When pollsters asked Missouri voters to name the most important issues last month, the economy was first, with health care right behind it.

In fact, the two issues are one and the same.

Skyrocketing health costs and the lack of affordable health insurance are leading contributors to the economic insecurity that plagues many middle-class families.

That makes the health care proposals of Republican Kenny Hulshof and Democrat Jay Nixon, both of whom want to be governor, of crucial importance. A close analysis of both illustrates stark differences in the candidates’ philosophies:

• Mr. Nixon would restore insurance coverage to tens of thousands of Missourians who lost it as a result of Gov. Matt Blunt’s Medicaid cuts in 2005. He believes government has a responsibility to provide coverage to people who, because of ill health and poverty, never have been well-served by commercial market forces.

• Mr. Hulshof, in contrast, would create what he describes as a “new marketplace” in which people could buy coverage for themselves and their families. Those who couldn’t afford to buy insurance would receive policies paid for by the state. Although his plan also relies on government to pay, Mr. Hulshof would use private insurance to cover people those companies typically have worked hard to avoid insuring.

There are two other important differences between the candidates’ proposals: what insurance actually would cover and how much it would cost state taxpayers.

What would it cover?

Mr. Nixon would restore comprehensive Medicaid coverage to thousands of working poor families. Under Medicaid, anyone who meets income qualifications is entitled to receive the medical care they need. That approach has proven to be better at controlling chronic illnesses.

Mr. Nixon says that Missourians who get health coverage through their jobs — the overwhelming majority of state residents — also would benefit from his plan. Extending coverage to some of the uninsured would drive down costs for everyone else, he maintains.

That’s because it would reduce the so-called cost-shift: the higher prices hospitals and doctors charge privately insured patients to make up the costs of caring for the uninsured.

Health economists generally accept that the cost shift adds to insurance premiums, but they disagree over how large a factor it is.

Mr. Hulshof would rely on Health Savings Accounts, plans with high deductibles. These policies don’t start paying for care until after the insured person has paid substantial amounts out of pocket.

Under Mr. Hulshof’s plan, participants would be expected to pay 5 percent of their incomes as their share of the plan’s expenses. They would receive up to $500 per year in preventive care.

People in ill health and with few financial resources, a common combination among low-income working people, often find it hard to come up with cash for out-of-pocket health expenses. Faced with such circumstances, they often put off getting care until their condition is more advanced and difficult — not to mention more expensive — to treat.

What would it cost?

The theory behind HSAs is that health costs are rising rapidly because comprehensive insurance coverage leads people to get medical care they don’t really need. Making them pay a greater share of the costs would cut down on unnecessary care and make people shop for better prices.

But most health care economists say that other factors play a much bigger role in driving up health spending. Chief among them is the rapid embrace of new technologies that often are only marginally better than what they replace — but are much more expensive.

Neither candidate’s approach matters very much if there’s no way to pay for it. The candidates make this point themselves.

Mr. Hulshof, for example, repeatedly has said that his opponent’s plan is too expensive. He charged during a debate last week that it would have cost state taxpayers $1.6 billion this year if Gov. Matt Blunt’s Medicaid cuts had not been made. Mr. Nixon, of course, wants to reverse those cuts.

But the number Mr. Hulshof used is inflated and misleading because it combines the federal and state shares of Medicaid costs. In fact, the federal government pays more than 60 percent of the cost of Medicaid. When Missouri cut more than 100,000 people from those programs, it also lost hundreds of millions of dollars in federal money.

Federal funds come from taxpayers, too. But Missourians didn’t benefit when the Blunt administration turned down those federal funds. Instead, the money went to other states.

Mr. Nixon says the real cost of restoring Medicaid would be $265 million in state tax revenue, most of which would come from so-called provider taxes, not those paid by ordinary taxpayers. That $265 million in state funds would generate $431 million in federal funds — money that would be spent providing health care and creating, according to Mr. Nixon, an estimated 11,500 new jobs.

Mr. Hulshof says his plan would cost state taxpayers much less — just $50 million in direct costs and another $10 million to $20 million in tax incentives. But those figures come with a big caveat.

Mr. Hulshof proposes to take as much as $1.8 billion from a private organization: the Missouri Foundation For Health. It’s questionable whether that would be legal. If nothing else, any state attempt to take the foundation’s assets would provoke an extended legal fight.

The Missouri Foundation For Health was created after Blue Cross/Blue Shield of Missouri, a nonprofit corporation, was transformed into a for-profit company called Right Choice. At the time, Attorney General Nixon said that the change amounted to an illegal transfer of funds that had been accumulated by a nonprofit entity. He sued to recover the money and won, and, in 2000, the Missouri Foundation for Health was created.

The Missouri Foundation is not unique — similar stories lie behind the Health Care Foundation of Greater Kansas City, the Deaconess Foundation and the Incarnate Word Foundation.

It underwrites the cost of health programs all across Missouri to the tune of millions of dollars every year. It pays to provide cervical cancer vaccine to low-income and uninsured women. It pays for dental, primary care, tobacco-education and health-literacy programs. Its grants pay for invaluable professional research on health matters used to guide policymakers’ decisions.

Mr. Hulshof’s health care plan is entirely dependent on getting hold of the Missouri Foundation’s assets. Absent any clear legal authority to do so — and having firmly pledged not to raise taxes — Mr. Hulshof’s health care plan probably would be dead on arrival.

What’s realistic?

Even under optimal conditions, neither candidate’s proposal could be implemented immediately. Both would require approval from — and almost certainly would be altered by — the Legislature.

Even so, both proposals provide insight into how the candidates would approach the job of governing. By that standard, Mr. Hulshof is proposing a fig leaf of a plan. He claims that it would cover more people, but there is scant evidence of that. Even if it did, the extent of the coverage would be limited.

Mr. Hulshof says his plan would cost less. But little of the spending he outlines would qualify for matching federal funds, which are the most efficient way to get the most bang for state taxpayers’ health care bucks. And his plan relies on a source of funding that probably will not be available.

Mr. Nixon’s plan relies on an older model of providing coverage. But that system has the advantage of having operated in the real world, where, over the years, it has done a better job of holding down health spending than private health insurance plans.