Americans want changes to their healthcare, and the candidates in this year’s midterms are making bold promises about how they are going to improve it: Medicare-for-all, or a public health insurance option, or free primary care for everyone. If Democrats win big this year, they could build up momentum to control Congress and the White House in 2029, which could leave them well-positioned to take on the thorny problem of how to fix the US health system.

History suggests that this won’t be easy. For every Affordable Care Act, you have the failed attempt to repeal it or the calamity of the Clinton-era healthcare initiative. Americans want change — but they fear it, too. I’ve spent years reading healthcare polls, talking to voters, attending focus groups. The public’s opinion of the healthcare industry has grown more and more sour, and distrust of the medical establishment is at an all-time high. People are sick of having a broken health system, but they worry that big changes could end up being bad for them. 

Even though a meaningful attempt at reform is still years away and universal health care in any form might seem like a progressive pipe dream, the industry is not sitting idly by. 

As Democrats have started to roll out policy proposals in anticipation of winning back Congress, the industry has been there to start making its case. In some campaigns, that means backing Republicans, but it also means lobbying Democratic Party leaders to hold the line against their more progressive members who want to push for far-reaching changes. 

The question now is: Will their old playbook work? Can the industry convince Democrats to scale back their policy ambitions, or is their grip on Congress loosening?

“The next two years are actually quite pivotal, for doing the groundwork and all the necessary socializing, consensus-building,” said Kim Monk, a former congressional healthcare staffer who co-founded the private-sector research firm Capital Alpha Partners. “That’s the work that gets you to a point where either party decides, okay, this will be on our platform — or not.”

That will be the tug-of-war of the next two years: a PR battle waged between health companies with hundreds of millions of dollars at their disposal on one side and progressive lawmakers, activists, and patient advocates on the other that will ultimately determine what’s possible in the next phase of American healthcare.

The healthcare industry doesn’t want Democrats to win too big

In the short term, the industry is hedging its bets in the face of a Democratic wave. 

Private enterprise has historically backed the Republican Party, but that’s starting to shift. What the healthcare industry values above all else is balance. Democrats operating without any constraints are more likely to impose government regulations on medical companies. But full GOP control comes with its own risks, like the $1 trillion in Medicaid cuts passed as part of the One Big Beautiful Bill Act, which has already led to clinics and hospitals laying off staff or even closing facilities altogether.

“At least for the short term, I imagine the healthcare industry would welcome control of Congress by Democrats, creating more predictability, forestalling more cuts in Medicaid and the Affordable Care Act, and potentially reversing or delaying some of the cuts that have already been made,” said Larry Levitt, executive vice president for health policy at KFF. “The longer-term political calculus for the healthcare industry is more complicated. Many Democrats are pushing for a bigger role for government in health care.”

In other words, while healthcare companies might welcome a Democratic House as a check on President Donald Trump’s unpredictability, they aren’t necessarily hoping for a massive blue wave that could make significant reforms a serious possibility if Democrats were to win the White House in 2028. 

The industry’s MO when it looks like a wave election is brewing is to balance the scales: I reported in 2016 how, in what was looking like a good year for Democrats, the drug industry poured money into the campaigns of Republican candidates by a 6-to-1 margin in competitive races, hoping to stifle the agenda of presumed President Hillary Clinton. (Of course they, like the rest of us, are still susceptible to being wrong.)

And that’s how the industry has been approaching the 2026 election: In many of the pivotal House and Senate races, they are backing the GOP. 

As healthcare journalist Merrill Goozner reported last week, the American Hospital Association PAC and PhRMA, a drug industry trade group, have given a combined $14,500 to Republican incumbent Jon Husted and none to his Democratic challenger Sherrod Brown in the historically expensive Ohio Senate race. In Maine, Republican Sen. Susan Collins has received donations from all of the major healthcare trade groups — hospitals, pharma, insurers, and doctors — while her opponent, Democrat Troy Jackson, got none. (He also has sworn off corporate PAC money.) Even in an open race without an incumbent, like the Iowa Senate campaign, the Republican candidate has scored donations from hospitals and pharma, but the Democrat has not, Goozner reported.

If Democrats take the House but not the Senate, that would immediately put a damper on their healthcare reform plans — whereas winning a Senate majority would allow them to start drafting and debating bills in both chambers with an eye toward what could actually pass if they win in 2028 too.

