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.”

Welcome to The Midterms, Actually. Every week I’ll be writing about two things: one big idea or trend I see forming across the 2026 primaries, and one thing I’m hearing from a voice on the ground. Let’s get into it.

One thing I’m thinking about: Electability and identity are intertwined 

On Sunday, former President Barack Obama did something most others seemed to avoid: He called out the Trump administration’s targeting of Rep. Ilhan Omar.

The administration, Obama wrote, is “actively trying to deport Congresswoman Omar” over a theory he called unsubstantiated: that she was 18, not 17, when her father was naturalized. The effort, he said, “should outrage all Americans, regardless of how they feel about Congresswoman Omar’s political views.” 

The statement stands in contrast to the mixed response of Democrats on the campaign trail and the relative silence of the mainstream press. House leadership put out a statement condemning the raid — but there’s been nothing from Senate Democratic leadership and little from the crop of elected officials expected to run for president in 2028. 

As The Intercept’s Adam Johnson pointed out, the August 2025 raid on former Trump adviser John Bolton drew scathing editorials from the New York Times, Washington Post, and the Wall Street Journal within days. The same goes for other ways Trump has weaponized the federal government against his political enemies, from the cases against James Comey and New York Attorney General Letitia James to the pursuit of Federal Reserve officials (Obama named all three in his statement). Omar’s raid has drawn much less intense coverage. Last week, I got three requests from cable outlets to discuss “news of the day” — each mentioned fired White House press secretary Katie Zacharia, new midterms polling, and some combination of Pete Hegseth and the war with Iran. None mentioned Omar.  

The entire episode has reminded me of Trump’s targeting of Black journalists like Don Lemon and Georgia Fort. Earlier this year, they were indicted after covering an anti-ICE protest that disrupted a service at Cities Church in St. Paul, and both have pleaded not guilty. In that case, there was also a muted reaction from the establishment press, possibly because of mixed feelings about Lemon personally or the lack of solidarity with independent Black media. Still, that silence was shortsighted, as the Trump administration used the incident as a stepping stone to target the wider media apparatus (See: Trump’s September attempt to bar CNN, MS NOW, and Politico from the White House).

With that in mind, I don’t think it’s hard to guess why Omar hasn’t received the fulsome backing of her party. I don’t think it’s the merits of the case: She hasn’t been charged with a crime, and the theory depends on a decades-old immigration filing by a father who died in 2020. It’s likely the fact that the Minnesota progressive has herself had a tense relationship with the Democratic establishment. That dates back to the 2019 fight over comments Omar made about the influence of the pro-Israel lobby in Congress, which some took to be antisemitic. In recent weeks, Minnesota Democrats, including Rep. Angie Craig and Sen. Amy Klobuchar’s office, criticized Omar’s plans to appear at an October 26 event hosted by state Sen. Omar Fateh with Hasan Piker, the controversial leftist Twitch streamer who has become a lightning rod in this year’s primaries.

But there’s another factor that we should also name in this episode: Islamophobia. As I discussed with Mehdi Hasan on Substack Live a couple weeks ago, the rise of the progressive left cannot be untangled from Muslim elected officials who have become its face: Omar in Minnesota, Abdul El-Sayed in Michigan, and Zohran Mamdani in New York City. And in each case, these candidates have faced attacks that explicitly seek to frame their religion and identity as inherently anti-American, a threat not only to our national values but our democracy itself.

Asked on CBS whether he believed El-Sayed was a terrorist, Republican Mike Rogers said to “look at the data — it’s pretty clear.” In a recent television ad (a seven-figure buy titled “Threat”) launched by Rogers and the National Republican Senatorial Committee, its narrator says, “Abdul raises money from dangerous people who finance terrorist networks,” tying the candidate to the Muslim Brotherhood and al-Qaeda. The NRSC’s ads also notably use his full name, Abdulrahman Mohamed El-Sayed.

