To read their statements, Colorado’s major-party candidates for governor have dramatically contrasting views on how to lower the costs of health coverage in Colorado.
But a closer reading of their plans reveals … well … that there’s nothing to read closely. While both Republican Walker Stapleton and Democrat Jared Polis have offered big ideas for how to change health care in the state, in addition to more incremental proposals, neither has actually explained their precise visions — or how they would implement them.
This leaves still-undecided Colorado voters facing a dilemma entering the final week before Election Day: Health care is tied as the No. 1 priority for the state’s voters, according to a recent poll, but it is difficult to predict how Colorado’s health coverage landscape would change under either candidate. Or if it would change at all.
“(N)either candidate seems likely to immediately dismantle the current system,” the nonpartisan Colorado Health Institute concluded when it examined the candidates’ proposals earlier this year.
Both candidates have health care sections on their websites that offer up general frameworks. But to learn more about their ideas, The Colorado Sun on Oct. 23 submitted a list of 10 identical yes-or-no health policy questions to both campaigns as well as a smaller set of unique questions about a Big Idea that either Polis or Stapleton has proposed.
Both campaigns declined to answer the questions, though, citing late-campaign busyness. (For transparency, the questions are included at the bottom of this story.)
In lieu of answers, here’s what we know about Polis’ and Stapleton’s proposals and an explanation of what we need to know in order to actually understand them.
The Big Idea:
Single-payer health care.
Polis supports a national “Medicare for All” model, and, in February, he wrote an editorial for the Aspen Times where he vowed, “If I’m elected governor of Colorado, I will work with other western states to tackle our shared health challenges. Together, we can pioneer a groundbreaking multi-state consortium to offer a universal, single-payer option out west.”
What we don’t know:
Almost everything else.
Polis has repeatedly declined to specify how a single-payer system would be paid for or how, exactly, it would work. Would it replace all private insurance in Colorado or would it compete in the market alongside private plans? Would it charge copays or deductibles? How would it set the rates it pays doctors or decide what it covers and what it doesn’t?
A true single-payer system for even a modestly sized state such as Colorado is a massive undertaking. When a proposal to create one here was on the ballot in 2016 — Polis opposed that specific plan, by the way — the Colorado Health Institute estimated it would need to bring in somewhere around $36 billion in its first year to pay its bills. That’s more money than McDonald’s restaurants generate in a year, and it’s roughly $8 billion more than the entire current state budget.
There’s also a question of whether other states would go along with this plan. Polis told Colorado Politics this summer that he would reach out to the governors of other states once in office to get talks on a regional consortium rolling. As The Denver Post has noted in writing about Polis’ plan, even the Democratic candidate for governor in New Mexico has said the numbers for single-payer “don’t work.”
There’s a long list of additional approvals needed to put a single-payer system in place. State lawmakers would likely have to sign off on large chunks of the plan. Voters would need to approve tax increases to pay for the plan.
If Colorado intends to include Medicaid recipients — and federal Medicaid dollars or money that currently goes to pay Obamacare premiums — in the plan, it would need approval from the federal government, too. That last one is especially unlikely to happen anytime soon, since the Trump administration last week announced new guidance for state innovation waivers that prioritizes private-sector solutions. (More on this guidance below.)
And do Colorado voters really want single-payer?
When the Kaiser Family Foundation and the Colorado Health Foundation polled voters late this summer, only 19 percent identified passing a single-payer plan as the most important health issue facing the state legislature. An additional 32 percent said it was a somewhat important issue — bringing the total number of people generally supporting the idea above 50 percent. But that still placed single-payer dead last among the issues polled, well behind lowering health care prices and better funding for mental health services.
The Big Idea:
A federal 1332 waiver.
These waivers give states a pass on certain Affordable Care Act (i.e. Obamacare) regulations in order for the states to come up with their own innovative solutions. Stapleton has written that he wants to apply for a waiver to “allow for more diverse types of coverage” that could bring down health insurance costs for some.
What we don’t know:
While Stapleton has talked about using the waivers to enable short-term plans, catastrophic plans and other arrangements, he has never actually said what specific Affordable Care Act rules he wants to waive.
This is significant because the Trump administration’s guidance on the waivers gives states new latitude to authorize substantially skimpier plans than what otherwise must be offered. It is possible, for instance, that the Trump administration might OK a 1332 waiver that would allow people to use taxpayer subsidies to buy plans that offer less-comprehensive coverage for pre-existing conditions.
And about those pre-existing conditions. Stapleton has said he will protect them.
“We would look to make more affordable plans available to Coloradans, but this would not mean those with pre-existing conditions would be excluded,” he said in a statement his campaign sent to The Colorado Sun.
