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.”

Texas Attorney General Ken Paxton could have picked any number of messages for his first Senate campaign ad of the general election back in May. Texans care a lot about cost of living, border security, healthcare, and corruption, among other issues. But Paxton’s very first ad went with something that pollsters don’t generally ask about. He accused his opponent, Democratic state Rep. James Talarico, of being “Too Low-T for Texas.” Too low in testosterone. Not manly enough. 

Voters generally don’t rank masculinity as a top issue in any race, but Paxton’s opening salvo wasn’t completely out of left field. Young men broke for President Donald Trump by a shocking margin in 2024. During that campaign, Trump played to the “manosphere”, appearing on many a bro-y podcast and leaning on his macho, politically incorrect image for an audience burned out on the politics of Woke 1. 

Paxton, whom Trump endorsed over incumbent Republican Sen. John Cornyn (R-TX) in the primary, is as closely linked to the president as any candidate on the ballot — so it’s not all that surprising to see him attempt the same strategy.

And Texas, after all, has its stereotypes: rugged individualism. Cowboy boots. Smoked meats. Texas Rangers. The list goes on.

Starting with the “Low-T” ad, the Paxton campaign has been all in on exploiting the politics of masculinity and traditional ideas about gender and gender roles to cast Talarico as not man enough to serve as senator — and the rest of the Republican ecosystem has followed suit. 

In May, Trump policy adviser Stephen Miller tweeted that “The Democrats made history in Texas by nominating their first transgender senate candidate.” Vice President JD Vance recently walked right up to the line of calling Talarico gay at a rally in the state. Elon Musk’s super PAC has flooded the state with AI slop commercials like this one, in which an adult drag queen in a sparkly jersey dunks on some female athletes. The commercial attacks Talarico for being supportive of trans athletes. Trump himself has also weighed in, accusing Talarico of veganism — fighting words in some Texas circles. (Talarico, 37, is a cis man, says he has a girlfriend, and denies being a vegan.)

Attacks are one thing, though, and an effective political strategy another. To figure out whether Paxton’s masculinity campaign is working, the Today, Explained team headed to Texas.

“People are mad about other things”

At a Paxton rally in Fort Worth, Texas, on a recent Monday night, Jacenta and Susan Sims were riling each other up, seeing who could get the best dig in at Talarico’s manhood. 

Susan pointed to her own chest. “My shirt says ‘No Tala-freaking-way.’ Because he is kind of a freak,” she said. She listed some of Talarico’s past comments on gender to support her statement. “Like, how are you talking about God like he’s nonbinary and there’s six sexes?” 

Talarico said God was nonbinary during a Texas legislative session in 2021, making what he later described as a “cringey” point about God being above human categorization. Also in 2021, he claimed during a debate over trans kids in sports that there were six sexes. He recently walked that statement back, saying there were only two sexes.

Jacenta Sims at the Paxton rally wasn’t having it: “If you really had to look deep, he’s probably got some lace on his panties. There’s nothing masculine about him.” Susan piped in, “He looks like a little boy. He’s not tough enough.” Back to Jacenta: “And we need masculinity back in Texas.”

Perhaps it’s not surprising that voters who are already all in on Paxton would also be all in on this line of attack. But those are not the voters Paxton needs to convince.

“I don’t care if Talarico’s gay or not. I don’t believe he is, but it wouldn’t matter to me if he is.” Jesse Sandoval said outside the Tarrant County Elections Center in Fort Worth. He’d just cast his ballot in early voting. “I just felt that they were doing that to try to deflect from the real issues.” 

Another early voter, Michael, didn’t want to give his last name, and works as a cook at a local restaurant. “I just feel like this whole toxic masculinity thing is so unnecessary,” he said. “I was raised by someone who was very, very aggressive and just a very macho man. And I feel like you have to educate yourself as to why those things are not — why saying stuff like that isn’t okay, you know?”

