2026-04-12T10:00:55.782Z / https://www.cnn.com/2026/04/12/politics/medicare-for-all-health-care-cost-elections-analysis
单一支付体系再度迎来转机。
用完全由联邦政府资助和运营的全民医保体系取代私人健康保险，长期以来都是民主党左翼的优先议题。但在其主要倡导者伯尼·桑德斯参议员和伊丽莎白·沃伦参议员在2020年总统初选中难以捍卫这一理念后，民主党内部推动单一支付体系的势头似乎已奄奄一息。在持怀疑态度的乔·拜登总统任期内，民主党转而专注于通过《平价医疗法案》大幅扩大医保覆盖范围。
但如今，新一代民主党众议院、参议院甚至州长候选人正在重振单一支付体系的理念。“我确实认为人们对单一支付体系的兴趣出现了复苏，”桑德斯创立的组织“我们的革命”执行主任约瑟夫·吉瓦格塞斯表示，“当下，人们正以非常切实的方式感受到医疗保健领域的负担能力危机。”
与吉瓦格塞斯一样，大多数民主党幕僚认为，这一理念的复兴反映了人们对不断上涨的医疗成本的日益不满，而此时选民正为整体生活成本倍感压力。单一支付体系倡导者面临的矛盾在于，尽管更高的医疗成本在理论上让这一理念更具吸引力，但在实践中也让它变得更加棘手。
这一理念在2020年民主党总统竞选中失去势头的一个主要原因是，其支持者无法令人信服地解释如何为全面接管医疗体系的政府计划提供资金。根据智库城市研究所研究员约翰·霍拉汉独家向美国有线电视新闻网（CNN）分享的一项成本预测，随着美国医疗支出不断攀升，联邦单一支付体系计划的10年成本如今几乎是2020年的两倍。
专注于医疗问题的智库KFF负责卫生政策的执行副总裁拉里·莱维特表示，单一支付体系在民主党人中重新受到关注，是因为“成本不断上涨，且目前没有明显的解决方案”。“但《全民医保》（Medicare for All）的政治弊端依然存在，比如政府会加强对医疗保健的管控，以及需要大幅增税来为其买单。”
今年的民主党初选中，取代现有医保体系、由政府运营的单一支付体系提案层出不穷。在伊利诺伊州，上月以压倒性优势赢得民主党参议院初选的副州长朱莉安娜·斯特拉顿大力宣扬这一理念，并抨击对手收受医疗行业利益集团的捐款。在缅因州，首次参选的进步派候选人格雷厄姆·普拉特纳强调自己支持单一支付体系，而他在民调中持续领先州长珍妮特·米尔斯，领跑民主党参议院提名争夺战。
这一理念也在众多众议院选区竞选中重新浮现。社区组织者安娜利莉亚·梅希亚赢得了2月的民主党提名初选，将接替近日当选新泽西州州长的米奇·谢里尔进入国会，她是单一支付体系的坚定支持者。在备受关注的伊利诺伊州众议院民主党初选中，不仅是被视为党内左翼代表的候选人，最终胜出的埃文斯顿市长丹尼尔·比斯也支持《全民医保》。
同样，在竞争激烈的纽约市初选中，众议员丹·戈德曼和他的两位挑战者都支持这一理念。曾担任消防员、现为州消防员联盟主席的鲍勃·布鲁克斯，也是共和党众议员瑞安·麦肯齐在宾夕法尼亚州东北部选区竞选对手，同样持支持态度。“你不应该因为冲进火场救人，就只能等待65岁以后才能从政府那里获得医保，”布鲁克斯在其竞选网站上写道。
在加利福尼亚州，挑战民主党众议员迈克·汤普森、布拉德·谢尔曼和多丽丝·松井的年轻初选挑战者都支持单一支付体系——汤普森和谢尔曼本人也同样支持。该州州长初选中竞争左翼支持度最激烈的两位候选人汤姆·施泰耶和凯蒂·波特均表示，将推动建立州级单一支付体系。
除了布鲁克斯和普拉特纳，上述所有候选人都在民主党票仓深厚的州或选区参选。总体而言，摇摆地区的民主党候选人在支持单一支付体系方面仍谨慎得多。
但单一支付体系的复兴并不局限于深蓝地区。前众议员贾斯敏·克罗克特在得克萨斯州参议院初选中推动了这一理念，该选区最终于3月由州众议员詹姆斯·塔利科胜出。在挑战共和党众议员戴维·瓦拉达奥的民主党初选中，这一议题也是主要分歧点。尽管加州民主党人重划了国会选区，但其所在的中央谷地选区仍属于摇摆选区。以民粹主义激进派身份参选的兰迪·维列戈是直言不讳的单一支付体系支持者，而民主党领导层更青睐的州议员、医生贾斯米特·贝恩斯则转而呼吁加强现有医保项目。
