Americans are furious about the state of our healthcare system. 

A recent KFF poll found 60 percent of US adults worry about the cost of medical care — more than gasoline, food and groceries, or their rent or mortgage. One in three Americans say they worry every day or almost every day about their ability to afford healthcare, per a new survey from the Pew Research Center. There seems to be a growing appetite for reform, too: More than 65 percent of Americans say they support the government spending more tax dollars to lower healthcare costs. 

Democrats are trying to weaponize those frustrations against the Republicans who currently hold Congress and the White House. By a 2-to-1 margin, voters say they trust Democrats over Republicans on healthcare. That could mean single-payer Medicare-for-all or a new public insurance option or maybe something else. What all this energy leads to will depend on what happens in November. The candidates themselves are framing the stakes in those existential terms. 

“Medicare for all is where we need to go,” Abdul El-Sayed, the Democratic candidate in the Michigan Senate race whose support for the policy has been widely covered, said during an August interview with CNN. “And my hope is, both coming out of the 2026 midterms and then out of 2028, that we’re going to be on our way to a Senate majority to be able to get this done.”

Real change will have to wait for the 2028 presidential election and a new occupant in the White House. But this year’s midterms are still a make-or-break moment: The candidates who get elected this year, and how they shape the upcoming presidential primary debate and actions in Congress, will determine whether healthcare reform happens at all. 

If you’re fed up with the state of American healthcare, and you want to see a change, you should show up for the midterms on Tuesday, November 3.

Big midterm wins can beget big healthcare wins 

The classic pattern in American elections is that more voters go to the polls during presidential campaigns than during the midterm elections when only House and Senate seats are on the ballot. Turnout has started to tick up for the midterms in recent years, but it still trails behind presidential years. Midterms suffer from the perception that there’s not as much at stake if the White House is not on the line.

But that’s never been strictly true. 

Midterm elections are extraordinarily important in shaping the future of policymaking, even if the payoff is delayed. They help determine both the character of the Congress that could eventually pass a major bill after the next presidential election, and the kind of ideas and policies that are going to be prioritized.

“Voters should see 2026 and 2028 as the elections that will guide the next big change in our healthcare system,” said Natalie Davis, CEO and co-founder of the advocacy group United States of Care, in a statement to Vox. “These elections will be how voters’ demands are heard — and will tell us whether the next real window for change will come with serious reforms or missed opportunity.”

A walk through the recent history of healthcare reform should help make the stakes of the 2026 elections clear.

In 2006, the national mood looked similar to what we’re seeing today. A very unpopular Republican president was in office, and the country had soured on his agenda. George W. Bush’s foreign wars and his misguided attempt to overhaul Social Security gave Democrats an opportunity to win big in the 2006 midterms — and they did. Dems won more than 30 seats and secured a comfortable majority in the House. In the Senate, they won six seats and narrowly took control of that chamber too.

It was a resounding rejection of the Bush administration, and it set up the next decade of Democratic policymaking. At the highest level, the midterms gave energy to the progressive wing of the Democratic Party, united as they were around their opposition to the Iraq War, and that energy carried over to the presidential primary. Barack Obama defeated Hillary Clinton and won the presidency, springboarding off of the excitement that started with the 2006 elections.

Dems’ success in the midterms also helped put lowering healthcare costs at the forefront of the Democratic agenda. That encouraged both Obama and Clinton to develop detailed healthcare policy proposals during their primary campaigns and ultimately set the stage for the Democrats to pursue the Affordable Care Act once they had full control of the government in 2009.

And then there is the literal size of the congressional majorities that parties need to pass their agenda. Voters may not spend much time thinking about whip counts, but one or two elections in a midterm year can ultimately decide the fate of the next president’s agenda. 

