Rising premiums, expiring subsidies and Medicaid cuts have pushed health care back toward the center of the 2026 midterm campaigns. Along with that has come the return of an idea that many considered politically dormant: universal, government-financed health coverage. But while the debate is national, the most concrete proposals are coming from states, with Oregon furthest along [1].
The national picture
According to KFF Health News, Democratic members of Congress and candidates are preparing to use any midterm gains to expand coverage. Their proposals include boosting Affordable Care Act subsidies, reversing the Medicaid cuts in the 2025 budget reconciliation law and lowering the age at which people qualify for Medicare [1]. The 2025 law is projected to reduce federal Medicaid spending by about $911 billion over a decade, according to KFF, and the enhanced ACA premium subsidies expired at the end of 2025, pushing average marketplace premiums up again for 2027 [2][3]. Few experts expect a national single-payer system anytime soon. "There is no chance that 'Medicare for All' can be passed at the national level" in the short to medium term, said Jonathan Oberlander, a health policy professor at the University of North Carolina who has long studied the issue [1]. That assessment helps explain why advocates are focusing on states, where legislatures can act with smaller majorities and different politics.
Oregon's plan
In 2023, Oregon's legislature created a nine-member Universal Health Plan Governance Board to design a single-payer system for the state. The board must send its proposal to lawmakers by December 1, 2026 [1]. Legislators could then vote on it during the 2027 session or refer it to voters as a 2028 ballot measure. If the plan is approved, coverage would begin in 2032 [1]. The plan would cover medical, vision, dental and mental health care for every Oregon resident, with no premiums, deductibles or copayments [1]. Instead of paying premiums and out-of-pocket costs, residents and employers would pay new taxes, pooled into a single public fund that would pay doctors and hospitals. The board says total health spending in the state would stay roughly the same; the difference is who pays and how [1]. The board has offered examples. A 30-year-old earning $55,000 who buys a benchmark silver plan on the ACA marketplace pays about $5,478 a year in premiums today; under the plan, that person would pay about $2,331 in taxes, according to the board's estimates. A worker earning $55,000 with employer coverage, who now pays about $3,063 a year in premiums and out-of-pocket costs, could pay nothing [1]. The board estimates that 31% to 60% of Oregonians would pay nothing for their benefits, while more affluent residents could pay more. A payroll tax would apply to employers with payrolls over $500,000 [1]. Miriam McDonell, the board's director, describes the idea as everyone contributing based on their ability to pay rather than on how much care they use [1].
Payments to doctors and hospitals
Under the plan, payments to providers would fall somewhere between Medicare rates and private insurance rates. The board says total payments to physicians would stay about the same, but money would shift toward primary care [1]. Hospitals are wary. Becky Hultberg, president of the Hospital Association of Oregon, argued that the plan keeps a fragmented system while adding taxes and complexity and could destabilize hospitals [1].
The federal problem
There is a major obstacle. A true single-payer system would need to include people on Medicare and Medicaid, which requires federal waivers to redirect those federal dollars into a state fund. Backers do not expect the Trump administration to approve such waivers, so Oregon may start by covering only residents who are not on Medicare [1].
Other states
Oregon is not alone. In California, Democratic candidates for governor are debating how, not whether, to implement single-payer. New York lawmakers continue to debate the New York Health Act, and Washington state created a commission to design a universal plan [1]. History offers caution. Vermont's legislature voted for a universal plan in 2011, but Governor Peter Shumlin abandoned it in 2014, citing economic concerns. Voters in California in 1994, Oregon in 2002 and Colorado in 2016 rejected single-payer or similar ballot measures by large margins [1]. Massachusetts took a different path to near-universal coverage in 2006, using private insurance and subsidies, a model that later shaped the Affordable Care Act [1].
The opposition
Health insurers have not formally commented on Oregon's plan, but a single-payer system would effectively eliminate private health insurance in the state [1]. Chris Bond, a spokesperson for the insurance industry group AHIP, said Americans are generally satisfied with their coverage, pointing to more than 180 million people with employer coverage and 36 million in Medicare Advantage [1]. Wendell Potter, a former insurance industry executive who now supports reform, predicts opponents will warn of high taxes, lost choice and "socialized medicine" [1]. Supporters, meanwhile, believe momentum could build regionally. Richard Bruno of Physicians for a National Health Program argues that if West Coast states adopt single-payer, it could build support nationwide [1]. Rebecca Schoon, a Pacific University professor joining Oregon's board in January, summed up the challenge: deciding who wins and who loses under a new financing system is difficult, and explaining it to voters may be even harder [1].
What voters would weigh
If Oregon's plan reaches the ballot, voters would be asked to make a trade-off that is hard to judge in advance: giving up private premiums, deductibles and copays in exchange for new taxes. The board's estimates suggest many middle-income residents would come out ahead, while some higher earners and businesses would pay more [1]. Past ballot measures in other states failed in part because opponents focused on the tax increases, which are concrete, while the savings on premiums and out-of-pocket costs were harder for voters to picture [1].
Why it matters
The United States remains the only wealthy country without universal health coverage. The debate over how to change that has swung between incremental steps, like the ACA, and sweeping proposals, like Medicare for All. Oregon's plan will be the most detailed state-level single-payer blueprint in years. Whether its legislature and voters embrace it, and whether any federal administration would grant the waivers it needs, will be watched closely by both supporters and opponents across the country.
Sources
- 1. Markian Hawryluk, "Midterms Have Revived Universal Healthcare Debate. These States Are Ahead of Everyone," KFF Health News, October 2, 2026. https://kffhealthnews.org/elections/single-payer-universal-healthcare-debate-midterms-oregon-proposal/
- 2. Akash Pillai, Elizabeth Williams and Robin Rudowitz, "Medicaid and Upcoming State Budget Debates," KFF, January 23, 2026. https://www.kff.org/medicaid/medicaid-and-upcoming-state-budget-debates/
- 3. Matt McGough et al., "How Much and Why ACA Marketplace Premiums Are Going Up in 2027," KFF, August 3, 2026. https://www.kff.org/affordable-care-act/how-much-and-why-aca-marketplace-premiums-ar e-going-up-in-2027/ Information in this article is current as of October 10, 2026. Bracketed numbers refer to the sources listed above.