“If there is actually a blue tsunami next week and Democrats get 51-plus [members] in the Senate, that’s a really big deal,” Monk said. “You can’t just say this doesn’t matter because Trump’s going to veto it, because I think it very much becomes a 2028 issue.”

And even as they work to push the next Congress more to their ideological liking, the healthcare industry is preparing for the fight that comes after.

The industry is prepping its counterattacks on ambitious healthcare proposals

After the midterms wrap up, the next two years in Congress and on the presidential campaign trail will be crucial. The industry is already working to set the terms of the debate and push back against big changes.

Each subset of the industry has its own versions of this argument: Pharma warns that price controls could stifle innovation, insurers warn that coverage mandates will increase premiums, hospitals warn that constraints on their funding could lead to closures and job losses. (There’s a well-known saying among DC insiders that every congressional district has a hospital, making every member potentially susceptible to the industry’s message that new healthcare legislation could result in their own constituents losing their jobs.)

They’ve started by trying to discredit the more sweeping health policy proposals before new members ever arrive in Washington, DC. In Texas, for instance, Republican groups have leaned on an industry-commissioned study to attack Democratic Senate candidate James Talarico for supporting Medicare-for-all, warning that it would lead to cuts for rural hospitals — at least according to an analysis produced by the Partnership for America’s Future, a coalition of industry groups that exists explicitly to oppose Medicare-for-all or a public option. They ran a similar ad against Democrat Janelle Stelson, who’s trying to topple incumbent Rep. Scott Perry in Pennsylvania. 

The industry is trying to plant the idea in voters’ minds that these big, bold proposals may sound superficially appealing, but carry significant risks: You could lose your plan, you could lose your doctor, you could pay higher taxes. (And they often have their own studies to back those arguments, like the one cited in this year’s campaign, to counter the evidence offered by advocates in support of reform.) And it might work exactly like it has in the past. As John McDonough, a former congressional healthcare staffer and author of America’s Wrong Turn: US Health Care in the Neoliberal Era, put it to me, the history is clear: “Every comprehensive effort, defeat, and every incremental effort succeeds.” That is in part because of the healthcare industry’s influence and its success in framing the debate.

On top of trying to sway the competitive races, the industry is also trying to keep its most important allies within both parties happy ahead of the midterms. As the Center for Health and Democracy’s data shows, the health insurance industry PACs alone have given tens of thousands of dollars to Democratic and Republican leaders, as well as senior members of the healthcare-focused House and Senate committees.

It’s another hedge, an attempt to keep the members who will decide what’s on the agenda next year on their side. The industry supports reversing the GOP’s massive Medicaid cuts and increasing funding for the ACA marketplaces, two top-priority items for Democrats if they win Congress in the midterms. But they are hoping the party’s leaders will steer their members away from some of their more radical ideas for overhauling healthcare. Because while individual sectors within healthcare may squabble over smaller-scale reforms, the entire industry is united against plans to fundamentally change the US health system. (They are also increasingly owned by the same parent company, as consolidation in the medical sector becomes more and more common.)

“The healthcare industry is all for more people having coverage and stable government financing,” Levitt said, “but will circle the wagons to fight Medicare-for-all.”

Already, whenever Democrats start talking about their health policy ideas, the industry is ready with a response. Last month, as some Democrats announced support for a public insurance option, the Partnership for America’s Health Care Future argued it would reduce access. “A public option is not the answer to the affordability and access challenges patients and families are facing,” said the group’s executive director, Lauren Crawford Shaver.

Meanwhile, the health insurance lobbying group, AHIP, released a 40-page document in October on how to improve affordability and access, using it in part to argue against a public option because it would “stifle competition and threaten the coverage most Americans want to keep.” Centrist Democratic groups who receive industry support have said they are “preparing for war” against Medicare-for-all, according to the news outlet Sludge.

The industry is not omnipotent, however, and the debate could still change if Americans’ healthcare gets worse over the next few years. The US uninsured rate has been on the rise as pandemic protections expire and the costs of healthcare rise for millions. Unless Democrats succeed in stopping the Republican Medicaid and ACA cuts in the OBBBA, that problem is going to get worse — and that could also force Democrats to think bigger about how to fix it.

“I am not sure anyone has fully absorbed how damaging and disruptive that is going to be — including to hospitals and health systems,” Jonathan Oberlander, professor of social medicine at the University of North Carolina and the former editor of the Journal of Health Politics, Policy and Law, told me over email. “Large coverage losses will trigger great instability in health politics and perhaps open more of a window to bolder proposals.”

