The most important Democratic health care debate is raging again

Analysis by Ronald Brownstein, CNNSun, April 12, 2026 at 10:00 AM UTC

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Protesters supporting “Medicare for All” hold a rally outside PhRMA headquarters in Washington, DC, in April 2019. - Win McNamee/Getty Images

Single payer is getting a second wind.

Replacing private health insurance with a universal coverage system funded and run solely by the federal government has long been a priority for the Democratic Party’s left wing. But the push for a single-payer plan, also known as Medicare for All, appeared to be on life support among Democrats after its leading advocates, Sens. Bernie Sanders and Elizabeth Warren, struggled to defend the idea during the party’s 2020 presidential primaries. Under President Joe Biden, a single-payer skeptic, Democrats focused instead on substantially expanding health coverage through the Affordable Care Act.

Now, though, a new generation of Democratic House, Senate and even gubernatorial candidates are resuscitating the single-payer idea. “I do think that there is a resurgence in interest in single payer,” says Joseph Geevarghese, executive director of Our Revolution, the organizing group founded by Sanders. “We’re in a moment where people are starting to feel the affordability crisis when it comes to health care in a very real way.”

Like Geevarghese, most Democratic operatives believe the idea’s revival reflects growing frustration over rising health care costs at a moment when voters are especially stressed about their overall cost of living. The paradox for single-payer advocates is that while higher health care costs make the idea more attractive in theory, they also make it more daunting in practice.

One principal reason the idea lost momentum in the 2020 Democratic presidential race was that its supporters could not convincingly explain how they would fund a complete government takeover of the health care system. Because of the nation’s rising health care spending, the 10-year bill for a federal single-payer plan would be nearly twice as high now as it was in 2020, according to a broad projection of possible costs shared exclusively with CNN by John Holahan, a fellow at the Urban Institute, a center-left think tank.

Single payer is receiving renewed attention among Democrats because “costs have risen and there are no obvious solutions on the horizon to deal with that,” said Larry Levitt, executive vice president for health policy at KFF, a think tank that focuses on health issues. “But the political liabilities of Medicare for All, like having the government exercise more control over health care and needing a big tax increase to pay for it, are all still there.”

Single payer sees a new surge among Democrats

Proposals to replace the existing health care system with a single-payer government-run system have sprouted in Democratic primaries this year. In Illinois, Lt. Gov. Juliana Stratton, who decisively won the Democratic Senate primary last month, forcefully touted the idea and attacked her opponents for taking contributions from health industry interests. In Maine, progressive first-time candidate Graham Platner has stressed his support for a single-payer system while opening a consistent lead in polls for the Democratic Senate nomination over Gov. Janet Mills.

The idea has resurfaced in a broad array of House races. Analilia Mejia, the community organizer who won a February primary for the Democratic nomination to succeed recently elected New Jersey Gov. Mikie Sherrill in Congress, is a strong single-payer advocate. And in a closely watched Illinois Democratic House primary, not just the candidates identified most with the party’s left flank but also Evanston Mayor Daniel Biss, the eventual winner, backed Medicare for All.

Similarly, in a closely contested New York City primary, Rep. Dan Goldman and both of his challengers have endorsed the idea. So has Bob Brooks, the former firefighter and president of the state firefighter union who is running against Republican Rep. Ryan Mackenzie for a northeast Pennsylvania seat. “You shouldn’t have to run into a burning building to get healthcare from your government or wait until you turn 65,” Brooks writes on his campaign website.

In California, younger primary challengers to Democratic Reps. Mike Thompson, Brad Sherman and Doris Matsui have all embraced single payer — as have Thompson and Sherman. Tom Steyer and Katie Porter, the two candidates competing most for support from the left in the state’s gubernatorial primary, each say they will pursue a state-level single-payer system.

Except for Brooks and Platner, all the candidates listed above are running in strongly Democratic states or districts. Generally, Democratic candidates in swing areas remain much more cautious about embracing single payer.

But the revival of single payer hasn’t been confined solely to deep blue places. Former Rep. Jasmine Crockett pushed it in the Texas Senate primary ultimately won by State Rep. James Talarico in March. The issue is also a major point of division in the Democratic primary to oppose Republican Rep. David Valadao, whose Central Valley district remains a toss-up even after California Democrats redrew the state’s Congressional maps. Randy Villegas, who is running as a populist insurgent, is a full-throated single-payer supporter, while state Assembly member Jasmeet Bains, a physician whom Democratic leaders prefer, talks instead about strengthening existing programs.