密歇根州民主党参议院提名初选可能是单一支付体系辩论最为突出的竞选。底特律卫生局前局长、医生阿卜杜勒·赛义德长期以来一直是坚定的单一支付体系倡导者。但正如当地一名记者所言，在过去几个月里，“他开始补充了一个附加条件，称人们应该能够通过工会或雇主获得额外保险”。
这一立场让赛义德与他的两位提名竞争对手更趋一致：立场最温和的众议员黑利·史蒂文斯和意识形态介于两人之间的州参议员马洛里·麦克莫罗。史蒂文斯和麦克莫罗都不支持《全民医保》。相反，两人都主张建立“公共选项”，允许所有年龄段的美国人加入医疗保险，与私人保险公司竞争。史蒂文斯的竞选通讯总监阿里克·沃克表示，史蒂文斯认为《平价医疗法案》中的公共选项是必要的，“这样那些近乎垄断的保险公司就会面临竞争”。
这种做法已成为许多抵制单一支付体系的民主党人的首选替代方案。在得克萨斯州，塔利科在击败克罗克特的过程中就推广了他所谓的“全民医保Y’all计划”。爱荷华州的克里斯蒂娜·博安南等多个摇摆选区的众议院候选人也支持公共选项。
单一支付体系支持者与公共选项支持者之间的分歧，重现了2020年民主党总统初选时的争论。当时拜登和皮特·布蒂吉格是单一支付体系的主要批评者，他们表示将创建公共选项——布蒂吉格曾形象地称之为“愿意者均可加入的全民医保”。
今年如此多的民主党候选人重新关注单一支付体系，几乎肯定会让民主党在2028年总统初选中再次面临类似2020年的辩论。“仅从中期选举的情况来看，”“我们的革命”的吉瓦格塞斯表示，“我毫不怀疑2028年将围绕单一支付体系展开一场斗争。”
单一支付体系的理念在2020年民主党总统初选浪潮中崭露头角。桑德斯在2016年对阵希拉里·罗德姆·克林顿的选举中表现意外强劲后，许多民主党人认为他的激进进步主义在党内占据上风。最终有四位寻求2020年提名的民主党参议员支持了桑德斯的单一支付体系法案：沃伦、卡玛拉·哈里斯、科里·布克和柯尔斯滕·吉利布兰德。
但事实证明，单一支付体系在反击面前异常脆弱。拜登和布蒂吉格率先发起攻击，主要矛头指向当时在早期民调中表现强劲的沃伦。第三道路智库（一个中间派民主党组织）负责政策的执行副总裁吉姆·凯斯勒表示，一旦单一支付体系的支持者“被迫为他们的计划辩护，解释如何为其买单以及实际运作方式”，这一理念就暴露了“玻璃下巴”。哈里斯后来出人意料地放弃了这一主张。
尽管桑德斯公开支持大幅增税，但沃伦却难以解释如何为她的计划买单。以拜登和布蒂吉格为首的批评者还质疑，将管控美国人医保的如此多权力移交给联邦政府，以及迫使那些喜欢雇主提供保险的人放弃现有保险转而选择政府方案是否合理。拜登在初选初期遭遇困境后，他对单一支付体系的反驳“被我们的竞选视为一个转折点”，安德鲁·贝茨说道，他曾是拜登竞选期间和白宫时期的高级通讯助手。
尽管拜登在初选期间将公共选项作为单一支付体系的替代方案，但他上台后这一想法从未付诸实施。相反，国会民主党人批准了大幅增加资金，以扩大《平价医疗法案》的覆盖范围。这一努力成功将美国人的医保覆盖率在2024年推至创纪录的92%。
但成本仍在持续上涨。联邦数据显示，政府、企业和个人的全国医疗总支出从2020年的4.2万亿美元飙升至2024年的5.3万亿美元。更紧迫的是，根据KFF的数据，2020年至2025年，雇主提供保险的平均保费累计上涨了26%，这一涨幅超过了2015年至2020年21%的涨幅，而正是后者在2020年助推了单一支付体系的兴起。
2026年，大多数民主党候选人在传递医保信息时，首先会批评去年特朗普和国会共和党人对《平价医疗法案》的双重打击——《一揽子宏伟法案》中批准的大规模 Medicaid 削减，以及去年12月让《平价医疗法案》增强补贴到期的决定。但在党内意识形态光谱的各个阵营中，许多民主党人认为，仅仅扭转特朗普的削减措施，对于2026年的医保议程来说是不够的，更不用说2028年了。“是的，我们应该努力恢复医保税收抵免，修复Medicaid体系，但我们也应该尝试更进一步，”贝茨说道。