So, will the industry’s arguments still have juice? After the medical industry enjoyed a brief rebound in popularity during the pandemic, 50 percent of Americans say they have a negative view of it, while 37 percent have a positive view, per Gallup. And the appetite for reform is growing: 64 percent of Americans say it is the government’s responsibility to make sure that everyone has healthcare coverage — the highest share at any time, except for the late 2000s, shortly before the ACA became law.

Even the hospital industry, which has long enjoyed more public support than pharma or insurance companies, is seeing its popularity waver: A Families USA poll from August found that an overwhelming 81 percent of Americans thought hospital prices were unreasonable.

“Hospitals have done a great job of pleading poverty on Capitol Hill. ‘We’re probably the only provider who basically has to provide care to whoever shows up. We have no reason to be efficient. Just give us more money,’” Monk said. “I think that argument is wearing a little bit thin.”

Most Americans hate their cable companies. But not the 200,000-odd residents of Chattanooga, Tennessee, a city nestled in the Appalachian foothills. 

For many people, the city might seem off the beaten path — enough so that when Spain’s national team chose the city as their base during the FIFA World Cup over the summer, the internet exploded with jeers of incredulity. And yet, as many an urban planner, and certainly many a local, will tell you, Chattanooga is a special place, known not just because the Glenn Miller Orchestra immortalized it as a scenic hub for the choo-choo train.

No, what really has put Chattanooga on the map recently is its ridiculously fast, municipally owned internet. 

Unlike almost everywhere else in the country, the fiber-optic cables that keep much of Chattanooga online were laid neither by Comcast nor Spectrum, but by the city itself. In a $220 million gamble, its public power utility, EPB, has helped transform the once struggling post-industrial city into an unlikely marvel of civic reinvention, and an inspiration for many other dozens of copycat towns around the country.  

When it debuted in 2010, at one gigabit per second, the city’s ultra-speedy broadband was among the fastest in the world, as fast as global meccas like Hong Kong, and over 200 times faster than the average top-tier offering across the US. “This makes Chattanooga, a mid-sized city in the South,” declared then-Mayor Ron Littlefield to the New York Times, “one of the leading cities in the world in its digital capabilities.” 

In the decade and a half since Chattanooga rebranded as “Gig City,” its trademark broadband has proved to be far more than a mere fancy gimmick. It has added billions of dollars to the city’s economy, lured in hundreds of new startups, and, according to EPB, become the single largest source of funding for local public schools, and delighted hundreds of thousands of local customers. 

If you’re not a tech company or a prolific streamer, of course, you may not need such intensive internet service. But the city’s broadband service is widely beloved locally for bringing 70 percent of households online at, by far, the lowest price per megabit of bandwidth in the area and quite possibly, among the lowest in the country. Consumer Reports perennially ranks EPB among America’s best providers, a sentiment apparently shared by the legions of Chattanoogans who take to social media to sing EPB’s praises every time it swoops in to fix an outage minutes after a storm hits, or bemoan their loss when they move away and witness the sludgy pace at — and high rates — which the rest of us browse and scroll. 

“Chattanooga turned out better than anyone could have hoped,” said Christopher Mitchell, director of the Community Broadband Networks Initiative, part of the Institute for Local Self-Reliance, a group that researches locally owned infrastructure, “and the one thing that hasn’t changed are their prices. It’s rare, remarkable even.” That original single-gig service runs $68 per month, and faster speeds aren’t too much more.  

But even as the benefits of Chattanooga’s internet supremacy have compounded, public broadband networks like it are still a rarity across the US, which you probably already know if you, like most Americans, have ever sensed your internet growing ever more lethargic, even as your fees climb month after month. 

There is a better way, and Chattanooga has long since shown the nation how. For better or worse, the internet drives much of our daily lives and the economy, and what makes the internet possible? Broadband, which is powered by those stiff plastic-sheathed cables filled with strands of thin glass or braids of copper wire, beaming pulses of light or electricity into your modem. And yet, the US has outsourced the provision of this precious public good almost entirely to de facto monopolies that keep our internet slower, more expensive, and above all, more infuriating than it needs to be. 

“There was a generation that built water systems and electric systems. There was a generation that built the roads,” Mitchell said. Today, however, “People are just afraid of the idea of the government being ambitious and doing what Chattanooga did.”