Part of the reason Democrats were able to pass the ACA was that they built on their huge wins in 2006 with more wins in 2008 and held massive congressional majorities once Obama was sworn in. And once the debate over healthcare reform really got started, they needed every single vote. It was especially important in the Senate: Democrats had exactly 60 votes in 2009. That meant if all of them united together, they could pass filibuster-proof legislation — so long as nobody defected. That was only possible because in 2006 Mark Pryor won a Senate seat in Arkansas, Sherrod Brown triumphed in a Senate race in Ohio, and Jon Tester beat an incumbent Republican in Montana. 

Without those wins in 2006, the Democratic legislative agenda in 2009 would probably have looked different. They might’ve had to pursue a more limited healthcare reform plan; maybe the ACA wouldn’t have passed at all.

What kind of Democrats will be on the rise in 2028?

The 2006 midterms both created the opportunity for the ACA — and set the limits on what the legislation could actually achieve. Democrats had that 60-seat Senate majority, but within it were many more moderate members. Policies like the public option (which would have authorized the government to create its own health insurance plan to sell alongside private insurance) couldn’t get sufficient support. That is the dilemma of policymaking: You need those swing-seat members to win, which often means tacking to the center, but you also can’t pass anything they won’t get on board with. 

Nevertheless, that is a good kind of political problem to have, one which Democrats would be thrilled to face in January 2029. All of which brings us to 2026. What are we going to do now?

It all starts with the vote count. Most projections expect the Democrats to win between 10 and 20 House seats. But the difference between 10 and 20 could be substantial. The cushier the majority, the further you can push the policy agenda. More than 30 House Democrats actually voted against the ACA, but they could still narrowly pass the bill because of the huge majority that they had started building in 2006. 

If you live in one of the districts — like Arizona’s Sixth or Colorado’s Eighth or Florida’s 22nd, to name just a couple of the 21 toss-up races identified by the Cook Political Report this year — that forecasters say is competitive this year, you could have an outsized say in what the future of policymaking looks like. But even in safe districts, you should vote: Elections are the most reliable way we have to gauge public opinion, and strong victories for the candidates who prioritize healthcare send a message.

The same goes for the Senate. If Democrats sweep all of the competitive races, they could have up to 55 seats in the Senate in 2027 — with a chance to build on it in 2028. If you are a voter in Kansas, Michigan, Ohio, Texas, Alaska, Maine, New Hampshire, or Iowa, your ballot carries extra weight for the next steps in US healthcare reform. If the Democrats can reach 60 votes again in 2029, they would have much more flexibility about what to pass. Even if they fall short of that magic number, the more of a cushion they have above 50, the more likely that their Senate leaders can find support for altering Senate rules for the filibuster and get an ambitious bill approved.

The results of this year’s midterms will also set the terms of the debate among Democrats. We are likely to see “show” bills advanced by Dems next year that may have no chance of being signed by President Donald Trump, but that will give us a sense of what kind of policies the party wants to pursue and how much support there is for them. Believe it or not, the first Medicare prescription drug negotiations bill passed the House in 2007 after Democrats’ big wins in 2006 — even though the policy didn’t become law for another 15 years. The broader public may not pay much attention to this kind of doomed-to-fail legislation, but it is often a window into the future.

“One challenge for Democrats is finding the next big health care idea beyond the Affordable Care Act that will resonate with voters and respond to their affordability concerns,” said Larry Levitt, executive vice president for health policy at KFF. “One big difference between now and 2006 is that back then there was already a lot of coalescing around ideas that ultimately led to the ACA. All the major Democratic candidates for president in 2008 supported something like that. I’m not sure that’s true now, at least not yet.”

Democrats are already aligning on a wide range of healthcare ideas, from reviving the public option to free primary care to the full-blown Medicare-for-all supported by progressive candidates, some of whom are in competitive elections. If El-Sayed wins the Senate race in Michigan, for example, that could supercharge a debate around Medicare-for-all. It could also provide momentum to any progressives who run for president — Alexandria Ocasio-Cortez, to name one obvious example — and decide to make Medicare-for-all a pillar of their platform.