But that falls short of endorsing all the different protections for people with pre-existing conditions currently enshrined in state and federal law. For instance, the law prohibits insurers from: denying coverage to people based on pre-existing conditions; specifically excluding coverage for certain pre-existing conditions; charging people more for coverage based on pre-existing conditions; or setting annual or lifetime caps on the amount of coverage provided.
Would Stapleton make sure new plans have to comply with all of those rules? Or just some?
It is almost certain that Stapleton cannot request a 1332 waiver from the federal government without the state legislature’s approval.
Some of the new plan types that Stapleton has talked about — short-term plans, for instance, or catastrophic plans — already exist in Colorado, but they are subject to limitations by law and rule.
Short-term plans can last only for six months and be renewed only once, meaning they can’t be used as insurance for longer than a year. The state Division of Insurance has also proposed rules that would bring them more in line with ACA coverage requirements. Stapleton has not said whether he would keep these restrictions in place.
Catastrophic plans are for the most part available only to people under 30. The legislature, though, passed a bill earlier this year requiring the Division of Insurance to analyze the potential impact of opening such plans up to everybody. If all looks good, the state will request a 1332 waiver for expanded catastrophic plans by the beginning of next year — before Stapleton could even take office, if elected.
The questions we asked the campaigns
To both campaigns:
- Would you seek to change state laws that require health insurers to offer policies to anyone, regardless of their health status, and that prohibit insurers from excluding pre-existing conditions from coverage?
- Would you seek to change state laws that prohibit health insurers from charging people more for insurance because of their gender, current health needs or pre-existing conditions?
- Would you seek to shrink the list of essential health benefits that insurers are required to cover under state law?
- Would you support spending state funds to provide financial help to families living in high-cost health insurance areas, such as what was proposed earlier this year in HB 18-1205?
- Would you support spending state funds to create a reinsurance program that would at least partially reimburse health insurers for covering especially high-cost claims?
- Would you seek to end or reduce the Medicaid expansion in Colorado?
- Do you favor imposing work requirements or drug testing as a condition for receiving Medicaid benefits?
- Would you support giving Colorado residents above the income cutoff for Medicaid the ability to purchase Health First Colorado benefits — a Medicaid buy-in program?
- Do you support requiring hospitals to disclose publicly their chargemaster prices and requiring insurers to disclose publicly their contract terms for health care and prescription drug costs, as proposed earlier this year in HB18-1358?
- Do you support requiring hospitals to obtain from the state a Certificate of Need prior to building a new hospital, freestanding emergency room or other health services facility?
To Polis’ campaign only:
- In February, you wrote that you would work with other western states to “pioneer a groundbreaking multi-state consortium to offer a universal, single-payer option out west.” Is this still a priority of yours?
- If other western states aren’t interested in such a plan, would you abandon the idea or press on with creating a single-payer program for just Colorado? Do you envision a government-run, single-payer plan as replacing most private health insurance in Colorado?
- Do you anticipate asking Colorado voters during your first term as governor to approve a single-payer health care plan and tax increases to fund it? Or do you believe such a plan could be created without additional voter approval? Do you believe such a plan would require approval by the federal government? Do you have any rough estimate of how much individual Coloradans would have to pay per year in new taxes to cover the cost of a single-payer plan?
- A recent Colorado Health Foundation/Kaiser Family Foundation poll found that 19 percent of Coloradans believe passing a universal health insurance plan should be the most important health care priority in the state, while 31 percent believe it is not very important at all. How would you convince skeptical Coloradans that such a big endeavor is a good idea?
To Stapleton’s campaign only:
- Can you explain what specific federal rules or laws you would be requesting a waiver for? What, specifically, do you hope that a waiver would accomplish?
- On your website, you say that you hope a waiver would allow for “more diverse types of coverage” in Colorado. Some of those types mentioned — such as short-term plans — are also covered by state laws and rules. Will you seek to change any of those laws or rules? What will you change, specifically?
- You also write, “New plans must cover pre-existing conditions, young adults still on their parent’s coverage, and include options to cover maternity care.” Would these plans be required to cover all of the items on the state’s current list of essential health benefits? Would insurers offering these plans be allowed to charge customers more based on their pre-existing conditions? Would they be able to charge customers more for plans that cover maternity care? Would these plans be subject to prohibitions on annual or lifetime coverage caps? Would consumers be able to use ACA premium subsidies to pay for these plans?
- Do you anticipate needing or seeking approval in the legislature (or from voters) before requesting a 1332 waiver or do you believe, as governor, you could request the waiver under your own authority?