不过，“更进一步”的具体含义仍存在激烈争议。上周，领先的自由派智库美国进步中心发布了一份“患者权利法案”，试图通过对保险公司和医院实施新的监管限制，立即降低医疗成本。“公众迫切希望出台能立即降低成本的政策，而关于医保体系改革——无论是单一支付体系还是公共选项——的辩论可能需要十年左右的时间才能推进，”美国进步中心主席兼首席执行官、拜登前首席国内政策顾问内拉·坦登说道。
但许多民主党候选人希望对体系进行更深入的改革。曾广泛研究医保态度的民主党民调专家杰夫·加林表示，不断上涨的医疗成本让单一支付体系比2020年更具政治可行性。“许多选民认为医保体系严重受损，这种愤怒情绪比2019年和2020年《全民医保》上次被热议时更强烈，”加林说道，“正因如此，选民对转向单一支付体系的想法更加开放，包括一些支持特朗普的蓝领选民。”
但加林补充道，“成本和税收影响”仍是单一支付体系提案的一大障碍，“尤其是对于那些习惯由雇主承担大部分保险费用的选民来说”。
单一支付体系提案很快就会让人望而却步。2020年大选前，城市研究所预测桑德斯的计划在10年内将耗资34万亿美元，这一金额当时超过了社会保障、医疗保险和Medicaid的预计10年总支出。如今，这一数字甚至更加惊人。霍拉汉告诉记者，初步估算显示，单一支付体系计划在头十年的成本几乎是城市研究所2020年前估计的两倍，其中包括通货膨胀的影响。
这其中并非全部都是新增成本，因为联邦政府每年已经在医疗保健上花费约1.7万亿美元。正如霍拉汉指出的，如今的经济规模也比2020年更大，这将为这类提案提供更广泛的税收基础。但单一支付体系计划将要求联邦政府承担目前由家庭、私营企业以及州和地方政府承担的三分之二的全国医疗成本——这是一项艰巨的任务，需要大规模开辟新的收入来源。
作为对比，霍拉汉预测的单一支付体系10年成本，大致相当于国会预算办公室预测的联邦政府同期从所得税和工资税中获得的总收入。
这些惊人的预期成本为共和党人提供了绝佳的攻击目标。全国共和党国会委员会发言人迈克·马里内拉表示，尽管单一支付医保可能在民主党初选中颇具吸引力，但在竞争激烈的大选中，它将像其他先锋自由派政策一样脆弱，包括废除移民海关执法局和削减警察经费。“你会看到所有这些候选人彼此推挤，越来越左倾……他们将不得不在大选中为此负责，”他说道。
单一支付体系倡导者面临的另一个障碍是，卫生与公众服务部长小罗伯特·F·肯尼迪的破坏性任期，肯定会加剧人们对将医保体系如此多控制权交给联邦政府的担忧，包括保险公司将覆盖哪些医疗程序。“对政府卫生机构的信任处于历史最低水平，因此我认为这会让人们在将医保体系交给（政府）时有所犹豫，”KFF的莱维特说道。
单一支付体系拥有坚实的民主党支持基础——17名民主党参议员支持桑德斯的单一支付医保法案，超过一半的众议院民主党人也表示支持——而且这一数字可能会在11月继续增长。但在任何现实情况下，倡导者都远未获得参众两院的多数支持，即便民主党今年或2028年夺回两院控制权也是如此。
就目前而言，单一支付体系复兴带来的最切实影响，将是加大对民主党人的压力，要求他们推行远超扭转特朗普对《平价医疗法案》削减的医保议程——即便这会增加共和党反击的风险。
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https://www.youtube.com/watch?v=xdcX7FCVyBs
The most important Democratic health care debate is raging again
2026-04-12T10:00:55.782Z / https://www.cnn.com/2026/04/12/politics/medicare-for-all-health-care-cost-elections-analysis
Single payer is getting a second wind.
