The 2026 election could reshape healthcare

Americans are furious about the state of our healthcare system. 

A recent KFF poll found 60 percent of US adults worry about the cost of medical care — more than gasoline, food and groceries, or their rent or mortgage. One in three Americans say they worry every day or almost every day about their ability to afford healthcare, per a new survey from the Pew Research Center. There seems to be a growing appetite for reform, too: More than 65 percent of Americans say they support the government spending more tax dollars to lower healthcare costs. 

Democrats are trying to weaponize those frustrations against the Republicans who currently hold Congress and the White House. By a 2-to-1 margin, voters say they trust Democrats over Republicans on healthcare. That could mean single-payer Medicare-for-all or a new public insurance option or maybe something else. What all this energy leads to will depend on what happens in November. The candidates themselves are framing the stakes in those existential terms. 

“Medicare for all is where we need to go,” Abdul El-Sayed, the Democratic candidate in the Michigan Senate race whose support for the policy has been widely covered, said during an August interview with CNN. “And my hope is, both coming out of the 2026 midterms and then out of 2028, that we’re going to be on our way to a Senate majority to be able to get this done.”

Real change will have to wait for the 2028 presidential election and a new occupant in the White House. But this year’s midterms are still a make-or-break moment: The candidates who get elected this year, and how they shape the upcoming presidential primary debate and actions in Congress, will determine whether healthcare reform happens at all. 

If you’re fed up with the state of American healthcare, and you want to see a change, you should show up for the midterms on Tuesday, November 3.

Big midterm wins can beget big healthcare wins 

The classic pattern in American elections is that more voters go to the polls during presidential campaigns than during the midterm elections when only House and Senate seats are on the ballot. Turnout has started to tick up for the midterms in recent years, but it still trails behind presidential years. Midterms suffer from the perception that there’s not as much at stake if the White House is not on the line.

But that’s never been strictly true. 

Midterm elections are extraordinarily important in shaping the future of policymaking, even if the payoff is delayed. They help determine both the character of the Congress that could eventually pass a major bill after the next presidential election, and the kind of ideas and policies that are going to be prioritized.

“Voters should see 2026 and 2028 as the elections that will guide the next big change in our healthcare system,” said Natalie Davis, CEO and co-founder of the advocacy group United States of Care, in a statement to Vox. “These elections will be how voters’ demands are heard — and will tell us whether the next real window for change will come with serious reforms or missed opportunity.”

A walk through the recent history of healthcare reform should help make the stakes of the 2026 elections clear.

In 2006, the national mood looked similar to what we’re seeing today. A very unpopular Republican president was in office, and the country had soured on his agenda. George W. Bush’s foreign wars and his misguided attempt to overhaul Social Security gave Democrats an opportunity to win big in the 2006 midterms — and they did. Dems won more than 30 seats and secured a comfortable majority in the House. In the Senate, they won six seats and narrowly took control of that chamber too.

It was a resounding rejection of the Bush administration, and it set up the next decade of Democratic policymaking. At the highest level, the midterms gave energy to the progressive wing of the Democratic Party, united as they were around their opposition to the Iraq War, and that energy carried over to the presidential primary. Barack Obama defeated Hillary Clinton and won the presidency, springboarding off of the excitement that started with the 2006 elections.

Dems’ success in the midterms also helped put lowering healthcare costs at the forefront of the Democratic agenda. That encouraged both Obama and Clinton to develop detailed healthcare policy proposals during their primary campaigns and ultimately set the stage for the Democrats to pursue the Affordable Care Act once they had full control of the government in 2009.

And then there is the literal size of the congressional majorities that parties need to pass their agenda. Voters may not spend much time thinking about whip counts, but one or two elections in a midterm year can ultimately decide the fate of the next president’s agenda. 

Part of the reason Democrats were able to pass the ACA was that they built on their huge wins in 2006 with more wins in 2008 and held massive congressional majorities once Obama was sworn in. And once the debate over healthcare reform really got started, they needed every single vote. It was especially important in the Senate: Democrats had exactly 60 votes in 2009. That meant if all of them united together, they could pass filibuster-proof legislation — so long as nobody defected. That was only possible because in 2006 Mark Pryor won a Senate seat in Arkansas, Sherrod Brown triumphed in a Senate race in Ohio, and Jon Tester beat an incumbent Republican in Montana. 

