Health care ranks among the top issues in Colorado’s race for governor. But to hear the campaigns and their allies describe it, voters in November will be choosing between Democrat Jared Polis’ and Republican Walker Stapleton’s competing health scare policies.

Both candidates say it’s a top priority to expand Coloradans’ access to health care and control costs, but Stapleton and his supporters warn that Polis’ plans will impoverish the state and its residents, while the Polis camp argues Coloradans will lose coverage and financial protections under Stapleton’s proposals.

Nine years after a Democratic Congress – including five-term U.S. Rep. Polis – passed the Affordable Care Act, and a year after the Republican Congress failed to repeal it but managed to abolish its individual mandate for insurance coverage, the landmark legislation known as Obamacare remains a political hot potato.

While the two candidates differ sharply on issues related to the ACA, from Colorado’s individual insurance exchange to expanded Medicaid coverage, both are also banking on getting waivers from the federal government in order to implement some of their more ambitious plans.

According to a public opinion survey conducted earlier this year by the University of Colorado’s American Politics Research Lab, Coloradans consider health care the most important national priority, and fully half of the state’s residents surveyed said they support a “single-payer” health care system “in which all Americans would get their health insurance from one government plan that is financed by taxes.”

Asked before the June primary to name the issues that helped determine which gubernatorial candidate to support, unaffiliated voters said education was most important, followed by health care.

Polling, however, also shows Republican voters aren’t nearly as concerned about health care as Democrats and unaffiliated voters are, and the two party’s nominees have approached the topic differently on the campaign trail.

Just after Polis picked his running mate, former state Rep. Dianne Primavera – a four-time cancer survivor and then-CEO of Susan G. Komen Colorado, a nonprofit that raises money for breast-cancer programs, the Democratic ticket embarked on tour of the Western Slope devoted to discussions about health care.

Stapleton’s running mate, state Rep. Lang Sias, an Arvada lawmaker who passed a bipartisan bill last session requiring more transparency on costs and customer rights from freestanding emergency rooms, sits on the House Public Health Committee and Health Exchange Legislative Oversight Committee. But Stapleton introduced Sias, a former Navy “top gun” pilot, in front of a fighter jet at a Denver museum.

“Health care is a human right,” Polis said in a 15-second ad that aired during the Democratic primary. “I supported ‘Medicare for All’ for more than a decade because it will help Coloradans pay less for health care, and that’s who we should be fighting for.”

Polis described how he would implement his policies as governor in a series of opinion pieces published earlier this year in the Aspen Times.

“With the absence of leadership coming from Washington, we need to think outside the box and lead the charge ourselves to bring universal health coverage to Colorado,” he wrote in one. “I’m running for governor because it’s time for us to translate the core value that health care is a human right into public policy. It’s not only the right thing to do, but the most cost-effective way to reform health care in the long-term.”

Polis has outlined an array of approaches, including a proposal to band together with other Western states to establish a “universal, single-payer option,” as well as plans to attack the high cost of health care in rural Colorado, soaring prescription prices and the opioid epidemic.

Stapleton, a two-term state treasurer, wants you to know one thing, for sure, about his health care plan: “My plan won’t bankrupt the state,” he said in a small meeting room in Greenwood Village after opening a Republican campaign office on a recent Saturday afternoon.

While Stapleton has been short on specifics when it comes to his own prescriptions for health care – a page devoted to health care issues appeared on his campaign website only in the last week – his campaign and his supporters have pounded a steady drumbeat about Polis’ plan, calling it radical and pointing to a recent national study that found the federal government could spend $32 trillion over 10 years to implement a single-payer plan.

“Tell Jared Polis we can’t afford his government takeover of health care,” says a pro-Stapleton ad from State Solutions, an arm of the Republican Governors Association.

“Walker is committed to instituting reforms that will actually fix our health care system and bring about real relief to Coloradans that can’t afford the out-of-control costs of Obamacare,” Stapleton campaign spokesman Jerrod Dobkin said in a recent statement.