Replacing private health insurance with a universal coverage system funded and run solely by the federal government has long been a priority for the Democratic Party’s left wing. But the push for a single-payer plan, also known as Medicare for All, appeared to be on life support among Democrats after its leading advocates, Sens. Bernie Sanders and Elizabeth Warren, struggled to defend the idea during the party’s 2020 presidential primaries. Under President Joe Biden, a single-payer skeptic, Democrats focused instead on substantially expanding health coverage through the Affordable Care Act.
Now, though, a new generation of Democratic House, Senate and even gubernatorial candidates are resuscitating the single-payer idea. “I do think that there is a resurgence in interest in single payer,” says Joseph Geevarghese, executive director of Our Revolution, the organizing group founded by Sanders. “We’re in a moment where people are starting to feel the affordability crisis when it comes to health care in a very real way.”
Like Geevarghese, most Democratic operatives believe the idea’s revival reflects growing frustration over rising health care costs at a moment when voters are especially stressed about their overall cost of living. The paradox for single-payer advocates is that while higher health care costs make the idea more attractive in theory, they also make it more daunting in practice.
One principal reason the idea lost momentum in the 2020 Democratic presidential race was that its supporters could not convincingly explain how they would fund a complete government takeover of the health care system. Because of the nation’s rising health care spending, the 10-year bill for a federal single-payer plan would be nearly twice as high now as it was in 2020, according to a broad projection of possible costs shared exclusively with CNN by John Holahan, a fellow at the Urban Institute, a center-left think tank.
Single payer is receiving renewed attention among Democrats because “costs have risen and there are no obvious solutions on the horizon to deal with that,” said Larry Levitt, executive vice president for health policy at KFF, a think tank that focuses on health issues. “But the political liabilities of Medicare for All, like having the government exercise more control over health care and needing a big tax increase to pay for it, are all still there.”
Proposals to replace the existing health care system with a single-payer government-run system have sprouted in Democratic primaries this year. In Illinois, Lt. Gov. Juliana Stratton, who decisively won the Democratic Senate primary last month, forcefully touted the idea and attacked her opponents for taking contributions from health industry interests. In Maine, progressive first-time candidate Graham Platner has stressed his support for a single-payer system while opening a consistent lead in polls for the Democratic Senate nomination over Gov. Janet Mills.
The idea has resurfaced in a broad array of House races. Analilia Mejia, the community organizer who won a February primary for the Democratic nomination to succeed recently elected New Jersey Gov. Mikie Sherrill in Congress, is a strong single-payer advocate. And in a closely watched Illinois Democratic House primary, not just the candidates identified most with the party’s left flank but also Evanston Mayor Daniel Biss, the eventual winner, backed Medicare for All.
Similarly, in a closely contested New York City primary, Rep. Dan Goldman and both of his challengers have endorsed the idea. So has Bob Brooks, the former firefighter and president of the state firefighter union who is running against Republican Rep. Ryan Mackenzie for a northeast Pennsylvania seat. “You shouldn’t have to run into a burning building to get healthcare from your government or wait until you turn 65,” Brooks writes on his campaign website.
In California, younger primary challengers to Democratic Reps. Mike Thompson, Brad Sherman and Doris Matsui have all embraced single payer — as have Thompson and Sherman. Tom Steyer and Katie Porter, the two candidates competing most for support from the left in the state’s gubernatorial primary, each say they will pursue a state-level single-payer system.