But importantly, it’s not just Republicans engaging in overt bigotry. They have also been aided by moderate Democrats and the press, who have used the guise of “electability” to beat the same drum. Think back to the New York City mayoral race, where (Democrat!) Andrew Cuomo spent the final weeks running a campaign virtually indistinguishable from the tactics of the MAGA right. On a radio show, host Sid Rosenberg said Mamdani would cheer if another 9/11 happened, and Cuomo laughed, seeming to agree. Cuomo’s X account even posted, then deleted, an AI-generated ad called “Criminals for Zohran Mamdani,” which opens with a fake Mamdani eating rice with his hands. The campaign blamed a “junior staffer.”

The worst part: In following Republicans down the road of interrogating the Scary Muslims, we perpetrate a form of hate that has real costs. Just this May, two teenagers opened fire at the Islamic Center of San Diego, killing three people, and left behind a manifesto invoking the Christchurch mosque shooter. Analysts at the Anti-Defamation League found it expressed sweeping hatred of Muslims, Jews, Black and Hispanic people, and the LGBTQ+ community.

And journalistically, we avoid a more nuanced conversation that is the one worth having: the connection between identity and electability.

And journalistically, we avoid a more nuanced conversation that is the one worth having: the connection between identity and electability. The discussion about candidates El-Sayed and Mamdani, to this point, has focused on whether their progressive policy stances can play well in a general election. However, research shows that while candidates of marginalized backgrounds (women, Black and Latinos, Arabs, etc.) face an electoral penalty from voters regardless of ideology or political party, that’s especially true for Muslim candidates. A study of state legislative races in Politics and Religion this year found Muslim candidates were roughly 16 percentage points less likely to win general elections than non-Muslim candidates, and 10–15 points behind other racial minorities. Experiments by the political scientist Nazita Lajevardi, cited in that paper, found voters about 10 percent less likely to pick a Muslim candidate over a white one, with religion rather than race as the trigger.

This would seem to explain some of the reason El-Sayed seems to be running behind other Senate Democrats (if we believe the polling). But you rarely hear that reasoning given by the electability crowd, who more than often cites his progressive beliefs, and are we just supposed to nominate Christian white guys forever?

Here’s what is undeniable: Republicans have become quite adept at putting minority communities against each other in the Trump era, and they’re running that playbook in Michigan. Whether it’s telling Black communities that emerging immigrant populations are taking their jobs or telling immigrant communities that Democrats are too focused on Black issues, the strategy has been to exploit the racial tension at the heart of the Democratic base. And to some degree — it’s working.

In an August interview with Clay Cane at The Grio, a Black-focused outlet, El-Sayed said “mistrust among Black folk in Metro Detroit is well-founded,” pointing to what he described as tensions between some Arab and Muslim business owners. And the skepticism runs the other way too — as part of the difficulty El-Sayed has faced in Black communities is tied to the Islamophobia among that voting block. One example: At a July campaign event for Haley Stevens, a Farmington school board trustee told a Michigan Chronicle reporter, “Don’t just come in here speaking Arabic,” remarks the Council on American Islamic Relations condemned as anti-Arab racism and many read as aimed at El-Sayed. At an August 19 press conference, an older Black man in Detroit shouted at El-Sayed, “He’s an Arab — he don’t care nothing about Black folks.”

The layered nature of this issue should not be hard to grasp. Ask liberals about the 2024 election, and they are quick to point out the racism and sexism faced by candidates like Kamala Harris, and rightly argue that impacted her “electability” just as much as her refusal to break from President Joe Biden or embrace a clear ideological lane. But they conveniently leave out the importance of identity when it comes to Omar, El-Sayed, Mamdani, or even candidates like Francesca Hong in Wisconsin or Angie Nixon in Florida. As Zaid Jilani wrote recently, establishment Democrats are “effectively denying that prejudice exists in the United States if they’re really going to argue that Abdul El-Sayed will perform a few points behind other Democrats because of his PolIcY ViEwS rather than the GOP hating Muslims for 25 years.”

