One Issue Where Republicans, Democrats, and Independents Actually Agree
When was the last time 73% of Republicans, Democrats, and Independents agreed on anything?
According to recent polling, that share of American voters across all three groups now believes the U.S. health care system needs major change or a complete rebuild. In the latest Gallup survey, 61% of adults rank the availability and affordability of health care as a "great deal" of concern, pushing it past the economy as the country’s top worry heading into the 2026 midterms. KFF polling shows 56% of adults expect health care to become even less affordable next year, and one in three U.S. adults has rationed prescription doses, borrowed money for medical expenses, or skipped meals to pay for care.
This is no longer a partisan flashpoint. It is a kitchen-table emergency.
How We Got Here
The U.S. spent roughly $14,885 per person on health care in 2024, more than double the OECD average of $5,967. That works out to 17.2% of GDP, compared to 9.3% across peer nations. Despite this, U.S. life expectancy lags behind most wealthy countries, maternal mortality is several times higher than European averages, and roughly 36% of households carry medical debt. About two-thirds of personal bankruptcies in the U.S. cite medical bills as a primary cause, compared to 19% in Canada, 10% in Australia, and 8.2% in the United Kingdom.
The average annual premium for employer-sponsored family coverage rose 6% in 2025 to nearly $27,000. For families on the ACA marketplace, the expiration of enhanced premium tax credits at the end of 2025 has produced sharply higher net premiums in 2026. People are not imagining the squeeze. They are living it.
The "Cut Out the Middleman" Argument
A growing chorus argues that more health care should be delivered directly, removing insurance companies as the middleman. Supporters point to the explosive growth of direct-to-consumer companies offering everything from sex-enhancement medications and GLP-1 weight-loss drugs to Botox and cosmetic fillers. The conclusion they draw is that Americans clearly have an appetite for paying directly for health products, so why not extend the model to medicine more broadly?
The comparison is tempting, but it deserves scrutiny.
A consumer choosing whether to buy semaglutide for weight loss or Botox for forehead lines is making a discretionary purchase. They can decline. They can shop. They can wait. They can decide that the product is not worth the price and move on with their day. None of those options are available when a child develops a fever that won’t break, when a parent has a stroke, or when a routine screening turns up something that requires urgent intervention. Discretionary and luxury health products operate in a market. Essential medical care operates closer to a necessity, like water or electricity, where consumers have neither the time nor the information to bargain.
Most Americans now reflect this distinction in how they talk about the issue. In recent polling, 73% of voters say they prefer to view health care as a public good rather than a business governed by supply and demand. That sentiment crosses party lines. Whether or not policymakers want to call it a "right," the public increasingly treats access to basic care as a baseline expectation of a functioning society.
What a Two-Tier Approach Could Look Like
A reasonable framework that has gained traction in policy circles separates health care into two layers. The first layer guarantees a basic level of care for everyone. The second layer, covering elective and discretionary services, can be financed through private insurance, supplemental plans, employer benefits, or direct payment, depending on what people want to buy.
Below are three of the most-discussed options for delivering that guaranteed first layer, with the trade-offs that come with each.
Option 1: Single-Payer (Government as the Sole Insurer)
Modeled loosely on Canada and the United Kingdom, this approach uses tax revenue to fund a single public insurance plan that covers a defined package of essential services for all residents.
Pros. Administrative costs typically run far lower than in the U.S. multi-payer system. Risk is pooled across the entire population, which lowers per-person costs. Negotiating leverage with hospitals, drug manufacturers, and device makers is significant. Universal coverage is achieved by definition, and medical bankruptcies become rare. Canada’s medical bankruptcy share sits near 19%, the U.K.’s near 8%.
Cons. Wait times for elective procedures are a recurring complaint in single-payer systems. OECD data shows median waits of two to three months for hip replacements in Sweden and Spain, and six months or longer in some Eastern European countries. Tax burdens are higher. Innovation incentives can shift, since government price negotiation reduces margins for drug and device makers. Transition costs in the U.S. would be enormous given how deeply embedded employer-sponsored insurance is in the labor market. The 2018 Mercatus Center analysis of Medicare for All estimated federal costs of roughly $32 trillion over ten years, though many studies suggest total national health spending could fall once private premiums and out-of-pocket spending are netted out.
Option 2: Multi-Payer with Universal Mandate (Bismarck Model)
Used in Germany, the Netherlands, Switzerland, and France, this model keeps multiple insurers in the system but requires every resident to carry coverage. Insurers are tightly regulated, often required to be non-profit or to offer a standard benefit package, and premiums are subsidized for lower-income households.