Except for Brooks and Platner, all the candidates listed above are running in strongly Democratic states or districts. Generally, Democratic candidates in swing areas remain much more cautious about embracing single payer.
But the revival of single payer hasn’t been confined solely to deep blue places. Former Rep. Jasmine Crockett pushed it in the Texas Senate primary ultimately won by State Rep. James Talarico in March. The issue is also a major point of division in the Democratic primary to oppose Republican Rep. David Valadao, whose Central Valley district remains a toss-up even after California Democrats redrew the state’s Congressional maps. Randy Villegas, who is running as a populist insurgent, is a full-throated single-payer supporter, while state Assembly member Jasmeet Bains, a physician whom Democratic leaders prefer, talks instead about strengthening existing programs.
The primary for the Democratic Senate nomination in Michigan is probably the race where the single-payer debate has featured most prominently. Physician Abdul El-Sayed, a former director of the Detroit Health Department, has long been an unwavering single-payer advocate. But in the past few months, as one local reporter put it, “he has started adding an asterisk, saying that people should be able to obtain additional coverage from their union or employer.”
That position brings El-Sayed closer to his two rivals for the nomination, Rep. Haley Stevens, the most centrist candidate, and State Sen. Mallory McMorrow, who ideologically falls in between the other two. Neither Stevens nor McMorrow supports Medicare for All. Instead, each has argued for creating a “public option” to compete against private insurance companies by allowing Americans of all ages to buy into Medicare. Stevens believes a public option in the ACA is necessary “so that the insurance companies that are acting as a near-monopoly have competition,” says Arik Wolk, her campaign communications director.
That approach has become the preferred alternative for many Democrats resisting single payer. In Texas, Talarico promoted such a plan — what he called “Medicare for Y’all” — in his victory over Crockett. Several House candidates in competitive seats, such as Christina Bohannan in Iowa, have endorsed a public option, too.
This split between supporters of single-payer and a public option reprises the arguments from the 2020 Democratic presidential race. Both Biden and Pete Buttigieg, then the principal critics of single payer, said that instead they would create a public option — what Buttigieg memorably called “Medicare for all who want it.”
The revival of interest in single payer from so many Democratic candidates this year virtually guarantees the party will face another version of that 2020 debate in its 2028 presidential primaries. “Just based on what we are seeing in the midterms,” says Geevarghese of Our Revolution, “there’s no doubt in my mind there will be a fight over single payer in ‘28.”
The single-payer idea surged into the 2020 Democratic presidential race on a wave of momentum. After Sanders’ unexpectedly strong performance against Hillary Rodham Clinton in 2016, many Democrats concluded that his expansive progressivism was ascendant in the party. Four Democratic senators who sought the 2020 nomination ultimately endorsed his single-payer legislation: Warren, Kamala Harris, Cory Booker and Kirsten Gillibrand.
But single payer proved surprisingly vulnerable to counterattacks. Biden and Buttigieg led the charge against it, focusing their fire mostly against Warren, who looked strong in early polls. Once the single-payer advocates “were forced to defend their plan and explain how they were going to pay for it and how it would actually work,” the idea turned out “to have a glass jaw,” says Jim Kessler, executive vice president for policy at Third Way, a centrist Democratic organization. Harris memorably retreated from the idea.
And while Sanders openly embraced massive tax increases, Warren struggled to explain how she would pay for her plan. The critics, led by Biden and Buttigieg, also questioned shifting so much authority to control Americans’ health care to the federal government and forcing people who liked their employer-provided insurance to surrender it for the government alternative. After his early struggles,Biden’s pushback on single payer “was seen as an inflection point by our campaign,” said Andrew Bates, a top communications aide to Biden during the campaign and in the White House.
Though Biden during the primaries embraced the public option as his alternative to single payer, the idea never got off the ground once he took office. Instead, congressional Democrats approved a major funding increase to expand coverage under the ACA. That effort succeeded in increasing the share of Americans with health insurance to a record 92% by 2024.