Walt Thompson, also at the polling place, said, “Because he’s soft-spoken, they feel that he’s gay. And you know, he’s not. He’s just not this big rugged looking guy. They can’t accept that.”

Nate, a 32-year-old construction worker who also declined to share his last name, said 2026 is a whole different moment from the last presidential election. “If this was 2024, those [messages] are effective. But I think this year it’s not gonna be effective,” he said. “People are mad about other things. When people care about gas prices, they can’t run on that.”

In other words, the culture wars hit differently when you can’t afford to feed your family or drive to work. 

It’s (still) the economy, stupid

Matt Angle is director of the Lone Star Project, a Democratic research PAC and communications firm. He says these attacks on Talarico’s masculinity are a tell from Republicans. 

“What the Republicans are worried about is people staying home,” Angle told Today, Explained. “Those people, they’re mad about the economy, they’re mad at Trump, and [Republicans] are trying to motivate them by playing to their prejudices. … They desperately need fear to be the motivator rather than anger and frustration.” 

So far, it doesn’t seem to be working. Most recent polling puts Talarico in the lead. The Cook Political Report is calling the race a toss-up. The last time Texas elected a Democratic senator was 1988, but Talarico appears to have a real shot at breaking decades of Republican dominance. 

Angle says Talarico’s laser focus on a message of affordability is breaking through to voters.  

“They’re understanding that their salaries aren’t going as far as they should. And they like that somebody’s talking to them about the cost of groceries, the cost of housing, the cost of healthcare,” he said. 

Who gets to own masculinity, anyway?

There’s another key factor in how the GOP’s masculinity attacks are landing: the messenger. Paxton, after all, isn’t exactly a paragon of traditionally masculine virtue. (Just ask Trump, who can’t stop needling his hand-picked candidate for the way he dresses, looks, and talks.)

According to Jill Tate, president of the Texas Federation of Republican Women, many of her members had grown skeptical of Paxton’s candidacy. That’s because his wife, Texas state Sen. Angela Paxton, filed for divorce last year on what she described as “biblical grounds.” The actual filing listed adultery as the reason for divorce. 

“I’ve been involved in Texas politics over 30 years,” Tate said, “and this is the first time I’ve truly been concerned we could lose a statewide [race] since the Republicans took over in the ’90s.” 

Angela Paxton recently did her ex a solid, giving a speech to the Republican women in Tate’s group called the “elephant in the room” speech. She also cut an ad boosting “the Republican ticket,” though not Paxton by name.

“She talked about the fact that while our candidates may fall down and they may do things that are disappointing and morally wrong, it is extremely important to remember that that is the human side. And that’s not what they’re going to do in office,” Tate said of the speech, which urged the audience to vote for the team — for Republicans — rather than on the moral failings of one person. 

Tate believes that the speech changed some minds and could push women in the room to vote for Ken Paxton instead of just staying home. But outside of a room of diehard Republicans, that message — vote for Ken Paxton despite Ken Paxton — may not be a compelling one, no matter how much ads try to paint his opponent as less masculine.

“Texas is a knife fight uphill every day for Democrats,” Angle, the Democratic strategist, said. But in 2026, the mix of a weak Republican candidate and anger at the economy might be enough to give Democrats a chance — and help neutralize Paxton’s efforts to turn the race into a referendum on a very specific view of masculinity.

Ryan Rusak, a veteran Texas politics writer, agrees. “I think that where Talarico can use this to his benefit is to turn it around to say, ‘Okay, well, these guys who wear the boots and eat all the brisket are the ones that got us $5 gas. They’re the ones that got us into a war in Iran. They’re the ones that have gotten it to where you can’t buy a house even in a place where we still make it fairly easy to build houses.’”

“Had we not had an environment like this,” Angle said, “I think it might have been harder for James to break through.”

This story appeared in Today, Explained, a daily newsletter that helps you understand the most compelling news and stories of the day. Subscribe here.

