Issue explainer

Health care

Most Americans get health insurance through a job, while others rely on Medicare, Medicaid or the ACA marketplace. Texas has the highest uninsured rate in the country. Larger marketplace subsidies expired at the end of 2025, and the debate runs from more market competition to government coverage for everyone.

The basics

In 2024, 53.8% of Americans had job-based coverage for some or all of the year, 19.1% had Medicare, 17.6% had Medicaid and 10.7% bought their own coverage¹. Some people have more than one type. Nationally, 8.2% of people were uninsured in 2024, according to the Census Bureau's American Community Survey².

The Affordable Care Act (ACA) marketplace is where people without job-based coverage can buy private plans, with tax credits based on income³. Larger, temporary tax credits first passed in 2021 expired at the end of 2025³. KFF estimates average monthly marketplace enrollment could fall to about 17.5 million people in 2026, down from 22.3 million in 2025³.

In January 2026 the House voted 230 to 196 to bring the larger credits back for three years, and the bill went to the Senate⁴. As of mid-2026, the larger credits had not returned³.

The 2025 tax and spending law also changed Medicaid⁵. Starting January 1, 2027, adults covered through Medicaid expansion must work, volunteer or be in training at least 80 hours a month, with some exemptions⁵.

Key terms

Medicare: Federal health insurance mainly for people 65 and older and some people with disabilities. It covered 19.1% of Americans in 2024¹.
Medicaid: Health coverage for people with low incomes, paid for jointly by the federal government and the states and run by each state. It covered 17.6% of Americans in 2024¹.
ACA marketplace: Where people without job-based coverage shop for private plans, with income-based tax credits to lower premiums³.
Public option: A government-run plan that would compete with private plans on the marketplace. No national public option exists today.
Medicare for All (single payer): A system in which one government plan covers everyone and replaces most private insurance.

In Texas

Texas had the highest uninsured rate of any state in 2024: 16.7%, compared with 8.2% nationwide².

Texas is one of 10 states that have not expanded Medicaid under the ACA⁶⁷. As a result, Texas Medicaid covers few adults. A parent in a family of three loses eligibility at about $4,098 a year in income, the lowest limit in the nation⁷. Supporters of the current approach point to cost and state control, while supporters of expansion point to federal matching money and coverage gains in other states.

Because Texas did not expand Medicaid, the new federal Medicaid work requirement for expansion adults largely does not reach Texas⁵⁷. The end of the larger marketplace tax credits does affect Texans who buy their own coverage³.

How people see it

The strongest case for each view, in terms its supporters would recognize. We don't pick a side.

Mostly private market

Supporters say government rules and programs drive up costs and limit choice. They would roll back federal mandates, let people buy the plans they want, expand health savings accounts, and rely on competition to lower prices, with targeted help for people who truly cannot afford care.

Private insurance with more competition and price transparency

Supporters say patients should be able to see prices before they get care and shop for value. They would keep protections for people with pre-existing conditions, require hospitals and insurers to post real prices, and widen plan choices.

Keep the ACA and fix what is broken

Supporters say the ACA expanded coverage and protected people with pre-existing conditions, so the goal should be repair, not repeal. They would restore or adjust the marketplace tax credits and tackle high deductibles and drug prices.

Add a public option

Supporters say a government plan anyone could buy would add competition, especially where few insurers compete, and give people a lower-cost choice while keeping private insurance for those who like it.

Medicare for All

Supporters say health care is a right and the U.S. spends more than other wealthy countries without better results. One public plan covering everyone, they argue, would end surprise bills and gaps in coverage and use its size to bargain down prices.

Who decides

U.S. Congress and the President: Set national health law, Medicare, federal Medicaid rules and marketplace tax credits.
Centers for Medicare and Medicaid Services: Federal agency that runs Medicare and HealthCare.gov and oversees state Medicaid programs.
Texas Legislature and Governor: Decide whether to expand Medicaid and set Texas Medicaid rules and funding.
Texas Health and Human Services Commission: Runs Texas Medicaid and CHIP day to day.
Texas Department of Insurance: Regulates many private health plans sold in Texas.

Questions to ask a candidate

Should Congress bring back the larger ACA marketplace tax credits that expired at the end of 2025?
Should Texas expand Medicaid? If not, how would you lower the state's uninsured rate?
Would you keep protections for people with pre-existing conditions, and how?
What one step would you take to lower what families pay for health care?

Last reviewed 2026-09-26. Spotted something wrong? Every claim links to its source so you can check it yourself.