Pros. Universal coverage is achieved without abolishing private insurance. Choice and competition remain, which many Americans value. Quality outcomes are strong: Germany, France, Japan, and Switzerland consistently rank near the top of OECD outcome metrics. The model is incremental in spirit, building on what the U.S. already has rather than replacing it.
Cons. Switzerland, the system most often compared to a regulated U.S. marketplace, has high per-capita out-of-pocket costs, around $1,988 per person, which is actually higher than the U.S. figure of $1,425. Heavy regulation is essential to keep premiums affordable, and political appetite for that level of oversight is uncertain. Administrative complexity remains higher than in single-payer systems.
Option 3: Public Option Layered Onto the Existing System
This approach keeps employer-sponsored insurance, Medicare, Medicaid, and the ACA marketplace intact while creating a government-run insurance plan that anyone can buy into. Several states have piloted versions, and Washington became the first to launch a public option in 2021.
Pros. It is the least disruptive of the major reform paths. People who like their current coverage can keep it. The public option introduces price competition, which has been shown in early state pilots to put downward pressure on private premiums. It offers a safety net for the millions caught between Medicaid eligibility and affordable employer coverage.
Cons. A public option does not by itself guarantee universal coverage. Roughly 26 million Americans remain uninsured even under the ACA, and a public option would only reach those who actively enroll. Setting reimbursement rates is politically difficult: too high, and it fails to lower costs; too low, and providers refuse to accept it. Washington’s early experience showed modest enrollment and limited cost reductions, partly because the plan struggled to recruit hospital networks at lower payment rates.
A Direct Primary Care Layer for the Foundation
Some reformers have proposed that direct primary care (DPC) could form the actual delivery mechanism for the basic-care layer. In DPC, patients pay a flat monthly fee, typically $55 to $150, directly to a primary care practice in exchange for unlimited visits, basic procedures, and routine preventive care. Studies suggest DPC can reduce administrative costs, improve preventive care uptake, and increase physician satisfaction. The drawback is equity: in its current form, DPC is purchased by individuals or employers, which leaves out the people who most need consistent primary care. A government-funded DPC layer, paired with catastrophic coverage for hospitalizations, has been floated as a hybrid worth piloting.
What the Second Tier Could Cover
Once a basic care floor is established, the case for a robust private market becomes stronger, not weaker. Discretionary and elective care, including cosmetic procedures, fertility treatments beyond a basic package, premium private rooms, expanded mental health offerings, certain weight-management drugs, advanced dental and vision options, and concierge services, could be covered by:
Traditional private insurance plans purchased individually or through employers
Health Savings Accounts paired with high-deductible supplemental plans
Direct-to-consumer subscription services for specific therapies
Supplemental policies similar to Medigap, which already work alongside Medicare
In Germany and France, roughly 85% of residents carry some form of supplemental private insurance on top of the public baseline. In Australia, about 45% do. The presence of universal basic coverage has not killed private insurance in those countries. It has refocused it.
The Bipartisan Opening
The most striking finding in recent polling is not which reform Americans prefer. It is that they want one. Across party lines, voters describe the system as broken and want lawmakers to act. Republican voters tend to favor market-based reforms, expanded HSAs, and price transparency. Democratic voters tend to favor expanded subsidies, public options, and stronger drug-price negotiation. Independents generally want both sides to stop posturing and produce something workable.
A two-tier framework, guaranteed basic care plus a vibrant private market for everything else, borrows from both traditions. It addresses the moral concern that no one should go bankrupt or die because they cannot afford a hospital visit. It also preserves the consumer choice and market dynamism that many Americans value, including in the very direct-to-consumer health products that have grown so quickly in recent years.
The U.S. spends more than any nation on Earth on health care and gets less for it than most peer countries. That gap is not destiny. It is a policy choice, and policy choices can be revisited.
The voters are ready. The data is clear. The question is whether the people in office are willing to meet the moment.
What does basic care look like to you, and where would you draw the line between guaranteed coverage and discretionary choice? I would love to hear your thoughts in the comments.
A knowledgeable patient is a prepared patient. Learn how the system works to protect your health and your assets. “The Prepared Patient: Your Guide to Surviving the Health Care System” to be released August 11, 2026 and is available for preorder from Amazon, Barnes and Noble and Johns Hopkins University Press.