But we should be clear: “Hating Muslims” is not a prejudice that’s limited to the GOP, just as issues like racism, sexism, or antisemitism aren’t housed on one side of the aisle either. And in selectively ignoring the central role that prejudice plays in electoral politics — yes, even with progressive candidates — electability-focused Democrats aid the GOP’s desire to sow discord among their base.

The main reason for Democrats to stand up for Omar or El-Sayed is because it’s right, and they, too, have a place in American democracy. But at minimum, Democrats should see that in ignoring explicit Islamophobia — on the campaign trail or in the White House — they are being rather shortsighted. Trump’s campaign of retribution is unlikely to spare any enemy. Muslims may be the focus right now. But there’s no telling who’s next. You’re either for a multiracial, multifaith coalition — or you’re not.

One thing I’m hearing 

This week, we talked to Christian Paz, a Vox correspondent covering national politics and American religion. He’s been reporting from Kansas for an upcoming story on pastor and Democratic Senate candidate Adam Hamilton, whose race has emerged as a major campaign battleground in the final stretch. I wanted to ask him how Hamilton’s faith is shaping his campaign, what he is hearing from voters, and what the race could tell us about the Democrats’ ability to compete in long held Republican states. 

How is Adam Hamilton’s background as a pastor shaping his pitch, and what is he doing differently from other Democrats?

Watching Hamilton on the trail, it was remarkable to me how much his Methodist faith was at the heart of everything he talked about: about healthcare, climate, immigration, and foreign policy, about how his personal views either conflict with or bolster his policy stance, about how Trump and the GOP have failed Kansans, and about why he even decided to run (after he spent time dwelling on the Sermon on the Mount). He tailors his stump speech to different audiences, of course: At a progressive book shop, he leaned into a more anti-Trump speech; at a senior center he talked up his more conservative viewpoints on immigration and climate; at a Republicans for Hamilton rally he talked about the political center and why he wants to build a big tent; at a chapel, he led the audience in singing a hymn and quoted extensively from the Gospels as he shared his personally “pro-life” views — but it was all not just tinged, but immersed in Christianity.

“The race already tells us a few things, regardless of who wins or loses: Democrats should be creating opportunities to elevate religious people or clergy who want to run for office.”

It’s something I’ve only seen people like Rev. Raphael Warnock do, when speaking at churches on the campaign trail in 2020 and 2021. And it was different from James Talarico too — this guy leads a megachurch, and at times can slip into a kind of evangelical tone. That’s all pretty different than any other Democrat I’ve watched this cycle.

Hamilton needs to win over Kansans outside his party to have a shot. What were you hearing on the ground talking to voters?

The faith pitch is a huge part of why it does seem like he has a shot at winning: It doesn’t seem like he’s adopting or borrowing the language of the faithful, or their aesthetics, to talk politics, or just pitching the political center as a way to persuade voters. It’s that he’s adopting the tone and language of politics to talk about his faith — not the other way around. And the result is that when he talks about building a big tent, holding heterodox views, coexisting with people you disagree with — people trust and believe him.

I think I talked to more actual independents and Republicans who are backing Hamilton than actual die-hard Democrats over the days I was in Kansas. Some of these folks have voted at the local level for Democrats before, but tended to vote Republican at the national level. What unified those conversations was the sense that they think Hamilton is authentic, is a moral man with good character, and seems to be truly independent.

Others, including Democrats, said they appreciated how much time Hamilton spent talking about freedom of religion and diversity of thought — they liked that he would preface his religious talk with assurances that he wasn’t trying to convert anyone or force religion into people’s lives, but would also say he wasn’t going to compromise on it because of how genuinely he believes those things.

What could this race tell us about Democrats’ ability to reach religious voters in other Republican states?

The race already tells us a few things, regardless of who wins or loses: Democrats should be creating opportunities to elevate religious people or clergy who want to run for office. Those who aspire to run for office should also feel more comfortable talking about their faith if it’s actually a part of their lives. And Democrats shouldn’t feel beholden to the secular/atheist/none of the above/nothing in particular segment of their base because that isn’t big enough to actually win elections.