How Elizabeth Warren Got to ‘Yes’ on Medicare for All

Two days before Senator Elizabeth Warren rolled out a fundamental reimagining of America’s health care and tax system — a $20.5 trillion package that would dwarf all her previous plans combined — she was working the phones to personally preview her proposal and sell it to a select group of political influencers.

One was Paul Krugman, the Nobel Prize-winning economist and New York Times columnist, who had written skeptically days earlier that her plan to pay for “Medicare for all” was a “make-or-break moment” for her, if not the whole 2020 race. Another call was to Representative Pramila Jayapal, the lead sponsor of Medicare for all legislation in the House and a leading liberal as the co-chair of the Congressional Progressive Caucus.

“Pramila,” Ms. Warren told her, “we’re gonna do this.”

She would soon need every ally possible: Ms. Warren’s announcement of her Medicare for all financing package is perhaps the riskiest political bet of her campaign. Her Democratic rivals have attacked her plan as unfeasible and some voters worry that it is too radical. Ms. Warren would guarantee government health coverage to every American for the first time, erase the existing system of private insurance that currently covers more than 170 million people and pay for it with huge new taxes on corporations and the wealthy but not, her campaign claimed, with “one penny” from the middle class.

The sprawling plan is the culmination of Ms. Warren’s yearslong journey toward a full embrace of Medicare for all and a clear sign that she believes her path to the Democratic nomination, and her party’s to the White House, is through full-throated liberalism.

And yet the politics of health care have always been thorny — they powered the Democratic takeover of the House in 2018 and the Republican wave in 2010. Ms. Warren appeared to nod to that reality on Friday, announcing a two-step transition plan that would give her up to three years to try to pass Medicare for all.

The twist is that health care was never supposed to define Ms. Warren’s candidacy. That was Senator Bernie Sanders’s signature issue. Ms. Warren had entered the race and gained momentum with a populist agenda focused on breaking up Big Tech, tackling corruption in Washington and on Wall Street, and making corporations and the wealthiest Americans pay more in taxes.

But her decision to remake the health care system is now a major part of the 2020 debate, and Ms. Warren’s upward momentum in the polls has stalled as her opponents have assailed her. Political strategists say the sheer scope of her plan and her support for ending private insurance threaten to subsume her candidacy.

“She took most, if not all, of her chips and put them on this — and I do think it took a lot of political guts,” said Chris Lehane, a veteran Democratic strategist who worked in the Clinton White House. “By going big on health care, she will either go to the White House on this issue or go home because of it.”

How Ms. Warren came to put together her blueprint, including her determination to avoid middle-class tax increases, offers a revealing window into the methodical way that she operates, her approach to political balancing acts and how she might govern as president. It is a story that begins with Ms. Warren researching medical bankruptcies at Harvard nearly two decades ago and ends with her as a front-runner for the Democratic nomination, rolling out a plan while under siege from her rivals for more specifics.

Throughout, Ms. Warren has kept one eye trained on policy and the other on realpolitik: protecting her aspirational brand of liberalism and robbing Republicans (and her Democratic rivals) of a potent talking point about middle-class taxes. She ignored those in the Democratic establishment who had warned her against eliminating private insurance, and ultimately settled on a proposal whose math loosely adds up but that many, even within her party, see as mostly a values statement.

The transition she announced Friday focuses her first 100 days on a public health insurance plan closer to what her more moderate rivals have championed — drawing instant condemnation that she was trying to have it both ways. “We’re not going to beat Donald Trump next year with double talk on health care,” Kate Bedingfield, a deputy campaign manager for Mr. Biden, said on Friday.

The backlash seemed to ensure that Ms. Warren will face even more pressure to explain her stance in the Democratic debate in Atlanta on Wednesday.

“Up until putting a price tag on Medicare for all she had imposed her will on the primary and dictated the tempo on her terms,” Mr. Lehane said. “This is first time that she is having to react and not follow her campaign script.”

A plan conspicuous by its absence

Ms. Warren had a plan for everything. That was her calling card almost from the start of the race. But health care was conspicuous it its absence, all the way back to her first trip to Iowa, when she barely mentioned Medicare for all. In June, Ms. Warren simply tucked into the slipstream of her liberal rival, Mr. Sanders, on his signature issue.

“I’m with Bernie on Medicare for all,” she said at the first debate.

But by fall, health care was emerging as the No. 1 issue in the campaign, and the absence of a plan was increasingly untenable. She was dogged for weeks by questions about whom she would raise taxes on, saying only that total costs for the middle class would go down.

“Your signature, senator, is to have a plan for everything,” Mayor Pete Buttigieg took aim at the last debate. “Except this.”

What few people knew then was that Ms. Warren and her Boston-based team had been privately crunching numbers since at least late August, working with the internal imperative to craft a package without hiking middle-class taxes, according to interviews with people directly involved in the process.

The onslaught at the debate accelerated the timeline. One academic described working so hard with Warren officials in late October that he was distracted from his teaching duties; another said she made final edits on a letter endorsing Ms. Warren’s math in her car at her child’s school during a Halloween parade.

“Syria is easier compared to this,” said one Warren adviser, granted anonymity to speak about the process of crafting a plan.

Kristen Orthman, Ms. Warren’s communications director, said the campaign had not been and would not be buffeted by “the cable news flavor of the week.”

“We are running a campaign on identifying what’s broken, presenting big ideas to fix it, and building a grass-roots movement to make it happen and that’s exactly what we did here,” Ms. Orthman said.

