Republican Rand Paul and Democrat Jack Conway squared off in their third debate on Thursday morning at a performing arts center in Paducah, and reports out of the region detail disagreements on just about every topic from health care to unions to term limits.

A national vs. local tug-of-war is playing out between these two candidates, with the 40-year old Democrat trying to drag the race into the state arena -- talking about Kentucky's major drug problem and the safety of coal miners in this coal-producing part of the country.

A tea party favorite, Paul has portrayed attorney general Conway as a big-spending, liberal trial lawyer who will be a rubber stamp for the Obama agenda, a formula used by a number of Republican newcomers in this cycle in states that went for McCain in 2008. Case in point, Paul has slammed Conway's support of the recent health care reform law and its $500 billion cut to Medicare as proof positive that the Democrat is an Obama yes man.

But it is a Paul stumble on Medicare that recently gave Conway an opening on the issue. Paul, a 49-year old ophthalmologist, had to alter an ad saying he "never" supported higher Medicare deductibles after Conway produced an ad using his opponent's own words against him from 2009, saying, "The real answer to (saving) Medicare would be a $2,000 deductible." Paul's altered spot said merely he "doesn't support higher Medicare deductibles."

But that was not enough. The issue is now front and center on Paul's website, as well, and the campaign released this ad showing an elderly Paul patient saying not only that she trusts her physician, that he "doesn't want higher Medicare deductibles for seniors like me," but that "career politician" Conway "jeopardizes" the program with his big spending.

From the outset of this campaign, the odds were overwhelmingly in Paul's favor, particularly with his high name recognition and sour national mood toward Democrats. But Conway has closed the gap and with undecided voters in recent polls taken into account, this race appears to be much more of a true toss-up, though most experts still give Paul a slight advantage.

A Fox News/Opinion Dynamics poll released Thursday shows Republicans maintaining a nine-point advantage over the majority party, making the closeness of the Kentucky race particularly notable, especially given that Conway has also been vastly outspent by his opponent.

The DSCC's executive director, J.B. Poersch, predicted earlier this week that this race would be the surprise of the night on Nov. 2, breaking for Conway in a nail-biter, an outcome his counterpart at the NRSC, Rob Jesmer, flatly refuted. The state has not sent a Democrat to Washington since 1992.

Conway spokesman John Collins cited the rampant prescription drug problem in the state as another area of fertile ground for his law and order candidate. Paul has questioned the pressing nature of the abuse, prompting a number of sheriffs to endorse Conway, though a handful still support Paul.

It's certainly no surprise that energy and coal are key issues in this campaign. An NRSC spokesman said Conway had flip flopped on cap and trade, citing articles in 2009 that say the Democrat supported the measure and that any problems could be worked out to prevent high energy costs.

Conway now says he opposes the measure, with his spokesman noting that "Conway even sued the EPA."

The NRSC also recently slammed Conway for a flip flop on whether or not to extend the Bush tax cuts. The Democrat said recently he would support extending all of the expiring tax cuts, but in this NRSC "Flip Flop Jack" ad, Republicans use video of Conway saying he would "favor letting expire probably the majority of the Bush tax cuts."

A host of mine tragedies has put the issue at the forefront of this campaign, as well, and statements by Paul early in the year heightened the profile of the issue. "We had a mining accident that was very tragic," Paul told Good Morning America in May. "Then we come in, and it's always someone's fault. Maybe sometimes accidents happen."

The unions and Conway pounced, saying Paul wanted to end federal regulation of mine safety. The Republican had to clarify his position in August saying he wanted more of a balance between the feds and state officials. But then a controversy erupted over federal mine inspectors, which prompted Paul, more of a state's rights Libertarian, in response to a questionnaire from The Associated Press, to insist that he would not only enforce federal safety rules, but he would also possibly add more mine inspectors.

Kentucky is home to some 18,000 miners and their families, comprising a key voting bloc in the state.

Both candidates have had political rock stars in the state making their case. Former President Bill Clinton, and not President Obama, stumped for Conway earlier this month; former Alaska Gov. Sarah Palin, a Fox contributor, campaigned for Paul.

And though Paul was not the first choice of Kentucky's senior senator, Mitch McConnell, very popular in the state, the senator has also been campaigning for the tea party maverick. The minority leader has helped Republicans across the threshold in the past, so it's possible he could do so once again.

Still, 19 days out, Collins, savoring his boss' underdog status, says the Conway campaign "is exactly where we want to be...We're on the offense. We're focused on Kentucky issues and things that are cutting through the national noise."

The campaign is set to announce third quarter numbers near $1 million, an amount Collins says will keep the campaign on the air until Nov. 2 (and they are poised to drop a new ad - topic tba), despite the 13 media markets spread across the Bluegrass state. It is not yet clear how much Paul has raised, though fundraising has not been an issue for the conservative.

The next debate, of the two that remain before the election, will occur Sunday night at the University of Louisville.