Single-payer healthcare has majority public support. A KFF poll found that 65% of voters support Medicare for All — including 78% of Democrats, 71% of independents, and 49% of Republicans. When nearly half of Republican voters support a policy their party uniformly opposes in Congress, the explanation is not ideological disagreement between the public and its representatives. It is something else. This part examines what that something else is — the financial interests, the organized opposition, the political mechanisms, and the structural obstacles that have prevented a majority-supported policy from receiving a floor vote in either chamber of Congress.
What the Industry Stands to Lose
The starting point for understanding the political obstacles to single-payer is understanding what is at stake financially for the industries that oppose it.
Under single-payer, private health insurance for basic coverage is eliminated. The four largest health insurers in the United States by revenue — UnitedHealth Group, CVS Health, Centene, and Elevance Health — posted combined revenues exceeding $1.2 trillion in 2025. This is not a lobby protecting a business interest. It is an industry protecting its entire reason for existing.
The pharmaceutical industry faces a different but comparably significant threat. Under single-payer, the government negotiates drug prices as the sole buyer for the entire country — monopsony power that every other wealthy nation exercises and that the US currently prohibits in Medicare. The drug price differential documented in RAND Corporation research — US prices averaging 2.78 times comparable country prices — represents the financial value of that prohibition to the pharmaceutical industry. Single-payer eliminates it.
For-profit hospital systems face pressure on reimbursement rates under single-payer, as government-set rates replace the negotiated rates that allow high-margin procedures and privately insured patients to cross-subsidize lower-margin care. Community and nonprofit hospitals have a more complex relationship with reform — many would benefit from the elimination of uncompensated care and administrative complexity — but the for-profit hospital lobby has aligned with the opposition.
The Lobbying Infrastructure
The financial interests at stake have generated a lobbying infrastructure commensurate with their scale.
Reported industry-wide lobbying in the healthcare sector topped $439 million in 2025. The largest Medicare Advantage insurers deployed more than 220 lobbyists to Capitol Hill in 2024 and spent more than $330 million on lobbying across all issues over the preceding five years.
PhRMA — the pharmaceutical industry’s primary trade association — spent over $20.6 million lobbying the federal government in just the first half of 2025. The pharmaceutical and health products sector overall spent $226.8 million in lobbying in the first half of 2025 — approximately $22 million more than the same period in 2024.
The American Hospital Association increased its lobbying spending in the first quarter of 2025 by more than $1 million over the prior year. The Federation of American Hospitals — representing for-profit hospital systems — increased its spending to $1 million from $650,000.
These figures represent disclosed lobbying expenditures under federal reporting requirements. They do not include campaign contributions, which flow through separate reporting systems, or the funding of third-party organizations, think tanks, and advocacy groups that advance industry positions without direct disclosure of the funding source.
The Partnership for America’s Health Care Future
The Partnership for America’s Health Care Future was formed specifically and exclusively to defeat single-payer healthcare proposals. It is not a free-market advocacy organization with a broad policy agenda. Its stated purpose is opposition to Medicare for All and similar proposals.
Its founding members included the Federation of American Hospitals, America’s Health Insurance Plans, and PhRMA, with the American Hospital Association and Blue Cross Blue Shield Association joining after formation. The American Medical Association was an early member but departed the coalition in August 2020; the AMA has maintained its own positions on healthcare reform independent of PAHCF membership. The coalition’s broader membership includes more than one hundred organizations in total. The organization funded online advertising campaigns, lobbying operations, and media outreach specifically designed to reduce public support for single-payer proposals during the period when Medicare for All was receiving significant congressional attention.
The Partnership’s existence and activities are documented through its own disclosures, news coverage, and congressional testimony. It represents the organized coordination of the industries most financially threatened by single-payer reform.
PhRMA and the Project 2025 Connection
PhRMA donated $530,000 to organizations involved in the Project 2025 agenda. Project 2025 called for repealing Medicare drug price negotiation provisions — provisions that had been enacted with bipartisan support and that polling found supported by 76% of Americans, including two-thirds of Republicans.
The Medicare Drug Price Negotiation program, implemented through the Inflation Reduction Act, gave Medicare limited authority to negotiate prices for a defined set of high-cost drugs. PhRMA opposed it. The industry donated to political organizations working to reverse it. The Congressional Budget Office estimates that the rollbacks to the drug pricing negotiation program included in subsequent legislation will save the pharmaceutical industry $8.8 billion over the next decade — at a corresponding cost to Medicare beneficiaries and taxpayers.
This transaction — industry funding of political organizations that produce policy outcomes worth billions to that industry — is the documented mechanism of legislative influence. It is legal. It is disclosed, imperfectly, through various reporting requirements. And it produces policy outcomes that are directly opposed to the preferences of the public majorities that support drug price negotiation.
The Regulatory Capture Problem
Regulatory capture describes the process by which the agencies responsible for overseeing an industry come to serve that industry’s interests rather than the public interest. The healthcare sector provides a documented example.