But if El-Sayed and other progressives were to fall short, that could make Democrats more timid about being ambitious in the 2028 campaign and afterward. Still, he’s far from the only candidate in a crucial race to put their support behind Medicare-for-all. There is Randy Villegas in an important California House race. Troy Jackson has bet on it as part of his bid to topple Sen. Susan Collins in Maine. All of these races will send a signal to the party about what the public wants and is willing to turn out for.

In some ways, winning elections is the easy part. Legislating is hard, and any eventual healthcare law will surely involve compromises and unexpected surprises. Who knows what will be happening in the world in 2029? 

“The bottom line is: 2026 is a healthcare election,” the leaders of the advocacy group Protect Our Care wrote in a campaign memo this month. “After November, it’s up to Democrats to keep up the fight to deliver relief to families and make healthcare affordable and accessible for every American.”

The harrowing allegations of rape at a Cornell University fraternity have been rippling out in both New York state and national politics.

Democrats have tended to voice sympathy with the accuser, saying that they stand with her and other victims. Rep. Alexandria Ocasio-Cortez (D-NY) said there was “a culture of rape, sexual assault, and pedophilia” in elite institutions across the country. Michigan Senate candidate Abdul El-Sayed said Cornell “protected her abusers, letting them off with a slap on the wrist.” 

New York Gov. Kathy Hochul said the accuser was “failed” by local police and county prosecutors who did not bring charges, so Hochul appointed state Attorney General Letitia James to take over the investigation. Days before that appointment, James posted on social media that “what this young woman has been forced to endure is horrific and unacceptable,” adding: “To her, and to all survivors: you’re not alone. We stand with you.” 

Some Republicans, meanwhile, are accusing Democrats of rushing to judgment. Saritha Komatireddy, who is running for attorney general of New York against James, said in a debate that James had “screwed this one up by prejudging it.” The investigation, Komatireddy said, “requires someone who approaches the case with fairness, impartiality and integrity.” And right-wing commentators like Megyn Kelly and Ben Shapiro have questioned the accuser’s story.

But beyond the procedural fight over this particular investigation, many Democrats have also called for changing the law to make cases like it that involve drugs or alcohol easier to prosecute in general. 

This might seem like a clean issue for the party, in line with prior progressive efforts to crack down on sexual assault via Title IX and expanding statute of limitations laws. 

However, it’s not so simple: According to my conversations with experts and advocates involved in these reform conversations, this is where the Democratic unity begins to fray, because of a divide between two key parts of the progressive coalition. 

The impulse to create stronger protections for victims has crashed into the left’s longstanding suspicion of the criminal justice system. And as a result, a coherent policy response has been hard to craft — and may end up being impossible to get agreement on.

On one side are advocacy groups for women and for victims of rape or sexual assault. They argue that current law — in New York and other states — makes it far too difficult to successfully prosecute perpetrators, and that it should be changed. They’ve advocated for closing what they call the “voluntary intoxication loophole,” which they say makes it harder to prosecute abusers of victims who have willingly consumed drugs or alcohol.

On the other side are various progressive or left constituencies that are deeply skeptical of the criminal justice system. These constituencies — which include key figures in New York’s Black political establishment, public defenders, supporters of criminal justice reform, and members of the Democratic Socialists of America — are united by a shared antipathy to mass incarceration and what they see as disproportionate police targeting of minority communities. 

The former camp argues that false rape and sexual assault allegations are vanishingly rare, that these crimes are hugely underpunished, and that the law needs to be updated to make these prosecutions easier. But the latter camp argues that Black and other nonwhite men are often falsely accused, and that it would be unwise to hand prosecutors another tool they could use to put men in jail in cases where ascertaining consent is more difficult.

It’s a fraught debate. Modern-day progressives have strongly backed the Me Too movement as well as campaigns for racial justice and criminal justice reform. Progressives want to be on the side of victims against the privileged and powerful — but sometimes, they have different ideas about who falls into which category.