But costs continued to rise. Federal statistics showed that total national spending on health care by governments, businesses and individuals soared from $4.2 trillion in 2020 to $5.3 trillion in 2024. Even more pressingly, the average premium for employer-provided insurance rose a cumulative 26% from 2020 through 2025, according to KFF. That was even larger than the 21% increase from 2015 to 2020 that boosted single payer in the 2020 race.
For 2026, most Democratic candidates begin their health care messaging with criticizing last year’s double-barreled assault from Trump and congressional Republicans on the ACA — the massive Medicaid cuts approved in the One Big Beautiful Bill Act and the choice to let the enhanced ACA subsidies expire last December. But across the party’s ideological spectrum, many Democrats argue that simply reversing Trump’s cuts is an insufficient health care agenda for 2026, much less 2028. “Yes, we should try to restore the health care tax credits and we should try to make Medicaid whole, but we should also try to go further,” Bates said.
What “further” means, though, remains a matter of intense dispute. Last week, the Center for American Progress, a leading liberal think tank, released a “Patients’ Bill of Rights” to try to immediately reduce health care costs through new regulatory restraints on insurers and hospitals. “The public is hungry for polices that will lower their costs now and the debate about health care system change — whether it’s single payer or a public option – are going to take a decade or so to happen,” said Neera Tanden, the CAP president and CEO and former chief domestic policy adviser for Biden.
Many Democratic candidates, though, want deeper changes in the system. Geoff Garin, a Democratic pollster who has extensively studied health care attitudes, said rising health care costs have made single payer more politically viable than in 2020. “There is a lot of anger about what many voters see as a badly broken health insurance system, more than when Medicare for All was last litigated in 2019 and 2020,” Garin said. “And for that reason, voters are more open to the idea of moving to a single-payer system, including some blue-collar Trump voters.”
But, Garin added, “the cost and tax implications” remain a big hurdle for single-payer proposals, “especially for voters who are used to having an employer pay for most of their insurance costs.”
Single-payer proposals very quickly run into sticker shock. Before the 2020 race, the Urban Institute forecast that Sanders’ plan would cost $34 trillion in federal spending over 10 years, an amount that at the time exceeded the projected 10-year spending on Social Security, Medicare and Medicaid combined. Today the figure would be even more daunting. Holahan told me that as a first cut, he projects a single-payer plan could cost nearly twice as much over the first decade as the Urban Institute estimated before 2020, including the impact of inflation.
Not all of that would be new costs, since the federal government already spends about $1.7 trillion annually on health care. And as Holahan pointed out, the economy is also larger now than it was in 2020, which would provide a broader tax base to support such a proposal. But a single-payer plan would require the federal government to assume responsibility for the two-thirds of national health care costs now covered by households, private businesses and state and local governments — a formidable responsibility that would require massive new sources of revenue.
For comparison, Holahan’s projected 10-year cost for single payer roughly equals the total amount of revenue the Congressional Budget Office forecasts the federal government currently will raise from the income and payroll tax combined over that same period.
These eye-popping prospective costs present an irresistible target for Republicans. Mike Marinella, a spokesperson for the National Republican Congressional Committee, said that while single-payer health care may be attractive in Democratic primaries, in competitive general elections it will be as vulnerable as other vanguard liberal policies have proven, including abolishing ICE and defunding the police. “You see all these candidates pushing each other further and further to the left … and they are going to have to answer for it in the general election,” he said.
One other obstacle for single-payer advocates is that the wrecking-ball tenure of Health and Human Services Secretary Robert F. Kennedy Jr. seems certain to compound fears of providing the federal government so much control over the health care system, including which procedures insurance will cover. “Trust in government health agencies is at its lowest level ever, so I think that would give people some pause at turning over the health insurance system to (them),” said Levitt of KFF.
Single payer has a solid core of Democratic support — 17 Democratic senators have endorsed Sanders’ single-payer health bill, as have more than half of House Democrats — and that is likely to grow in November. Under any realistic scenario, though, the advocates will remain well short of majority support in either the House or Senate, even if Democrats win back both chambers this year or in 2028.
For now, the most tangible impact of single payer’s revival will be to increase pressure on Democrats to pursue a health care agenda that extends well beyond reversing Trump’s cuts to the ACA — even if that increases the party’s vulnerability to Republican counterattacks.
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