The primary for the Democratic Senate nomination in Michigan is probably the race where the single-payer debate has featured most prominently. Physician Abdul El-Sayed, a former director of the Detroit Health Department, has long been an unwavering single-payer advocate. But in the past few months, as one local reporter put it, “he has started adding an asterisk, saying that people should be able to obtain additional coverage from their union or employer.”

Democratic primary candidate for US Senate Abdul El-Sayed speaks at a campaign event at the University of Michigan in Ann Arbor, Michigan, on April 7. - Julia Demaree Nikhinson/AP

That position brings El-Sayed closer to his two rivals for the nomination, Rep. Haley Stevens, the most centrist candidate, and State Sen. Mallory McMorrow, who ideologically falls in between the other two. Neither Stevens nor McMorrow supports Medicare for All. Instead, each has argued for creating a “public option” to compete against private insurance companies by allowing Americans of all ages to buy into Medicare. Stevens believes a public option in the ACA is necessary “so that the insurance companies that are acting as a near-monopoly have competition,” says Arik Wolk, her campaign communications director.

That approach has become the preferred alternative for many Democrats resisting single payer. In Texas, Talarico promoted such a plan — what he called “Medicare for Y’all” — in his victory over Crockett. Several House candidates in competitive seats, such as Christina Bohannan in Iowa, have endorsed a public option, too.

This split between supporters of single-payer and a public option reprises the arguments from the 2020 Democratic presidential race. Both Biden and Pete Buttigieg, then the principal critics of single payer, said that instead they would create a public option — what Buttigieg memorably called “Medicare for all who want it.”

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The revival of interest in single payer from so many Democratic candidates this year virtually guarantees the party will face another version of that 2020 debate in its 2028 presidential primaries. “Just based on what we are seeing in the midterms,” says Geevarghese of Our Revolution, “there’s no doubt in my mind there will be a fight over single payer in ‘28.”

How single payer flatlined in 2020

The single-payer idea surged into the 2020 Democratic presidential race on a wave of momentum. After Sanders’ unexpectedly strong performance against Hillary Rodham Clinton in 2016, many Democrats concluded that his expansive progressivism was ascendant in the party. Four Democratic senators who sought the 2020 nomination ultimately endorsed his single-payer legislation: Warren, Kamala Harris, Cory Booker and Kirsten Gillibrand.

But single payer proved surprisingly vulnerable to counterattacks. Biden and Buttigieg led the charge against it, focusing their fire mostly against Warren, who looked strong in early polls. Once the single-payer advocates “were forced to defend their plan and explain how they were going to pay for it and how it would actually work,” the idea turned out “to have a glass jaw,” says Jim Kessler, executive vice president for policy at Third Way, a centrist Democratic organization. Harris memorably retreated from the idea.

And while Sanders openly embraced massive tax increases, Warren struggled to explain how she would pay for her plan. The critics, led by Biden and Buttigieg, also questioned shifting so much authority to control Americans’ health care to the federal government and forcing people who liked their employer-provided insurance to surrender it for the government alternative. After his early struggles, Biden’s pushback on single payer “was seen as an inflection point by our campaign,” said Andrew Bates, a top communications aide to Biden during the campaign and in the White House.

Pete Buttigieg, Elizabeth Warren and Joe Biden participate in a Democratic presidential primary debate in Manchester, New Hampshire, in February 2020. - Joe Raedle/Getty Images

Though Biden during the primaries embraced the public option as his alternative to single payer, the idea never got off the ground once he took office. Instead, congressional Democrats approved a major funding increase to expand coverage under the ACA. That effort succeeded in increasing the share of Americans with health insurance to a record 92% by 2024.

But costs continued to rise. Federal statistics showed that total national spending on health care by governments, businesses and individuals soared from $4.2 trillion in 2020 to $5.3 trillion in 2024. Even more pressingly, the average premium for employer-provided insurance rose a cumulative 26% from 2020 through 2025, according to KFF. That was even larger than the 21% increase from 2015 to 2020 that boosted single payer in the 2020 race.

Can Democrats find a post-Trump prescription for health care?