How Chattanooga built the world’s best broadband

Long before Chattanooga grew famous for its broadband, it was known, for a period of time, as “the dirtiest city of America,” a moniker bestowed by Walter Cronkite in 1969. 

According to local lore, the moon pie, which originated at a bakery in Chattanooga, came to be when a coal miner asked for a snack “as big as the moon” to sustain him for long shifts down the shaft. The coal he mined fueled the industrial boom that defined Chattanooga until the mid-20th century, when the city’s factories, furnaces, and railroads belched a smog so noxious, it melted women’s nylon stockings off their legs as they walked. 

By the 1980s, the city knew it needed to change, seeding a hunger for reinvention that experts told me would come to define its municipally-owned internet. By the 2000s, Chattanooga had more than cleaned up its air and its reputation, building a huge aquarium in the heart of downtown and carefully revitalizing its riverfront and natural areas. But in the early aughts, with the remaining heavy industry in deep retreat, and a fragile recovery threatened by the Great Recession, the city craved a new economic engine. 

The city’s EPB, which originated as a municipally owned electric utility in 1935, had already set out to build a smart electrical grid in 2008, retrofitting it with a two-way digital communications system that could detect and fix problems as they arise. This process would involve laying hundreds of miles of new fiber-optic cable lines along existing power lines, monitoring them and relaying information back and forth with operators. But as the EPB laid plans for its new grid-helping fiber, it realized that for roughly the same amount of effort and cost, it could repurpose those cables to also serve as a cutting-edge internet service. 

Laying those hundreds of miles of new cables, along every single power line in the city, is an expensive and time-consuming process. But since EPB already had power lines plugging into almost every home and business throughout the city, it didn’t even need permission to get it done. And once the cables are there, there’s no real limit on how much data they can carry, meaning that they’ll work just as well whether they’re relaying the power grid’s data exclusively or if they’re carrying petabytes upon petabytes of data from hundreds of thousands of internet customers. This same quality has made it easy for EPB to pump up the volume of data it offers over the years, eventually allowing it to become the first city in the nation to offer a 25-gigabit-per-second service, which it did for its customers in 2023. More recently, EPB became the first provider nationwide to hook its fiber-optic cables up to a quantum computer — which uses advanced physics to solve mind-bogglingly complex problems — and offer its use to researchers and customers across the city. 

“If we’re going to own that fiber communications network to help automate our grid, why not offer that as a service to our customers? We thought, ‘Why not go big? Why not be ambitious?’” Janet Rehberg, CEO of EPB, told me. “People thought we were crazy. And we said, ‘If we can do it, why not?’ So, we did.”

Equipped with a $111 million federal stimulus grant from the recession-era American Recovery and Reinvestment Act, plus about $222 million in municipal bonds, EPB was able to complete the project — initially expected to take a decade — in just two years. 

In 2010, Chattanooga became the first city in the nation to offer one-gigabit-per-second fiber optic internet. 

“This was a huge shift for our city’s fortunes,” Andy Berke, mayor of Chattanooga from 2013 to 2021, told me. “All of a sudden, we were a place where you could try to discover the next big thing.” 

Hundreds of startups flocked to the city for its super-fast broadband, with tech incubators setting up shop in shuttered storefronts and abandoned industrial factories dotted along the city’s downtown. In its first 10 years, EPB’s fiber network brought more than $5.3 billion in economic benefits and 10,420 jobs to the city, about 31 percent of all jobs created during that period, according to a study by the University of Tennessee at Chattanooga. This has transformed “the way we thought about ourselves and what we thought was possible technologically,” Berke said. 

The broadband investment has long since paid for itself and then some in the fees people pay to access its service. EPB expects to earn about $190 million over the next year alone from its telecommunications and enormously popular internet service, all of which will flow back into the business itself or into the city. As a result, EPB chose not to increase electricity rates at all this year, in stark contrast to much of the rest of the country. And the utility now pays tens of millions of dollars annually straight back into city services, like public schools. 

Under Berke’s mayoral administration, the city also integrated EPB into initiatives meant to get more Chattanoogans online. When the pandemic hit, and local schools went virtual, the city built a new program called EdConnect that saw EPB provide free internet to every family with a child who received free or reduced lunches, the first program of its kind nationwide, and one that continues to this day. 