Republicans have been long on hyperbole, attempting to tie Polis to Amendment 69, a ballot measure he opposed, which would have established a single-payer health care system in Colorado but was defeated by voters nearly 4 to 1 in 2016. Stapleton co-chaired the opposition group to that proposal, called “ColoradoCare,” with former Democratic Gov. Bill Ritter.

Stapleton describes Polis’ plan as potentially more expensive to taxpayers than the projected $25 billion cost for the failed ColoradoCare proposal.

“He’s promising universal coverage to people,” Stapleton told Colorado Politics. “It’s responsible, if you’re making that promise, to explain to people how you plan to pay for it.”

It’s important to note there’s a distinction between universal coverage – something nearly every industrialized country except the United States guarantees its residents – and a single-payer system, like the “Medicare for All” legislation Polis is sponsoring in Congress. While Polis supports both, his campaign points out that there are plenty of ways to approach universal coverage for Coloradans without implementing a single-payer system either at the state or federal level.

“If we don’t set a goal, it’s impossible to get to where we want to go,” Polis is known for saying – and his campaign maintains that his push for universal coverage could develop in different ways but will have to lower costs in order to move ahead.

Here’s how Polis says his proposed multistate health consortium could work: Once in office, he plans to meet with governors from Western states – possibly including Washington, Montana, Nevada, Oregon and New Mexico – and develop a framework for how they could provide health care at a lower cost by expanding the risk pool to include all their residents, as well as increase purchasing power for medicine and other services.

The states might also come up with other programs such as reinsurance for rural areas, expanded mobile health clinics, fixed-price reimbursement to Medicaid providers and common consumer rules and transparency requirements for prescription drugs.

After what could be a couple years to put together the plan – particularly because the states don’t have the same legislative calendar, and some might require different steps to approve the proposition, including taking the question before voters – the states would submit waiver applications under Obamacare to the federal government, taking advantage of flexibility built into the law.

Although it could take years to put in place, the plan could result in a regional single-payer system, or it could turn into the kind of robust public option Polis and other Democrats have been lobbying for, bringing more competition to the health insurance market while bringing down costs for participants.

“We can turn this idea into reality by working in a bipartisan way on a shared set of strong legal standards for implementing the system,” Polis wrote. “By removing the moral hazards and perverse incentives to deny coverage that exists in private insurance, we can put people before politics and be a regional model for the rest of the nation. Insurance creates the most value with the largest possible risk pool, so why shouldn’t all of us be in one risk pool to prevent gaming the system?”

In the meantime, Polis is contemplating a legislative agenda that includes encouraging more physical activity among schoolchildren; allowing municipalities to raise their own tobacco taxes; implementing paid family and medical leave policies; and permanently funding the Long-Acting Reversible Contraception program, which significantly reduced teen pregnancy and abortion rates as a pilot program.

Along with encouraging broadband development in order to make some medical technologies more available throughout the state, Polis is proposing a range of solutions to bring more affordable health care to rural and mountain areas, where it’s as expensive and scarce as anywhere in the country.

“I’ve been calling on Colorado for years to redefine its geographic rating system to reduce the expenses facing mountain-area families, and I’m prepared to solve this issue as governor,” he said.

Stapleton’s health care plan is built from a blueprint of if’s:

If the Legislature would support major reforms, meaning if both chambers have a Republican majority.If Republicans in Washington turn over Obamacare to the states.If Colorado’s health exchange proves otherwise unworkable.If federal block grants, vouchers and waivers allow the governor to unilaterally dictate care for the medically needy.If he can find private partners to fill the gaps at a better price than the way care is delivered now.If, politically, he can get away with turning away Medicaid recipients at emergency rooms, instead directing them to community clinics that could provide the service more cheaply.Stapleton calls his plan a “managed model” for Medicaid, which provides care for more than 1.3 million Coloradans.

“It means actively managing what is going on with the expansion of Medicaid, so we can deliver on the promises we’ve made, so we don’t wind up with 64 counties with one choice of health care (insurance) provider seeing double-digit increases, and people are paying more for their insurance than they are their mortgages,” he said.