Mehmet Oz, appointed by the Trump administration to lead the Centers for Medicare and Medicaid Services — the agency responsible for overseeing Medicare Advantage — disclosed during his 2022 Senate campaign hundreds of thousands of dollars in investments in UnitedHealth Group and CVS Health. He now regulates the industry in which he held those investments.
The conflict of interest this creates is not hypothetical. CMS is the agency that sets Medicare Advantage payment rates, reviews upcoding allegations, and oversees the program that MedPAC has found generates $84 billion in annual overpayments. The administrator of that agency held financial interests in the companies generating those overpayments before his appointment.
The Bipartisan Funding Problem
The insurance and pharmaceutical industries do not fund only one party. Campaign contribution data shows substantial flows to members of both parties, with particular concentration among members of committees with jurisdiction over healthcare legislation — the Senate Finance Committee, the House Ways and Means Committee, and the House Energy and Commerce Committee.
This bipartisan funding pattern explains an otherwise puzzling historical fact: Democrats held the presidency, the House, and the Senate simultaneously in 2009–2010 and again in 2021–2022. In neither period did Medicare for All receive a floor vote in either chamber. The explanation offered by advocates of single-payer is straightforward: the financial flows from the healthcare industry to Democratic members of Congress — particularly those representing swing states and districts where the industry is a significant employer and donor — were sufficient to prevent the votes from being assembled, even when the legislative majority existed.
This is not a partisan observation. It is a structural one. The healthcare industry’s political strategy does not require defeating single-payer in a direct legislative confrontation. It requires only that enough members of both parties be unwilling to bring it to a floor vote. The lobbying investment is calibrated to that much more achievable goal.
The Filibuster as Final Shield
Single-payer healthcare cannot pass the Senate under current rules with 51 votes. It requires 60 votes to overcome a filibuster. The Senate has not had 60 votes for single-payer healthcare in modern legislative history and is not close to it.
The filibuster is not mentioned in the Constitution. It is a Senate procedural rule that can be changed by a simple majority vote of the Senate. It has been modified or eliminated for specific categories of legislation — judicial nominations, executive appointments — when the majority party found those modifications politically advantageous. It has not been eliminated for domestic legislation generally, in part because members of both parties have used it or anticipated using it as a minority protection.
The interaction of the filibuster with the lobbying infrastructure described above creates a specific dynamic: the industry does not need to prevent 60 senators from supporting single-payer. It needs to prevent 41 senators from supporting cloture on a single-payer bill. Given the financial flows to members of both parties, that is a substantially more achievable target.
The Taiwan Lesson, Revisited
Part 4 of this series noted that Taiwan implemented single-payer in 1995 in part because the private insurance industry did not yet exist in sufficient force to prevent it. That observation becomes more pointed in the context of this part’s evidence.
Taiwan’s health policy architects, reflecting on their 1995 implementation, have noted explicitly that the window for reform closed as Taiwan’s private insurance market grew. The absence of an organized, well-funded opposition at the moment of reform was not incidental to Taiwan’s success. It was a primary enabling condition.
The United States faces the inverse of that condition. The industry that would be most disrupted by single-payer reform has had decades to build its political infrastructure, its lobbying operations, its regulatory relationships, and its funding of both parties’ elected officials. The obstacles to reform in the United States are not technical — the evidence on how to design and fund a universal system is abundant. They are political, and the political obstacles are the direct product of financial interests that are both enormous and well-organized.
The Current Moment
The Congressional Budget Office has projected that Medicaid cuts in recent federal legislation will result in 15 million Americans losing health insurance over the next decade and a $1.1 trillion reduction in health sector spending. The status quo is not stable. The number of Americans without meaningful healthcare access is increasing.
The insurance industry’s revenue, its lobbying expenditure, and its political influence are all at historically high levels. The public support for fundamental reform is also at historically high levels. The distance between what the public wants and what the political system produces on healthcare has not been wider in recent memory.
Whether that distance narrows — and through what mechanism — is a question this series documents but cannot resolve. The evidence on the policy is clear. The evidence on the political obstacles is equally clear. What happens next is determined by factors that research can illuminate but not predict.
Sources
KFF: Medicare for All polling data, support by party affiliation.
OpenSecrets: Healthcare sector lobbying database, 2025 expenditures.
Senate Finance Committee: Medicare Advantage lobbying report, lobbyist deployment data.
Partnership for America’s Health Care Future: Organizational disclosures, membership, activities.
PhRMA: Lobbying disclosure filings, first half 2025.
CBO: Medicare drug pricing rollback analysis, $8.8 billion industry savings estimate.
CBO: Medicaid cuts coverage loss projection, One Big Beautiful Bill.
American Hospital Association: Lobbying disclosure filings, Q1 2025.
Federation of American Hospitals: Lobbying disclosure filings, 2025.
Dr. Oz financial disclosure filings: 2022 Senate campaign, UnitedHealth Group and CVS Health holdings.
Taiwan NHI implementation history: Health policy research literature.
KFF: Combined health insurer revenue, 2025.
The Complete Single Payer Healthcare Series
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