“A lot of communities set up something similar during the pandemic, but most of those are done, they kind of faded away. But we made a commitment — our community did — for 10 years, and we’re already discussing what the next 10 years looks like,” said Sammy Lowdermilk, CEO of the Enterprise Center, the nonprofit that administers EdConnect. “We’ve heard from parents using online resources to look for a job, to create resumes, to do medical research. The entire family gets to benefit from it.”

Your city could have Chattanooga’s internet. It just has to try.

Over the years, Chattanooga’s publicly owned internet has drawn countless city planners and far-flung mayors to Tennessee’s fourth-largest city to learn just how they pulled it off.

But every time one visited Berke in his time in office, and every time he gave one of his “little sales pitches” on EPB’s success, over and over, they’d replied with the same refrain: “Oh, it’s incredible what you’ve done here. I mean, we can’t do it, but it’s great — good for you guys,” he recalled. Many cities don’t have a publicly owned electricity company at the ready as Chattanooga did, and many face significant barriers from state laws that restrict or heavily discourage the development of municipally owned broadband altogether. 

“The number one challenge for most infrastructure projects is political. It’s not financial. It’s not conceptual. It’s not technological. It’s the web of difficulties that make it harder to get it done.”

Andy Berke, former mayor of Chattanooga

Nevertheless, some places tried anyway, and many have succeeded — over 700 of them, according to Mitchell’s last count. In Utah, for example, a consortium of cities has spent the past few decades building out a municipally owned fiber network with the bold name Utopia. For many years, said Mitchell, the network suffered from severe financial and legal roadblocks. But even so, Utopia has managed to build out a system that Mitchell calls an “unqualified success” today, bringing tens of thousands of households online across the state. 

While only a tiny fraction of all broadband networks nationwide have some level of municipal ownership, strikingly, nine out of ten of the nation’s fastest broadband networks do or are part of a public-private partnership. 

However, Chattanooga’s brand of municipally owned broadband hasn’t spread nearly as widely as many people hoped it would, or think it could. And most of that, said Mitchell, can be attributed to the fact that large internet companies like Comcast or AT&T, clearly aware of how dominant well-run municipally owned networks can become, have spent the past several decades fighting to prevent more from coming online.

More than 12 states now have explicit laws barring or restricting cities from offering publicly owned broadband, which has made it difficult for many municipalities to create networks of their own. Even Chattanooga faced a brutal legal challenge when it tried to expand EPB’s coverage to rural and underserviced areas right outside of the city, the result of a 1999 state law meant to restrict municipally owned broadband access. 

“The number one challenge for most infrastructure projects is political. It’s not financial. It’s not conceptual. It’s not technological,” said Berke, but rather, it’s a matter of navigating the special interests and lobbyists that dominate the status quo. “It’s the web of difficulties that make it harder to get it done.” 

But that doesn’t mean that it’s impossible to pull off. Utopia, for example, has withstood a blitz of dark money attack ads likely bankrolled by cable companies in its effort to expand across the state. And in Colorado, hundreds of communities over the years across the state have voted to opt out of a 2005 law banning municipal broadband networks. This momentum ultimately proved strong enough to convince the state legislature to repeal the original ban in 2023.      

Even today, broadband remains out of reach in many parts of the country that are either too rural for for-profit networks to build there at all, or where it does exist, locals can’t afford it. Americans consistently pay more for slower service, compared with their counterparts in Europe or Asia. 

Combined, those barriers have left tens of millions of American households without internet access. With AI poised to further transform our economy, Chattanooga, it seems increasingly clear, could be among the first few cities outside of Silicon Valley to truly benefit from the biggest technological shift in generations, while many other post-industrial cities seem likely to fall even further behind because they don’t have the right digital infrastructure to thrive in the economy today.

Quietly chugging along on the banks of the Tennessee River, the city is making a case that states and cities should take broadband seriously as a transformational infrastructure that underpins our modern lives much the way the rail lines did in the 19th century or highways did a century later.

Luckily, there are now hundreds of models — from fully public utilities like EPB to Tribal-built broadband networks to public-private partnerships — for cities hoping to carve a publicly owned path to a better internet themselves. Laying coils of fiber-optic cables is still much cheaper and, lawsuits notwithstanding, far easier a feat than building a new highway system or a railway network. But even if it were harder, Chattanooga shows that it would be worth doing. “Projects that are most difficult are also the most rewarding,” as Berke put it. “You have to be willing to take on the status quo — that’s what can transform a community.”

This story was supported by a grant from Arnold Ventures. Vox had full discretion over the content of this reporting.