Single-payer health care will be a hot-button issue in states with gubernatorial races, a policy idea that seldom if ever sparked debate prior to the passage of the Affordable Care Act, aka Obamacare.
Notably, two of the states where single-payer will get a hearing this fall, California and Colorado, have open governor's races and both of those states have already grappled to some degree with the issue.
With Republicans more or less united in their opposition to the policy, single-payer has shown the potential to cause rifts among the Democratic base, and has prompted questions about where unaffiliated voters may come down on the issue.
Jon Thompson, communications director for the Republican Governors Association, says the dilemma is a classic tightrope walk of candidates trying to navigate the differences between the primary and general elections.
"How far left do you go in a primary to appease your base?" Thompson told the Washington Free Beacon. "Are you going to go so far you can't come back to the center in the general election, and if you do [move to the center], are you going to anger the base?"
California shows single-payer can be an intra-party wedge issue in an environment where some Democrats are trying to pull the party further to the left.
The state has seen several iterations of single payer systems proposed, including a bill passed in 2006 that was vetoed by Republican Gov. Arnold Schwarzenegger.
Later in 2017, at the same time congressional Republicans were debating possible replacements for Obamacare, the California Senate passed a bill that would have created the first real single-payer system in the nation. However, House Speaker Anthony Redon later spiked the bill, calling it "woefully incomplete," while headlines floated potential price tags of $400 billion.
Redon's actions drew immediate backlash, most noticeably from socialist and potential 2020 Democratic nominee, Sen. Bernie Sanders (I., Vt.).
Former Los Angeles Mayor Antonio Villaraigosa appears to be using single-payer to cull the crowded primary down to a two-person race. Villaraigosa is on the record with his doubts about the costs and financing of a single-payer system, and is using his funding concerns to ding his rival.
"Enough with the slogans—it's time to show real leadership and have a serious in-depth discussion," Villaraigosa said in a statement on Monday, challenged the presumed front-runner, Lt. Gov. Gavin Newsom to a one-on-one debate on the topic.
"Newsom calls any attempt to demand details of his $200 billion tax increase and plan to force seniors off of Medicare as 'defeatist,'" Villaraigosa went on. "I call refusing to say how you will successfully persuade Californians to more than double their taxes while taking away their Medicare simply deceptive."
Villaraigosa's website says the former mayor supports "universal" health care.
Also of note, the debate challenge came just over a week after one of the most noticeable signals of the leftward shift in California when Democrats at the state assembly withheld their endorsement from U.S. Sen. Dianne Feinstein.
Neither the Villaraigosa or Newsom campaign responded to a request for comment.
Colorado has also flirted with single payer. A drive to create the first state-based single-payer system easily obtained the number of signatures needed to be placed on the ballot in 2016, only to be crushed that November with 78 percent of voters saying "no." Sanders, who also made campaign appearances in the state for the ballot question after he had been eliminated from the Democratic primary for president, endorsed the measure.
Those results have not deterred Rep. Jared Polis, one of the frontrunners for the Democratic nomination for governor, who is advocating a "Medicare For All" position, but is also giving single-payer a regional twist by proposing a multi-state system.
"I will work to develop partnerships with other western states to pioneer a groundbreaking regional multi-state consortium to offer a common-payer system in the West to reduce prices, expand coverage, and improve the quality of care," Polis says on his campaign website.
"With states partnering in cost sharing, development, and implementation, we can provide coverage to more people at a lower cost than a state implementing such a system alone would be able to do."
Polis stands out in the Colorado field because of his ability to self-finance his campaign. Despite that advantage, however, he made a surprise second-place showing in a non-binding preference poll in party caucuses Tuesday.
Former state treasurer Cary Kennedy was the surprise winner, garnering 50 percent of the preference poll. Kennedy's website says she supports a "public option."
Neither the Kennedy or Polis campaign responded to a request for comment.
Thompson also points to Maryland as a state in which single-payer could play a part.
"Ben Jealous, who is probably the [Democratic] front runner, has said that, if elected, he will institute single payer health care," Thompson said, but added that questions over cost have dogged the candidate.
The Republican Governors Association recently touted a new Mason Dixon poll showing Republican incumbent Larry Hogan leading all of his Democratic challengers by double-digit spreads.
The Jealous campaign did not respond to a request for comment.
The primary voting in all three states will be held in June.