Healthcare in the US: Costs, Coverage and the Debate

This deep dive reflects laws, regulations and polling available as of Oct. 31, 2026. Open enrollment for 2027 marketplace plans begins Nov. 1, and several figures here will change after the Nov. 3 midterms and as new data is released.

Overview

The United States spends more on health care than any other country, yet it is the only wealthy democracy without a system that covers everyone. National health spending reached $5.3 trillion in 2024, or about $15,474 per person and 18% of the economy, according to federal health data. Most Americans get coverage through an employer, while others rely on Medicare (for people 65 and older), Medicaid (for people with low incomes), or plans bought on the Affordable Care Act (ACA) marketplaces.

About 8% of Americans were uninsured in 2025, near the lowest level on record, based on a CDC national survey. That figure is widely expected to rise. Two policy changes are driving the debate in 2026: the expiration of enhanced ACA subsidies at the end of 2025 and the Medicaid changes in the 2025 budget law, which the Congressional Budget Office estimated could leave about 10 million more people uninsured over a decade.

This page does not take a side. It sets out how each side frames the issue, where policy stands, what has changed recently, and which questions remain open.

The Competing Frames

The coverage-guarantee frame holds that health care is a basic need and that government should make sure everyone can get it. Supporters point to medical debt, people who skip care because of cost, and the gap between US spending and health outcomes. They tend to favor expanding public programs, subsidizing private coverage, and having government negotiate prices.

The market-and-choice frame holds that competition, consumer choice and lower regulation will bring prices down more effectively than government programs. Supporters argue that subsidies paid to insurers hide the real cost of care, that Medicaid has grown beyond its original purpose, and that public programs carry fraud and improper payments. They tend to favor health savings accounts, price transparency, and giving money to patients rather than insurers.

Both sides now agree on one point: costs are too high. Where they differ is on who should control spending, and on whether more government involvement is the cause of the problem or the solution to it.

The Policy Spectrum

US proposals fall roughly along this range, from most to least government involvement:

Single-payer (“Medicare for All”): one public plan covering everyone, largely replacing private insurance.
A public option: a government plan offered alongside private plans, which supporters say would add competition.
An expanded ACA: the current mixed system with larger subsidies and Medicaid expansion in every state.
The ACA as it stands: employer coverage, Medicare, Medicaid and marketplace plans with standard subsidies.
Market-based reform: redirecting subsidies into accounts that patients control, allowing cheaper plans with fewer required benefits, and giving states more control over Medicaid through block grants or per-person caps.

Few national politicians now openly push for full repeal of the ACA or for immediate single-payer. Most of the live fights take place in the middle of this range.

The State Map

States shape health coverage mainly through Medicaid. The ACA offered states extra federal money to expand Medicaid to adults earning up to 138% of the poverty line, and after a 2012 Supreme Court ruling the choice became optional. KFF’s tracker counts 41 states, including Washington, D.C., that have adopted the expansion and 10 that have not, most of them in the South. Texas, Florida and Georgia, three of the largest non-expansion states, also have some of the highest uninsured rates. Georgia offers a limited form of coverage through Georgia Pathways, the only Medicaid program in the country that already requires work or other qualifying activities. It has enrolled far fewer people than state officials originally projected, and both supporters and critics of work requirements cite it as evidence for their position.

The map could shift in the other direction. Several expansion states have “trigger laws” that would end or reconsider expansion if federal funding falls, and the 2025 budget law reduces some of the financial tools states use to pay their share. States also differ in whether they run their own ACA marketplaces, add state subsidies on top of federal ones, or require insurers to cover specific treatments.

Where the Public Stands

Cost is the dominant concern. A KFF poll in April 2026 found that about 64% of adults worry about affording health care, making it voters’ top economic worry heading into the midterms. Among independents, half said they trusted neither party on health costs.

On the role of government, a Pew Research Center survey in November 2025 found that 66% of adults say the federal government is responsible for making sure everyone has coverage. That view is shared by 90% of Democrats and 41% of Republicans. Support for a single national government plan was much lower, at 35% overall, which suggests that agreement on the goal does not translate into agreement on the method.