The legal issues around “voluntary intoxication” and rape charges, explained

The current controversy in New York focuses on efforts to close what advocates call the “voluntary intoxication loophole” in rape and sexual assault law.

Every state says rape is a crime. Every state says it’s a crime to have sex with someone who is unconscious. And every state says it’s a crime to have sex with someone who is incapacitated due to unknowingly being dosed with drugs.

But what about someone who chooses to drink or take drugs, who remains conscious, and who doesn’t outright refuse consent? Should there be a standard by which the law deems that person incapable of meaningfully consenting, because they are too intoxicated? 

Many states have long had laws on the books saying yes — that someone who voluntarily drinks or does drugs can reach a state where they are too mentally impaired to consent to sex, even if they’re conscious and capable of communicating. But about half of states don’t have such a law, according to the Associated Press. And this hasn’t been an especially partisan issue to this point, with a mix of red and blue states adopting each standard.

The push to change the law in New York predates the Cornell case, and goes back to the late 2010s. At that time, the Me Too movement had put Manhattan District Attorney Cyrus Vance Jr. in the hot seat, with advocates criticizing him for not initially prosecuting Harvey Weinstein and arguing he was soft on rape and sex crimes generally. 

In the midst of pivoting on the issue (he had Weinstein indicted in 2018), Vance claimed that, in certain of these cases, his office was hamstrung by what he called a “loophole” in New York law involving intoxication. “Prosecutors cannot bring sex crime charges in cases where the victim became voluntarily intoxicated and was unable to consent,” he wrote in a letter. So really, Vance said, it was on the legislature to change the law.

Quickly, critics argued that Vance had misstated the law, saying it was not actually true that a loophole allowed people to rape voluntarily intoxicated New Yorkers with impunity. Vance’s office later acknowledged that his initial comments were “inartfully put.” 

The problematic cases, Vance’s team argued, were about victims who were “too intoxicated to consent” but who were also at least partially conscious and didn’t outright express their unwillingness — this, they said, was the “gap in the law.” “There’s a real problem that we have with people getting drunk and then being taken advantage of,” Vance said. 

So some Democrats and groups advocating for victims of sexual assault and rape kicked off an effort to change that law, in New York and elsewhere. Their favored bill says that lack of consent can be established if an alleged victim is “temporarily incapable of appraising or controlling their conduct” — and if the accused knew or reasonably should have known that.

Critics argue, though, that such bills go too far, and could make it easier to prosecute sexual encounters that, to the accused, seemed consensual. 

“The proposed legislation fails to provide any objective guidance about when a partner is too intoxicated to legally agree to engage in sexual conduct,” the New York State Association of Criminal Defense Lawyers said in an emailed statement.

Skeptics of the bill outlined several scenarios that concerned them, including scenarios where one person seems to consent but later decides that, in retrospect, they were too intoxicated for it to have truly been consensual. 

“You get all these scenarios where two people meet up at a bar and they both become voluntarily intoxicated,” said Yung-Mi Lee, a public defender and a former president of New York’s criminal defense lawyers association. “So then, if someone later says, ‘I was voluntarily incapable of appraising my conduct, I lost my inhibitions,’ they could say, ‘You committed a rape against me.’”

To advocates for victims’ rights, these concerns are overstated. “The burden that’s placed on a victim of sexual violence is such a large burden to bear in the first place that these changes to the law are really just slightly opening the door,” Rebecca Zipkin of the advocacy group World Without Exploitation told me.

“The current situation is not working to provide justice for survivors,” Stefan Turkheimer of RAINN, a network for rape and abuse survivors, told me. “The status quo is not okay.”

Why it hasn’t passed in New York

Versions of the voluntary intoxication bill have been signed into law in recent years in Minnesota, Michigan, and Texas. The bill has also repeatedly passed the New York state Senate by overwhelming margins. But it has never been brought to a vote in the lower chamber, the New York state Assembly.