For 2026, most Democratic candidates begin their health care messaging with criticizing last year’s double-barreled assault from Trump and congressional Republicans on the ACA — the massive Medicaid cuts approved in the One Big Beautiful Bill Act and the choice to let the enhanced ACA subsidies expire last December. But across the party’s ideological spectrum, many Democrats argue that simply reversing Trump’s cuts is an insufficient health care agenda for 2026, much less 2028. “Yes, we should try to restore the health care tax credits and we should try to make Medicaid whole, but we should also try to go further,” Bates said.

What “further” means, though, remains a matter of intense dispute. Last week, the Center for American Progress, a leading liberal think tank, released a “Patients’ Bill of Rights” to try to immediately reduce health care costs through new regulatory restraints on insurers and hospitals. “The public is hungry for polices that will lower their costs now and the debate about health care system change — whether it’s single payer or a public option - are going to take a decade or so to happen,” said Neera Tanden, the CAP president and CEO and former chief domestic policy adviser for Biden.

Many Democratic candidates, though, want deeper changes in the system. Geoff Garin, a Democratic pollster who has extensively studied health care attitudes, said rising health care costs have made single payer more politically viable than in 2020. “There is a lot of anger about what many voters see as a badly broken health insurance system, more than when Medicare for All was last litigated in 2019 and 2020,” Garin said. “And for that reason, voters are more open to the idea of moving to a single-payer system, including some blue-collar Trump voters.”

But, Garin added, “the cost and tax implications” remain a big hurdle for single-payer proposals, “especially for voters who are used to having an employer pay for most of their insurance costs.”

Sen. Bernie Sanders announces that he will reintroduce the Medicare for All Act with Rep. Pramila Jayapal and Rep. Debbie Dingell, as they rally with members of National Nurses United on Capitol Hill on April 29, 2025. - Chip Somodevilla/Getty Images

Single-payer proposals very quickly run into sticker shock. Before the 2020 race, the Urban Institute forecast that Sanders’ plan would cost $34 trillion in federal spending over 10 years, an amount that at the time exceeded the projected 10-year spending on Social Security, Medicare and Medicaid combined. Today the figure would be even more daunting. Holahan told me that as a first cut, he projects a single-payer plan could cost nearly twice as much over the first decade as the Urban Institute estimated before 2020, including the impact of inflation.

Not all of that would be new costs, since the federal government already spends about $1.7 trillion annually on health care. And as Holahan pointed out, the economy is also larger now than it was in 2020, which would provide a broader tax base to support such a proposal. But a single-payer plan would require the federal government to assume responsibility for the two-thirds of national health care costs now covered by households, private businesses and state and local governments — a formidable responsibility that would require massive new sources of revenue.

For comparison, Holahan’s projected 10-year cost for single payer roughly equals the total amount of revenue the Congressional Budget Office forecasts the federal government currently will raise from the income and payroll tax combined over that same period.

These eye-popping prospective costs present an irresistible target for Republicans. Mike Marinella, a spokesperson for the National Republican Congressional Committee, said that while single-payer health care may be attractive in Democratic primaries, in competitive general elections it will be as vulnerable as other vanguard liberal policies have proven, including abolishing ICE and defunding the police. “You see all these candidates pushing each other further and further to the left … and they are going to have to answer for it in the general election,” he said.

A boy sits on the grass during a vigil in protest against potential cuts to Medicaid in Washington, DC, on July 23, 2025. - Umit Bektas/Reuters

One other obstacle for single-payer advocates is that the wrecking-ball tenure of Health and Human Services Secretary Robert F. Kennedy Jr. seems certain to compound fears of providing the federal government so much control over the health care system, including which procedures insurance will cover. “Trust in government health agencies is at its lowest level ever, so I think that would give people some pause at turning over the health insurance system to (them),” said Levitt of KFF.

Single payer has a solid core of Democratic support — 17 Democratic senators have endorsed Sanders’ single-payer health bill, as have more than half of House Democrats — and that is likely to grow in November. Under any realistic scenario, though, the advocates will remain well short of majority support in either the House or Senate, even if Democrats win back both chambers this year or in 2028.

For now, the most tangible impact of single payer’s revival will be to increase pressure on Democrats to pursue a health care agenda that extends well beyond reversing Trump’s cuts to the ACA — even if that increases the party’s vulnerability to Republican counterattacks.

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