Slashed Subsidies and the Single-Payer Solution

Earlier this month, data from the Centers for Medicare and Medicaid Services revealed that enrollment in Obamacare has already dropped by 1.4 million this year after Congress failed to extend the enhanced subsidies at the center of last year’s government shutdown. In the coming months, this figure will likely climb further as enrollees whose plans were automatically renewed start to receive their first monthly bills, which are expected to double on average and in some cases jump by as much as 400%. Following years of progress in reducing the uninsured rate, millions are set to lose their health insurance, a reversal that will almost certainly increase the country’s already high toll of preventable deaths.

Most Americans understand that all of this could have been avoided had Republicans in Congress simply agreed to extend the enhanced subsidies; according to early polling, a majority will rightly blame Republicans for skyrocketing premiums heading into this year’s midterms. Yet as much as Republicans bear immediate responsibility, the current crisis also reflects the Democratic focus on preserving the status quo rather than confronting it.

Consider the subsidies themselves. First passed by Democrats in 2021, enhanced tax credits formed a pillar of President Joe Biden’s project to strengthen the Affordable Care Act and were developed in the aftermath of the 2020 election, when support for the more ambitious “Medicare for All” proposal had reached a high-water mark within the Democratic Party.

During the 2020 presidential primaries, Biden was one of the few Democratic candidates who adamantly opposed the single-payer reform then being championed by progressive candidates like Sen. Bernie Sanders and Sen. Elizabeth Warren. At one point, the former vice president even compared progressive calls for M4A to Republican calls to “scrap” the Affordable Care Act. Instead of overhauling the broken system, Biden suggested strengthening and “building on” Obamacare. In this context, the enhanced ACA subsidies must be understood as part of an overall effort by centrist Democrats to bolster the status quo and deflect demands for more radical policy solutions. 

Biden’s victory in 2020 killed the momentum behind single-payer reform. As Meagan Day recently summarized in Jacobin, the proposal migrated “almost overnight from the center of the primary debate to the margins of respectable Democratic Party discourse.” For the rest of the Biden years it looked as if the push for single-payer reform had hit a dead end, which continued into the 2024 election. Though once a co-sponsor of Sanders’ Medicare for All bill in the Senate, Democratic candidate Kamala Harris more or less renounced her past support for the proposal as part of a broader shift to the center. With the prospect of a second Trump term, few progressives complained.

Barely more than a year later, however, the Biden-led effort to put Obamacare on a more solid footing now seems to be unraveling completely. Indeed, the expiration of the enhanced subsidies exposes the failure of the Affordable Care Act to make health care universal or even affordable. 

One welcome consequence of the breakdown of Obamacare has been the resurgence of Medicare for All as a key issue in this year’s midterms. With the ACA’s flaws on full display, progressive candidates in several high-profile elections have placed Medicare for All at the center of their campaigns, much as Sanders did in 2016.

In response to this renewed push for M4A, opponents of single-payer have largely chosen to repeat their script from 2020: Adopt the banner of “universal health care” without actually backing proposals that would guarantee universal coverage. Most centrist counterproposals again focus on bolstering the ACA by extending enhanced subsidies and possibly introducing a public option to compete with private plans. Advocates of this approach have sold the public option as the “pragmatic” alternative to M4A that would guarantee near-universal coverage without upending the entire system. 

Some members of the consultant class that once opposed a public option are now backing it as a compromise to demonstrate the party’s commitment to reform while mostly leaving the current system intact. Speaking to Politico last month, several consultants insisted that a public option was more “politically palatable,” pointing to polling that shows a majority of Americans to be “satisfied” with their current insurance plans. 

“People don’t love their insurance corporation — they love their doctor,” said Abdul El-Sayed, a former Senate candidate in Michigan and author of “Medicare for All: A Citizen’s Guide.” “They don’t want the choice of which insurance corporation, but the choice of which provider. Our current system restricts which doctors we can see — and a public option wouldn’t solve that. Medicare for All protects the choices we actually want while guaranteeing us the security of knowing that we won’t lose our coverage if we get married, get divorced, turn 26 or have a job transition.” 