Eighteen years after his first conviction, and seven years after his much-debated death, the ghost of the convicted sex offender Jeffrey Epstein is suddenly inescapable again. 

He’s the subject of scores of midterm campaign ads, each more lurid than the last. A second bill mandating the release of the Epstein files is currently kicking around Congress. And on Monday, House Democrats released a new report alleging that the Justice Department helped cover up details of Epstein’s relationship with President Donald Trump, calling — very aspirationally! — for an independent criminal investigation.

Of course, no one really expects Trump’s attorney general to name a special counsel to investigate the Trump administration. In a statement, one White House spokesperson panned the report as “a desperate attempt by crazed Democrats to distract Americans.” (The timing, just one week before the midterms, does seem pretty fortuitous.)

The document, which runs to 50 pages, draws on public accounts and staff interviews with an unspecified number of survivors, including a former pageant queen who alleges that Trump raped her in 1993. The woman had previously accused Trump of groping her, which a Trump spokesperson dismissed at the time as “fake.”

Go a little deeper

When it comes to Epstein, however, Democrats don’t need a lot of new material to damage Trump. The scandal, and his administration’s handling of it, continue to cast a long, dark shadow over Republicans. 

That’s surprising to me, candidly, because the decades-old dealings of even a very despicable sex offender don’t have any bearing on Americans’ day-to-day costs or experiences. And Trump has been able to brush off a lot of other unsavory behavior and associations. 

But the Epstein story has lodged in the brains of some voters who helped elect Trump — including young voters whose growing disillusionment could make a big difference in next week’s elections.

Many of these young voters “resent the fact that Trump’s basically become part of the establishment” and see the Epstein files as evidence of that, the political analyst Rachel Janfaza recently told Vox. Some also feel burned by Trump’s campaign promise to release the government’s investigative files on Epstein…and his about-face once in office. 

Democrats, sensing an opening, are hammering the issue. Relentlessly so. According to data from the tracker AdImpact cited by NBC News, there are currently more than 500 campaign ads airing across the country that include the words “pedophile” or “predator.” 

Many of them reference Epstein or the so-called Epstein files, and three-quarters are backed by Democrats. One recent ad featuring an Epstein survivor, and targeted at Kansas Republican Roger Marshall, slams the incumbent senator’s September 2025 vote to block a procedural measure that would have released the Epstein files. (The Senate later moved to release the files by unanimous consent.) 

Another ad, this one in Maine, claims that Epstein’s “business partner” funneled $3 million to Sen. Susan Collins’s super PAC. (Importantly, the connection between Epstein and this purported partner is so tenuous as to be nonexistent.) 

These ads will fade after Tuesday, of course. But you haven’t heard the last word on this. Should Democrats win control of either chamber, they’ll gain the power to subpoena witnesses and documents for yet more Epstein investigations. 

Some Democratic leaders in the House are already salivating over that prospect.

One link for later

➨ Ask better questions than “what do you do?” Small talk is often dominated by idle chatter about traffic, weather, or jobs. To actually get to know your conversation partner, try leading with questions that get at their interests: what a friend’s friend is reading, for example, or what a barista’s favorite beverage is. You can even draft a little list of go-to questions in advance to deploy in conversation when you need them. Just don’t treat the exercise like a checklist. The real key to better small talk is being curious. 

Before you go…

• Did you know…that concrete is the second-most-used material on Earth? (The first is water!) Mixing and pouring concrete is responsible for a huge share of global emissions, but there are efforts underway to make it more sustainable.
• Today’s trivia: An arroyo is a stream — or at least, a streambed — found in what type of environment? (You can find this and other brain puzzles in Vox’s daily crossword. Look for the answer in tomorrow’s edition.)
• Yesterday’s trivia: Yesterday we asked you for the name of the lovable yellow dog in the comic strip Garfield. That would be Odie, whose look evolved over the years as illustrator Jim Davis sought to distinguish him from his iconic canine rival Snoopy.