Without those wins in 2006, the Democratic legislative agenda in 2009 would probably have looked different. They might’ve had to pursue a more limited healthcare reform plan; maybe the ACA wouldn’t have passed at all.

What kind of Democrats will be on the rise in 2028?

The 2006 midterms both created the opportunity for the ACA — and set the limits on what the legislation could actually achieve. Democrats had that 60-seat Senate majority, but within it were many more moderate members. Policies like the public option (which would have authorized the government to create its own health insurance plan to sell alongside private insurance) couldn’t get sufficient support. That is the dilemma of policymaking: You need those swing-seat members to win, which often means tacking to the center, but you also can’t pass anything they won’t get on board with. 

Nevertheless, that is a good kind of political problem to have, one which Democrats would be thrilled to face in January 2029. All of which brings us to 2026. What are we going to do now?

It all starts with the vote count. Most projections expect the Democrats to win between 10 and 20 House seats. But the difference between 10 and 20 could be substantial. The cushier the majority, the further you can push the policy agenda. More than 30 House Democrats actually voted against the ACA, but they could still narrowly pass the bill because of the huge majority that they had started building in 2006. 

If you live in one of the districts — like Arizona’s Sixth or Colorado’s Eighth or Florida’s 22nd, to name just a couple of the 21 toss-up races identified by the Cook Political Report this year — that forecasters say is competitive this year, you could have an outsized say in what the future of policymaking looks like. But even in safe districts, you should vote: Elections are the most reliable way we have to gauge public opinion, and strong victories for the candidates who prioritize healthcare send a message.

The same goes for the Senate. If Democrats sweep all of the competitive races, they could have up to 55 seats in the Senate in 2027 — with a chance to build on it in 2028. If you are a voter in Kansas, Michigan, Ohio, Texas, Alaska, Maine, New Hampshire, or Iowa, your ballot carries extra weight for the next steps in US healthcare reform. If the Democrats can reach 60 votes again in 2029, they would have much more flexibility about what to pass. Even if they fall short of that magic number, the more of a cushion they have above 50, the more likely that their Senate leaders can find support for altering Senate rules for the filibuster and get an ambitious bill approved.

The results of this year’s midterms will also set the terms of the debate among Democrats. We are likely to see “show” bills advanced by Dems next year that may have no chance of being signed by President Donald Trump, but that will give us a sense of what kind of policies the party wants to pursue and how much support there is for them. Believe it or not, the first Medicare prescription drug negotiations bill passed the House in 2007 after Democrats’ big wins in 2006 — even though the policy didn’t become law for another 15 years. The broader public may not pay much attention to this kind of doomed-to-fail legislation, but it is often a window into the future.

“One challenge for Democrats is finding the next big health care idea beyond the Affordable Care Act that will resonate with voters and respond to their affordability concerns,” said Larry Levitt, executive vice president for health policy at KFF. “One big difference between now and 2006 is that back then there was already a lot of coalescing around ideas that ultimately led to the ACA. All the major Democratic candidates for president in 2008 supported something like that. I’m not sure that’s true now, at least not yet.”

Democrats are already aligning on a wide range of healthcare ideas, from reviving the public option to free primary care to the full-blown Medicare-for-all supported by progressive candidates, some of whom are in competitive elections. If El-Sayed wins the Senate race in Michigan, for example, that could supercharge a debate around Medicare-for-all. It could also provide momentum to any progressives who run for president — Alexandria Ocasio-Cortez, to name one obvious example — and decide to make Medicare-for-all a pillar of their platform.

But if El-Sayed and other progressives were to fall short, that could make Democrats more timid about being ambitious in the 2028 campaign and afterward. Still, he’s far from the only candidate in a crucial race to put their support behind Medicare-for-all. There is Randy Villegas in an important California House race. Troy Jackson has bet on it as part of his bid to topple Sen. Susan Collins in Maine. All of these races will send a signal to the party about what the public wants and is willing to turn out for.

In some ways, winning elections is the easy part. Legislating is hard, and any eventual healthcare law will surely involve compromises and unexpected surprises. Who knows what will be happening in the world in 2029? 

“The bottom line is: 2026 is a healthcare election,” the leaders of the advocacy group Protect Our Care wrote in a campaign memo this month. “After November, it’s up to Democrats to keep up the fight to deliver relief to families and make healthcare affordable and accessible for every American.”