Health care was a top election issue for both urban and rural areas throughout the Democratic primary and leading up to the COVID-19 outbreak in the United States. After the pandemic swept the nation and pushed the health care system to its limits, concerns about health care access and affordability remain high.

Both Democrats and Republicans are fine-tuning their campaign messaging on health care through the lens of COVID-19. Sen. Cory Gardner, R-Colo., is facing a re-election campaign against former Gov. John Hickenlooper, who proposes building on the Affordable Care Act by establishing a national public option for health care.

Gardner has voted repeatedly to repeal the Affordable Care Act, but he released a television ad earlier this month saying he would guarantee coverage to people with pre-existing conditions “no matter what happens to Obamacare.”

Health policy experts like Jake Williams, executive director of the nonpartisan organization Healthier Colorado, say the bill Gardner brought to the table does not protect people with pre-existing conditions, or people who had health conditions like asthma, diabetes or cancer before the start of their new coverage.

Unlike the ACA, Gardner’s proposed legislation does not require insurance companies to sell policies to people regardless of their health status.

Williams said Gardner and Lauren Boebert, conservative candidate for the U.S. House of Representatives, are emphasizing protecting those with pre-existing conditions in their campaign messaging because of recent polls that show Coloradans overwhelmingly feel the government should do more to make health care more affordable and accessible for everyone.

Polls from Healthier Colorado, the Colorado Health Foundation and Colorado Pulse show that COVID-19, health care and the economy rank among the top concerns for Coloradans heading into election season, but for Williams, health care and job loss are linked. If workers are insured through their employer, they lose their health care when they lose their job.

“The ability to afford housing and health care is a big concern, and the signs are in the election rhetoric,” Williams said.

Gardner felt “compelled to introduce a bill that replicates some of the provisions of the ACA,” Williams said.

According to Gardner’s campaign website, the senator “understands any health care plan needs to cover pre-existing conditions and must be part of any plan he will support.”

And Gardner has worked to close the urban-rural divide when it comes to health care access. During his time in the Senate, he has introduced several bills to support telehealth programs, and the House of Representatives recently passed Gardner’s 9-8-8 suicide hotline bill.

The legislation designates 9-8-8 as the national suicide prevention and mental health crisis hotline, making it easier for those experiencing a mental health crisis to dial for help.

Calls to the mental health crisis line in Colorado have spiked 48%, partly because of COVID-19. About 60% of calls to the crisis line are related to the ongoing pandemic.

Eric Prinzler of Thornton, a former state legislator, said he is voting for Gardner because he “uses common sense” when it comes to things like health care. Under the ACA, young people have to pay monthly insurance premiums, when “most young people don’t need anything but catastrophic care,” he said.

Prinzler argues that if people spend less per month on insurance payments under the ACA, then they will have the money to pay the deductible if they need catastrophic care, such as a broken arm.

“The government shouldn’t dictate how insurance does business,” Prinzler said. “It drives up rates because they have a captive audience.”

Boebert also said protecting a privatized system is the way to keep health care affordable, because it creates competition for insurers to provide lower prices for procedures and prescription drugs.

The political newcomer did not comment on the ACA in a phone interview with The Durango Herald, but said she would “never vote to take away anyone’s insurance. ... Promises made to people with pre-existing conditions must be protected.”

Boebert said she is critical of both Republican and Democratic leaders for not doing more to make health care more affordable and accessible, particularly in rural areas where hospitals are in danger of being shut down.

But a public option is not the way to improve the system, she said.

“If you think the DMV is run well, wait until they run health care,” Boebert said.

Since the start of the COVID-19 pandemic, more than 200,000 people have died in the United States because of the virus. Millions have lost their jobs, and as a result, their health insurance.

And for those who have survived the virus, COVID-19 could become a pre-existing condition if the ACA is repealed.