While acknowledging that a public option would be better than nothing, El-Sayed says it would fail to address the root problems with the current system, much like Obamacare and other half-measure policies like enhanced subsidies. “Where Medicare for All would end the arms race of billing and bureaucracy and push costs down, a public option would not.” It would also fail to “guarantee health care” or “address the power of major corporations in our bloated system,” he said. 

Perhaps the greatest shortcoming of all is that a public option would not “empower government to negotiate prices down on our behalf,” which is a huge problem if the goal is to control costs and make health care more affordable. As of 2023, the United States spends nearly double what comparable countries spend per capita on health care. The key difference is that almost all of these countries have single-payer or public-managed health care systems where governments can control costs by reducing administrative waste and negotiating prices with private providers and drug companies. 

On why Medicare for All is the policy solution that Democrats should rally behind going forward, El-Sayed explained that it is the only plan that would actually address the root causes of the current system’s mounting problems: “Medicare for All ensures that every American has health care coverage, with no premiums, co-pays or deductibles. It fixes the structural pitfalls of our profit-driven system to allow us to finally negotiate prices, lower costs and guarantee coverage for every American.”

Looking ahead to the midterms and the 2028 presidential election, supporters of Medicare for All have at least some cause for optimism. According to a recent poll from Data for Progress, public support for single-payer reform is currently near an all-time high, with roughly two-thirds of Americans and 8 in 10 Democrats backing the proposal. What’s more, that support is relatively stable even when respondents are provided with talking points against the plan — i.e., that it would raise taxes and give the government “too much control over health care.” In the past, negative talking points resulted in a significant drop-off in support, but in the latest survey nearly 6 in 10 continued to back the proposal anyway. Other polls have also found expanding support for universal health care and single-payer.

While these polls show the growing popular appeal of single-payer health care, public opinion has never been the main obstacle to reform. Throughout American history, attempts to overhaul the health care system have repeatedly run up against fierce opposition from powerful interests committed to preserving the status quo — interests that are, if anything, even more entrenched today. Out of all the proposed reforms, M4A is the greatest threat to the bottom line of private insurers, drug companies and the increasingly consolidated for-profit hospital chains. Naturally, these organizations will mobilize their considerable resources to derail a proposal as disruptive as M4A.

This formidable opposition is one of the reasons most establishment Democrats continue to back incrementalist reforms. While many supporters of a public option might concede, if pressed, that Medicare for All is the superior policy solution, they continue to argue that it could never realistically overcome the powerful vested interests that oppose it. Hillary Clinton said this much in 2016 when she griped that people with health emergencies “can’t wait for us to have a theoretical debate about some better idea that will never, ever come to pass.” 

This is defeatism disguised as pragmatism, but it also comes from a legitimate insight about the current state of democracy in America. The hard truth is that as long as corporate interests and billionaire donors dominate the political system, sweeping reforms like Medicare for All will indeed remain out of reach. “Establishing a guaranteed, single-payer health care system will require tackling the corrupting force of pharma money, insurance money and for-profit hospital money in our politics,” said El-Sayed. “We won’t achieve Medicare for All without taking on the Citizens United regime directly, banning corporate PAC influence and returning our politics to the hands of the people.”

As costs continue to rise, the sector’s biggest players only grow more powerful. As Helen Santoro and Joel Warner recently pointed out in The Lever, consumer spending on health care grew more than any other goods or services in the last quarter of 2025 and now accounts for nearly a fifth of the nation’s economic spending, up from just 5% in 1960. This is not only bad news for Americans currently struggling to afford care, but for the long-run possibility of fixing our broken system. “[A]s ever more of the country’s economy becomes tied to medical spending,” Santoro and Warner write, “it becomes increasingly difficult to challenge the corporations and reform the system that are consuming all of that money.” Eventually, they observe, the broken health care system could become “too big to heal.” 

This makes the drive for real reform all the more urgent. As Democrats gear up for the midterms, the party’s so-called pragmatists will no doubt argue that the party should adopt a more “moderate” course on health care reform that stands a realistic chance at becoming law. But this is the very approach that got us into the current mess in the first place. As the window of opportunity for transformative reform narrows, Democrats cannot afford to make the same mistake. 

“As candidates and elected officials, our job is to lead with clarity and confidence, and to make popular what is right,” El-Sayed said. “The choice is between patching up a system that costs more and delivers less, and finally guaranteeing health care as a right for every American.”