That’s because, advocates for the bill told me, they’ve faced resistance from some influential parts of the Democratic Party and progressive coalition. 

Indeed, the skeptics are said to include two factions that are often at odds: New York’s Black political establishment and the Democratic Socialists of America. 

Assembly Speaker Carl Heastie controls which bills come to a vote in his chamber. He was an architect of the state’s sweeping bail reform law, a critic of what he called the existing “racist and classist system,” and has said he would be “a failure as a Black man” if he did not pass criminal justice reform. 

“It is generally known that Speaker Heastie does not believe in creating new crimes because he believes New York suffers from overincarceration,” Lizzie Asher, an advocate for changing the law and a co-founder of the Justice Without Exclusion Coalition, told me. (Heastie has said that he did not bring the bill to a vote because it lacked enough support among his chamber’s Democrats.)

Assembly member Latrice Walker is another champion of criminal justice reform; she even did a hunger strike in 2023 to protest rollbacks to the bail reform law. She spoke out about her concerns about the voluntary intoxication bill earlier this year, telling the New York Times that while she wanted survivors to get justice, she was “cautious about the creation of new laws and our duty to preserve due process protections.”

Zipkin and other advocates have also pointed to the six DSA-affiliated members of the assembly, who are associated with a general skepticism about the criminal justice system and incarceration, as a potential obstacle. None are currently listed as cosponsors of the bill. Back when Zohran Mamdani was in the assembly, he too declined to sign on, advocates noted. 

The DSA as an organization is very critical toward the police and prison system; many DSA members have called for defunding or abolishing the police in the past, and the DSA’s national platform still holds out “fully abolishing the police and prison system” as a long-term goal.

These objections may be harder to maintain amidst a wave of outrage around the Cornell case. Speaker Heastie announced he was creating a working group to reexamine the voluntary intoxication issue. The group includes Walker, whose office told Vox she would not comment on the law while “they undertake their important work.” Heastie told the group to give him recommendations by the end of the year, for consideration in New York’s 2027 legislative session. 

Is this a bigger divide among progressives?

The divide is coming into public view due to national attention on the Cornell case — but it’s long predated the current moment. 

Back in 2016, a California judge gave Brock Turner, a Stanford swimmer convicted of sexually assaulting an unconscious woman behind a dumpster, a six-month jail sentence. Advocates for victims’ rights were furious at what they deemed an inexcusably lenient punishment; nationwide outrage and an ultimately successful campaign to recall the judge ensued. 

But some progressive supporters of criminal justice reform felt queasy about the idea of punishing a judge for not locking up a defendant long enough. Skeptical of the criminal justice system and the value of incarceration, they worried this public fury would incentivize judges to be harsher across the board.

“What ultimately will happen is that the people that we represent — people of color, minorities, the disenfranchised, the poor in our communities that make up the people ensnared in our criminal justice system — they’re the ones that are going to bear the cost of this recall,” Sajid Khan, a public defender in Santa Clara County, California, said in 2018.

In practice, these two groups of advocates have generally managed to coexist in the progressive coalition. That’s in part because the Me Too cases that get the most attention have tended to be from white-collar work environments or college campuses, rather than in the dispossessed or marginalized populations that criminal justice reformers are more typically focused on.

But some argue that there’s a more fundamental tension here. Aya Gruber, a professor at the USC Gould School of Law, has written a book arguing that feminists’ efforts to ensure rape and domestic violence are punished more severely have, in practice, ended up contributing to racist mass incarceration. 

“I just think it is a really dangerous thing to start expanding the criminal law in ways that grant all this power to prosecutors,” Gruber told me. “This idea that somehow all this cultural power is going to be used against already privileged people and thus have some sort of egalitarian aspect to it makes it very tempting. But we can identify populations that are more heavily policed, and they are generally not privileged populations.”