Recent Changes

ACA subsidies expired. Enhanced premium tax credits, first passed in 2021 and extended in 2022, ended on Dec. 31, 2025, after a standoff that contributed to a long government shutdown. The House passed a three-year extension in January 2026 by a vote of 230-196, with 17 Republicans joining all Democrats after a discharge petition forced the vote. The Senate had already rejected a three-year extension, and bipartisan talks on a narrower two-year deal stalled in early 2026. Marketplace sign-ups for 2026 fell from 24.2 million to 23.1 million, the sharpest drop since the marketplaces opened. The administration says much of the decline reflects fewer ineligible or fraudulent enrollees, while critics say eligible people are dropping coverage because of cost. This article could not locate an independent estimate that settles how much each explanation accounts for.

Premiums keep rising. Insurers proposed a median increase of about 15% for 2027 plans, following a median 20% increase in 2026, according to a KFF analysis of insurer filings. Final rates are set state by state.

Medicaid work requirements. The 2025 budget law requires many adults covered through Medicaid expansion to show 80 hours a month of work, schooling or volunteering, with exemptions for groups such as caregivers and people with disabilities. Federal regulators issued an interim rule in June 2026, and the requirements take effect by January 2027. Supporters say work requirements encourage employment and protect the program for those most in need. Critics point to Arkansas’s 2018 experiment, in which many people lost coverage over paperwork rather than unemployment.

Drug prices. Medicare’s second round of negotiated prices, covering 15 drugs including the GLP-1 medications Ozempic and Wegovy, takes effect in January 2027. Federal officials estimate the new prices would cut net Medicare spending on them by 44% compared with 2024. Separately, the Trump administration has signed voluntary “most favored nation” deals with drugmakers to align some US prices with those paid abroad. How the two approaches interact is not yet clear.

Active Debates

Subsidies or direct payments. In January 2026, President Trump outlined a plan to stop routing subsidies through insurers and instead deposit money into health savings accounts that patients control. Supporters say this gives people more control and cuts out insurer markups. Democrats call it an inadequate replacement for the expired tax credits. As of this writing, no bill based on the plan has advanced in Congress.

The future of Medicaid. The central question is whether the program should continue as an open-ended entitlement with shared federal funding, or move toward fixed federal contributions that give states more flexibility and less money. Both sides expect the coverage effects of the 2025 law to become an issue in 2027 and 2028 as the provisions phase in.

Who controls prices. Proposals to cap prices, expand Medicare negotiation, or tie US drug prices to other countries draw support from some politicians in both parties. Drugmakers argue these steps would reduce investment in new treatments. The Congressional Budget Office has projected a modest reduction in new drugs from Medicare negotiation, a smaller effect than the industry predicts.

Public health and trust. Health policy debates in 2026 also include vaccine guidance, leadership turnover at federal health agencies, and the CDC’s direction under new leadership. These topics overlap with healthcare but fall largely outside the scope of this page.

View from Outside the US

Most wealthy countries guarantee coverage through one of several models: a national health service, as in Britain; social insurance funded through employers and workers, as in Germany, France and Japan; or tightly regulated private insurance that everyone must buy, as in the Netherlands and Switzerland. The Commonwealth Fund’s 2024 comparison of ten high-income countries ranked the US last on overall health-system performance despite its far higher spending, though the US scored better on some measures of care delivery. Critics of such rankings note that they weigh access and equity heavily and that other systems face their own waiting lists and funding strains. For a fuller comparison, see PoliTalking’s global guide, Healthcare Systems: The Global Picture.

Discussion Questions

How do people in your country usually get health insurance or health care?
Should health care be treated as a right or as a service people buy?
Why do you think the US spends so much more on health care than other wealthy countries?
Is it better to give subsidy money to insurers or directly to patients?
Should people be required to work to receive government health coverage?
Why might many Americans agree that government should ensure coverage but disagree on how?
Should states decide whether to expand Medicaid, or should there be one national rule?
What are the advantages and disadvantages of government negotiating drug prices?
Why has health care become such a divisive political issue in the US?
Imagine you are designing a health system from scratch. What would it look like?

Healthcare in the US: Where Things Stand