Although he said in earlier interviews that he wants to reduce the number of Coloradans on Medicaid, Stapleton told Colorado Politics last week that he isn’t looking to kick off people who got Medicaid coverage during the Obamacare expansion – about 400,000 people.

A July report about the expansion showed Denver County added 72,947 people to Medicaid, and El Paso County was next with an additional 63,294 recipients. That helped drop the state’s uninsured rate from 15.8 percent in 2011 to 6.5 percent in 2017, according to the same report from the Department of Health Care Policy and Financing.

Medicaid is a $10 billion enterprise in Colorado that is critical to public health and the health care industry, the way Democrats engineered it under Obamacare. Republicans have tried to deconstruct it through court cases, the tax code and President Donald Trump’s executive orders.

Stapleton said if he’s governor, the state’s exchange for individual health insurance, Connect for Health Colorado, will get a close re-examination in the name of services, cost and efficiency.

“I’m saying that everything should be on the table,” Stapleton said. “We need to see if the exchange is viable.”

As recently as April, Stapleton was delivering a somewhat different message to a Republican audience, saying he doesn’t believe the health exchange “is sustainable.”

“I believe the governor has known for a long time that it’s not sustainable,” Stapleton said at a GOP meeting at a Mexican restaurant in Greenwood Village. “The state audit took over a year, of the health exchange, even though they know that it’s not sustainable. And it is not a question of if, but when, we have to get rid of the health care exchange.”

Stapleton said when he became treasurer in 2011, the state budget was about $18 billion. This year, it topped $29 billion, and he blames much of that spending on the Medicaid expansion.

That’s misleading, however. Most of that money came from the federal government, not directly from Colorado taxpayers at the expense of other budget needs, such as transportation or education.

The federal government paid the full cost of the expansion for the first three years, through 2016, and will reduce its share by 10 percent by 2020. The federal share stays at 90 percent after that.

Stapleton can’t kill the exchange by fiat, but the governor has plenty of tools through appointments and the bully pulpit.

The governor appoints five of the nine voting members on the Connect for Health board, according to the 2011 legislation that set up Colorado’s exchange. The House speaker and Senate president, as well as minority leaders in each chamber, also make appointments.

The next governor will have his troops in charge of the state’s Department of Health Care Policy and Financing, the Department of Public Health and Environment and the Division of Insurance, the three main agencies that run the state’s Medicaid program.

Stapleton is confident his appointees can find and fix “issues with transparency, with billing, with fraud (and) overbilling,” he told Colorado Politics.

Joe Hanel, a longtime state Capitol reporter who is now the spokesman for the nonpartisan Colorado Health Institute think tank, said the next governor could potentially be the most important health care leader in the state, because of his role over Medicaid.

“The feds are giving states a lot more power over health care through Affordable Care Act and Medicaid waivers, but the governor has to be on board with whatever idea the state proposes,” he told Colorado Politics.

The governor’s positions could send political ripple effects that roil the economics of the system, communities and individuals, Hanel said.

“For example, if Medicaid changed the way it pays providers, it could incentivize different cost-saving ideas – or, if they did it wrong, it could cause havoc,” he said. “Also, Medicaid is especially important to rural Colorado and its hospitals, since such a large proportion of the rural population uses Medicaid. And there’s a political debate about how many people should be on the Medicaid rolls.”

The governor also is de facto the chief lobbyist for health care with the state Legislature and with the federal government.

“This is not an issue Washington is going to solve for us, regardless of who’s the president,” Stapleton said. “I think governors are going to play an outsized role in the future of Medicaid expansion.”

Stapleton has said in previous interviews he prefers a “proliferation of community health care systems” to handle different levels of care, which he maintains would cut costs.

Partnerships with the private sector are key to his plan, especially if the Trump administration still hopes to relinquish the remnants of Obamacare to the states in the form of block grants.

“We need these private-sector companies to bridge the gap and deliver on some of these promises that I think Coloradans want,” Stapleton said. “That is a system where we improve access and we improve affordability.”