Independent pollsters working for the Colorado Health Foundation found that health and health care, combined with the pandemic, was the top issue for one-third of those surveyed in the state. And 74% of those surveyed said ensuring access to health services for Coloradans, including basic-need resources like food banks, is a priority.

On the Western Slope, 77% of survey respondents rated access to health care as either “extremely” or “very important” on a scale of not important, somewhat, very or extremely important.

“Anxiety and loneliness were the most broadly shared impact,” said Dave Metz, one of the pollsters. But access to mental health care is a “significant problem in Colorado.”

Under the new lens of the COVID-19 pandemic, affordability and access to health care is “basically on par with education, jobs and the economy,” said pollster Lori Weigel.

This is still the case at a time when 38% of Coloradans are concerned they will not be able to pay their rent or their mortgage.

“That was really stark,” Weigel said. “Those are needs, not wants.”

And those needs are affecting what people want to see from the government, Metz said.

Julie Hagenbuch of Steamboat Springs said her top priority for the 2020 election is affordable health care. As someone who is self-employed, Hagenbuch relies on Medicare, and she is concerned about it being defunded.

Hickenlooper has her vote in the Senate race because he expanded Medicaid to an additional 400,000 Coloradans during his time as governor, Hagenbuch said in a phone interview with the Herald.

She recently organized a group of about 100 people, including “a bunch of old people who know the ramifications of no health insurance,” to hold signs that read “repair don’t replace the ACA” outside a donor event for Gardner. But the senator did not show up to the event, she said.

When it comes to both the U.S. Senate and U.S. House race, health care is a driving force for Hagenbuch at the polls. Her health care premium costs exceeded $31,000 last year with ACA coverage after a surgery procedure.

Then Hagenbuch had to pay for two deductibles, medical equipment to help her body heal and half the cost of the physical therapy.

“The insurance companies have an arbitrary limit on physical therapy, so someone that has a brain injury gets the same physical therapy covered as someone who breaks their ankle,” Hagenbuch said.

The Democratic candidate for the House, Diane Mitsch Bush, is “willing to listen” to voters about their health care concerns, Hagenbuch said.

“I am a supporter of Diane as ACA contains many protections,” Hagenbuch said, “but there is still a need to spread out costs and rein in insurance profits.”

Throughout her campaign, Mitsch Bush has emphasized strengthening the ACA with a public option for insurance.

“I am opposed to a plan that would take away options for people,” Mitsch Bush said in an interview with the Herald. “That would have a disastrous effect on people in this area.”

As COVID-19 continues to spread within Colorado, Mitsch Bush said, “we’ve seen quite clearly that the virus has started to be counted as a pre-existing condition.”

“It is more important now than ever to keep ACA for Medicaid coverage, as frontline workers are less likely to have health care coverage,” she said.

Mitsch Bush also emphasized the need to end the surprise medical billing that results from referrals to specialists that are out of someone’s insurance network. And her plan for health care includes adequate funding for rural hospitals and health clinics.

Coloradans pay some of the highest premiums in the country, said Nancy Spillane, a local organizer on health care issues in Routt County.

“Diane is committed to reducing the price of insurance premiums, and getting paid family leave,” Spillane said.

President Donald Trump has called for cuts to Medicaid, which is an “important source of coverage for rural voters,” said Geoff Garin, a pollster from Hart Research Associates in Washington, D.C.

Garin conducted polling on health care and rural voters for Families USA, a nonpartisan organization that advocates for high-quality, affordable health care for American consumers.

If cuts are made to Medicaid, it would lead to more job loss, Garin said. The health care industry is a major employer across rural America.

While conservative voters tend to be skeptical about the government’s role in systems like health care, Garin found that many rural areas want to expand Medicare to include things like dental and telehealth.

Regardless of whether voters are concerned about COVID-19 for health or economic reasons, containing the virus will save lives and allow the economy to fully reopen, Garin said. Trump’s handling of the pandemic so far is “starting to erode Trump’s support,” he said.

ehayes@the-journal.com