Gov. Mark Dayton's declaration that the federal health care overhaul is "no longer affordable" for more and more Minnesota residents could be the spark that sets off major health care changes.
The Democratic governor's remarks last week renewed calls to address rising costs in the individual market, where unexpectedly high medical claims have resulted in double-digit premium increases and has some top state officials worried that it can't survive.
Here's a look at the issues at play and the ideas to fix them.
Who is affected?
It's a major political issue in Minnesota, but the impact on its residents is quite small.
The vast majority of people are covered through employers, so the eye-popping premium increases -- 50 percent and more -- will only hit some of those who are not. Minnesota's offering of a so-called basic health plan, a subsidized public program called MinnesotaCare, reduces the individual market even more.
All told, less than 5 percent of residents purchase health care individually -- through the state's health insurance exchange, from an agent or directly from insurers. That's among the smallest individual markets in the country.
"I know that it only affects 5 percent of Minnesotans, but it scares every Minnesotan," Republican House Speaker Kurt Daudt said Friday.
What's the problem?
The small size is a big part of the problem.
Department of Commerce Commissioner Mike Rothman blamed a small and severely sick pool of insured people for driving up costs -- as much as 67 percent for next year. Those high costs can only spread out so far in Minnesota's small individual market.
"We're asking a very small group of people to carry the responsibility for the (sickest) people," said Sen. Kathy Sheran, DFL-Mankato.
Unable to sustain the business due to financial losses, insurers are eyeing the exit -- and some have left. Blue Cross Blue Shield of Minnesota's departure for 2017 makes it the second major insurer to leave since the Affordable Care Act was implemented in 2013.
And the whole market is on the precipice. State regulators scrambled to stop all seven remaining insurers from following Blue Cross' lead. Rothman called on lawmakers to act to ensure an individual market could survive into 2018 and beyond.
"Everyone needs to hear the sirens and the red lights," he said earlier this fall.
What can be done?
There's no shortage of ideas swirling for how to get costs under control and stabilize the health care market. But there's also little agreement on them.
Both parties agree that short-term relief is necessary to offset the 2017 premium increases, particularly for those Minnesota residents who earn too much to qualify for federal subsidies, but it's not clear how that would be doled out and paid for. Democrats have suggested using leftover money meant for a tax relief bill that failed this year, while Republicans have proposed tapping into some health care funds.
But the longer-term fixes are more difficult. One option is a state program that would help insurers cover high medical costs, hopefully controlling premiums long-term. But it's costly -- $590 million to roll back the rate increases slated for 2017, according to estimates from the Department of Commerce -- and the funding source is again a question.
And those potential fixes could get bogged down in other, familiar partisan battles. Republicans have renewed calls to abolish MNsure and move to the federal exchange, while Democrats say the state should consider allowing all Minnesota residents to pay for a spot in a public health care program. It could lower rates for those residents who make the switch, but the GOP views the idea as a government takeover and it could further harm the individual market.
Dayton agreed some state-level fixes will help, but he put the onus on Congress to make major changes that could drastically help in Minnesota.
Nor can the two sides agree on when to get to work.
Dayton has repeatedly said he won't consider calling a special session until after Election Day on Nov. 8, when voters will decide whether Republicans maintain control of the House and Democrats keep the Senate. Some Republicans have agreed that the politics make an early fall session impossible.
"Nov. 9," quipped Sen. Jim Abeler, R-Anoka. "Let's get the politics out of this."
But with uncertainty and big price hikes looming, Daudt said lawmakers can't afford to wait.
"We can't let Minnesotans sit and wait for a month while we campaign."
Correction (Oct. 17, 2016): An earlier version of this story incorrectly said when the governor's remarks were. This version has been updated.