This article by Stephanie Armour first appeared in KFF Health News, republished with permission.

In the run-up to the 2020 election, all 20 Democratic presidential candidates promised voters they’d pursue bold changes to health care, such as a government-run insurance plan or expanding Medicare to cover every American.

Fast-forward to the congressional stalemate that has closed the federal government for more than a month. Democrats, entrenched on one side of the legislative battle, staked their political future on merely preserving parts of the Affordable Care Act — a far cry from the systemic health policy changes that party members once described as crucial for tackling the high price of care.

Democrats succeeded in focusing national attention on rising health insurance costs, vowing to hold up funding for the federal government until a deal could be made to extend the more generous tax subsidies that have cut premiums for Obamacare plans. Their doggedness could help them win votes in midterm elections next year.

But health care prices are rocketing, costly high-deductible plans are proliferating, and 4 in 10 adults have some form of health care debt. As health costs reach a crisis point, a yawning gulf exists between voters’ desire for more aggressive action and the political urgency in Washington for sweeping change.

“There isn’t a lot of eagerness among politicians,” said Jonathan Gruber, an economist who played a key role in drafting the ACA. “Why aren’t they being more bold? Probably scars from the ACA fights. But health care is a winning issue. The truth is we need universal coverage and price regulation.”

Voters rank lowering health care costs as a top priority, above housing, jobs, immigration, and crime, according to a September poll by Hart Research Associates for Families USA, a consumer health advocacy group.

And costs are climbing. Premiums for job-based health insurance rose 6% in 2025 to an average of $26,993 a year for family coverage, according to an annual survey of employers released Oct. 22 by KFF, a health information nonprofit that includes KFF Health News. For all the attention given to grocery, gas, and energy prices, health premiums and deductibles in recent years have risen faster than overall inflation and wages.

Democratic Headwinds

The appetite for big, bold ideas to drive down such high costs has waned in part because Democrats lack political leverage, according to economists, political strategists, and health care advocates. They’ve also been burned before for backing significant changes.

After the ACA was enacted in 2010, for example, a backlash over the law — and its mandate that most everyone have insurance — helped Republicans win the House and gain seats in the Senate. In 2016, Democratic presidential candidate Hillary Clinton backed the public option, a proposed government-run plan that would compete against commercial insurance. She lost to Donald Trump.

Democrats are also outnumbered in Congress. Sweeping changes to health care, such as the creation of Medicaid and Medicare and passage of the ACA, historically have occurred when one party has controlled both Congress and the presidency. Republicans currently have all that muscle. So for now, Democrats are fighting to preserve the status quo while portraying Republicans as a threat to Americans’ insurance coverage.

If the ACA subsidies aren’t extended, many of the roughly 24 million people who buy coverage on the health law’s marketplaces will see their premiums more than double next year, according to KFF. A KFF Health Tracking Poll released Nov. 6 found that three-quarters of the public supported extending them.

“There’s no doubt people believe the current system needs reform,” said Jesse Ferguson, a Democratic strategist. “Protecting people from premium increases is part of that. You don’t win the future by losing the present.”

Even bipartisan legislative proposals aimed at lowering health costs have fizzled in an environment defined by political threats and partisan social media attacks.

Bills that would have improved health care price transparency and reined in companies that manage prescription drug benefits gained traction in late 2024 as part of a spending package. Then Elon Musk, who was serving as a senior adviser to President-elect Trump, took to his social media platform, X, to rally opposition, deriding the budget bill for what he asserted was excessive government spending.

GOP leaders dropped the health provisions, prompting Sen. Patty Murray (D-Wash.) to say on X that Musk “tweeted to kill” the bipartisan health policies that Congress had hammered out.

But Democrats’ focus on health care has cut both ways. Their messaging amid efforts to save the ACA from repeal and to preserve the law’s protections for those with preexisting conditions helped the party take back the House in the 2018 midterm elections. “I still have PTSD from the experience,” Republican Mike Johnson, now the House speaker, said recently.

And voters want relief. Six in 10 Americans are extremely or very worried about health care costs rising next year, according to an Associated Press-NORC Center for Public Affairs Research poll.

Hagen Wenzek, 56, is among them. The chief executive of GI Digital, a high-tech startup, felt a pain in his calf in late summer and asked OpenAI’s ChatGPT what it might be. It suggested he could have deep-vein thrombosis, or a blood clot. He went to the emergency room and obtained an ultrasound that confirmed the diagnosis, so doctors monitored him and gave him blood thinners.

His insurance was billed $7,422, and Wenzek got a bill for $890. The average cost of an ultrasound is about $400 without insurance, according to GoodRx, a digital health platform.

“The hospital is making thousands for a procedure that costs $500. It’s kind of ridiculous,” said Wenzek, of Sleepy Hollow, New York. “I have a $40 copay just to go see a doctor for anything, and I’m on a startup budget.”

‘Defending the Status Quo’

The lack of bolder ideas to tackle spiraling costs could also work against Democrats, some critics say. Comedian and political commentator Jon Stewart, in an episode of his podcast in October, accused Democrats of committing “malpractice” by not presenting ideas to fix what people hate about the health care system. Instead, he said, they’re shutting the government down to protect a system that voters already believe is failing them.

“Once again, the Democrats are in a position of defending the status quo of policies that most people in the United States think suck,” he said. “Meanwhile, on the same day, Trump rolls out TrumpRx. Hey, I’ll just threaten Pfizer with 100% tariffs and then just open up a prescription drug outside of the middle managers and sell directly to the public at a discount.”

TrumpRx, which is intended to help patients find lower-priced drugs, and pledges by Big Pharma to lower drug prices could help the GOP with voters, though Democrats are also hammering Republicans over the One Big Beautiful Bill Act, the bill the president signed into law in July that reduces Medicaid spending by about $1 trillion over a decade.

Republicans are promising fixes, using the shutdown to try to leverage voter frustration. Vice President JD Vance said on Newsmax in October that “we do have a plan, actually,” in reference to a question about health care reform. (Trump has promised repeatedly that he would produce a plan to replace the ACA but never has.)

Senate Majority Leader John Thune said on CNBC in October that Trump wants to overhaul the ACA and “give people health insurance that is higher-quality and more affordable.”

The White House did not respond to an email requesting comment from Vance.

“It’s not that Democrats are focusing on tax credits to the exclusion of bigger, bolder reforms,” said Anthony Wright, executive director of Families USA. “If you can get the conversation on health care, if we can prevent premiums from spiking, then we can focus on why health care costs so darn much to begin with.”

But some Democrats say voters are hurting and want bigger and bolder ideas now. Earlier this year, Minnesota Gov. Tim Walz said on the podcast “Fast Politics” that the party needs to offer more on health care in the next election.

“I’ll tell you what people are going to expect,” he said. “They’re not going to expect us to tinker around the edge with the ACA. They’re going to expect universal health care.”

For now, at least, there are more innovative ideas in states. Oregon has established a governing board to set up a single-payer health system in which the state would take on health care financing — eliminating private insurance, premiums, and all deductibles for all residents as soon as 2027. The question is whether it will work. Vermont abandoned a similar effort in 2014.

“With the political environment we’re in, there isn’t currently an appetite for big reform, but we know it needs to happen,” said Mona Shah, the senior director of policy and strategy at Community Catalyst, a health advocacy group. “Across party lines, people want government intervention in health care and people want universal coverage. The pain point that people are feeling, the public sentiment is where we were at before the ACA.”KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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This article first appeared on KFF Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.