might increase to cover increased costs for Medicare or that the government would gain “too much control” over care decisions.

There also is disagreement over projected costs of a national Medical-for-all program, with both supporters and opponents picking numbers from the most-comprehensive analysis of costs, which said that unless reimbursements to providers remain low, costs will increase by trillions of dollars. Minnesota-based Growth & Justice has also analysed the issue are concluded there could be savings for the insured.

Democratic candidates are united, however, when it comes to a campaign strategy: warning voters that the GOP could remove protections for pre-existing conditions as they continue pushing to end the ACA. Aiding that narrative is a pending lawsuit filed by Republican state attorneys general with the support of the Trump Administration, a suit that argues that when Congress ended the mandate for people to purchase insurance, the constitutional underpinnings of the ACA disappeared.

Alliance for a Better Minnesota, a DFL-aligned independent expenditure group, has been hammering Johnson on the threat of losing coverage for pre-existing conditions. While specifics are few, the gist of the claim is that letting healthier residents purchase “skinny” plans that might have higher deductibles and not cover preexisting conditions will make the high-risk pools too expensive: for government and for premium-payers.

The criticism also questions Johnson’s recollection of how the pools worked before the ACA made them unnecessary.

Johnson: help the private market make insurance more affordable

The normally unflappable Johnson bristles when talking about the ABM ads. “I have said from the start of this campaign that we will continue to guarantee affordable coverage to people with pre-existing conditions,” Johnson said.

He does favor reestablishing the pre-ACA concept of high-risk pools. When that pool existed before the ACA, there were 23,000 Minnesotans enrolled, at a cost of $178 million a year. Johnson said he didn’t know how many might be on that system in the future, but it was cheaper than the reinsurance program adopted in 2017 to help private insurance companies with their highest-cost policy-holders.

“There’s been heavy subsidizing of health insurance in Minnesota for many years and there will be going forward because it’s a value we have in this state,” he said, while noting that he wants to spend that money in ways that doesn’t harm the insurance markets, which he claims Obamacare did.

In his owns ads and in his public statements, Johnson criticizes the idea of a single-payer system. Last week, he stood with a Canadian radiologist who is a critic of Canada’s version of single payer, claiming it leads to long waits and delayed care.

“Single payer means there isn’t private insurance anymore,” Johnson said. “We all lose our insurance and we’re all forced on one government plan. I think we need to move in exactly the opposite direction.”

That means enhancing the private markets to make it more affordable, Johnson says, and his health care plan includes allowing small businesses, farmers or groups of churches to purchase group plans; forming regional partnerships with neighboring states to allow residents to buy plans across state lines; and a tax exemption for deposits into health care benefit accounts and health savings accounts.

More controversially, Johnson supports reducing the state coverage mandates: the 62 conditions and treatments that must be covered by plans sold in the state. Such reductions require waivers from the federal government, but the Trump Administration is more accepting of state requests.

Johnson, however, said he isn’t yet willing to list which mandates should be removed, saying that should come after a conversation with health care recipients, providers and policy makers. “I fully recognize how unbelievably politically difficult that is because if you eliminate that mandate the attack ads come out saying you don’t care about people with that particular condition,” he said. But adding more mandates “raises the cost of insurance for everybody.”

MinnesotaCare and ‘market fantasies’

Johnson’s lack of specifics on the mandates has opened him to a Walz attack: that he won’t be specific until after the election, denying voters the information to judge the proposals.

For his part, Walz has endorsed a MinnesotaCare buy-in. MinnesotaCare is the state-subsidized health insurance program for working people who make too much to be eligible for Medicaid but can’t afford private insurance. The program covers families earning between 138 percent and 200 percent of the federal poverty rate.

Republican have rebuffed the effort to expand access to MinnesotaCare, citing concerns by hospitals and medical providers that they already struggle with the amounts that MinnesotaCare pays in reimbursements. The Minnesota Hospital Association opposes the expansion, saying members accept lower reimbursements that are significantly below commercial insurance payments because of the vulnerability of the population using MinnesotaCare. If people moved from those commercial policies to MinnesotaCare, hospitals would see revenue declines.

Walz considers the buy-in plan as a step toward a single-payer system, which Johnson says worries him. “Even this step is a disaster for Minnesotans, and particularly for struggling hospitals and clinics all over the state,” Johnson said. “I know he was a geography teacher, but his math is really bad.”

Walz responds by saying Johnson is putting his faith in a private insurance market that doesn’t act like a real marketplace and hasn’t been doing a very good job holding down costs.

“Pretending that the market’s going to make all that happen, that’s simply fantasy,” Walz said. “If you’re running for governor and your plan is to scream single payer at me, you ain’t getting anything done.”

Of revenue and reinsurance

The candidates disagree on a significant source of money for state health care programs. Johnson supports allowing the so-called provider tax — a 2 percent tax on health care services — to expire at the end of 2019. That money currently is the dedicated source of funding for MinnesotaCare (and for former MinnesotaCare enrollees who moved to Medicaid under the ACA’s Medicaid expansion program). That’s nearly 1.5 million people in the state.

The hospital association, which Johnson quotes in opposing MinnesotaCare expansion, disagrees with Johnson on letting the provider tax expire until an alternative is crafted.

Walz would like to maintain the tax, which raises $500 million a year. Next year’s sunset was part of the compromise between Dayton and legislative Republicans to end the government shutdown in 2011. Without it, however, the next governor and Legislature will have to find money from other sources to pay for health care subsidies, and to continue a controversial reinsurance program to help insurance companies with the highest-cost policyholders.

Democrats voted against reinsurance and Dayton let it become law without his signature. It is now being touted by the GOP as the primary reason that the individual insurance market not only stabilized this year but saw rate cuts, and even Dayton’s Commerce Department credited reinsurance as one reason. About 155,000 residents get insurance from the individual market in Minnesota, while another 303,000 get benefits from the small group market for employers who have fewer than 50 workers. The two programs cover less than 9 percent of the state.

Both Johnson and Walz support stabilizing the insurance system until other changes can be made. Says Johnson of the reinsurance bill: “I likely would have signed it as governor but it’s a band-aid,” said Johnson. “It’s not sustainable to keep doing this year after year after year. ”