Skeptics of Medicare for all have ranged from Hillary Clinton to House Speaker Nancy Pelosi to former President Barack Obama, who on Friday night issued a warning of his own about disrupting people’s existing insurance. “Eighty-five percent of the country has health care,” Mr. Obama said. “They may not love it, but it roughly works for them.”

Kathleen Sebelius, who had a front-row seat to the health care wars of the last decade as Mr. Obama’s first secretary of health and human services, sounded a similar note of caution. “We saw the Republicans very effectively demagogue the issue,” she said.

Even some of Ms. Warren’s supporters are wary.

“It still kind of scares me,” said Eric Spera, a 40-year-old who attended a recent town hall in Goose Creek, S.C. “I love her. I think she’s the best candidate that there is. But that’s the only drawback I have with her.”

Yet in some ways, Ms. Warren has almost proceeded as if her announcement did not happen. On the stump, she only glancingly mentions health care. And speaking to reporters the day after unveiling her Medicare for all financing plan, she uncharacteristically stumbled over the specifics, insisting, incorrectly, that only billionaires would see their taxes go up.

From skeptic to supporter

Nearly two decades earlier, Ms. Warren was meeting with fellow Harvard researchers in her light-filled office at the university’s Radcliffe Institute to pore over hundreds of accounts of how Americans went bankrupt.

The same answer kept popping up: medical bills.

“We started to hear things like, ‘I have diabetes and I can’t afford to save,’ and older people who had no savings left because of their medical bills,” said Deborah Thorne, a researcher who worked closely with Ms. Warren on the project. “I do think you could have watched our views evolving then, both for Elizabeth and me.”

Ms. Thorne recalled one story that stood out especially: a middle-aged man who had spent hours debating with his wife about whether to go to the emergency room for a second heart attack; they were worried about the bills they could not afford to pay after the first one.

“Both of us were so moved by the data and the people’s experiences, it made it clear to us: This isn’t working,” Ms. Thorne said. “So what would?”

In 2008, Ms. Thorne and Ms. Warren co-wrote a book chapter where they described single-payer health care as “the most obvious solution” to medical bankruptcy. A few paragraphs later though, they acknowledged that other policy options exist “if single-payer health insurance is politically unacceptable.”

In Ms. Warren’s 2012 Senate run, her lone competitive race against a Republican, she resisted endorsing a government-run health care program, saying “you’ve got to stay with what’s possible,” an echo of what former Vice President Joseph R. Biden Jr. now says.

Four year later another member of the Harvard research team, Steffie Woolhandler, a longtime single-payer advocate, traveled to Washington to make her case for Medicare for all to Ms. Warren. But the senator demurred, saying that she would prioritize “supporting the Affordable Care Act and helping Democrats hold onto the Senate” in the upcoming election.

But a year later, it was Ms. Warren reaching out, inviting Ms. Woolhandler to her Massachusetts home on June 19, 2017. There, over tea on an indoor porch, Ms. Warren peppered her with questions about the economics of Medicare for all.

“She seemed to be thinking through the economics — essentially, why can other nations with single-payer spend no more than we do and cover everybody?” Ms. Woolhandler said.

Days later, she called for single-payer for the first time. And in September, she signed onto Mr. Sanders’s single-payer legislation. Mr. Sanders has framed health care chiefly as a matter of human rights, a way to provide medical care to the masses. Ms. Warren focused on eliminating the medical bankruptcies she had seen in her research.

Under Medicare for all, she said at the time, “Families don’t have to bear the costs of heartbreaking medical disasters on their own.”

But she stopped well short that day of saying it was the only way to proceed. “Everything should be on the table,” she said. “Medicare for all is one way.”

An early 2020 “litmus test”

The Sanders legislation represented an early 2020 ideological crossroads, not only for Ms. Warren but for much of the presidential primary field. Multiple advisers to potential candidates said the decision on whether to join with Mr. Sanders, who had made Medicare for all central to his insurgent 2016 campaign, presented one of the first sorting moments of the coming primary.

“There are people who thought it was a litmus test for being able to run for president,” said Senator Michael Bennet, a moderate Democrat who is using a long-shot presidential bid to warn his party about the electoral risk of Medicare for all.

But long after endorsing the Sanders bill, Ms. Warren’s language on Medicare for all remained fluid.

In March 2019, at a CNN forum, she said there were “a lot of different pathways” for universal coverage, and that private insurers “could” still have a role. By June, Ms. Warren was more unequivocal, raising her hand at the first presidential debate to endorse doing away with private insurers entirely.

Still, she allowed herself room to maneuver, especially on how the program would be paid for. She repeatedly refused to rule out raising middle-class taxes, saying only that she would lower overall costs. The tension came to a head in a July post-debate interview, when Chris Matthews, pressed her in a live interview on MSNBC to say what would happen to taxes. Over and over, she refused to answer.

By September, the headlines were everywhere: The candidate with a plan for everything did not have one for the issue at the center of the race. The tax question became so commonplace that Ms. Warren even got advice from the late-night host Stephen Colbert, who recommended she compare it to taxes for public schools.

Behind the scenes, her team was already pressing to get the senator on firmer rhetorical and financial footing. Two long-serving Warren aides, Jon Donenberg and Bharat Ramamurti, were spearheading the effort to develop a financing plan over the summer, with Mr. Donenberg briefing Ms. Warren on various cost options.

But the plan was not quite cooked yet by the time she stepped on the debate stage in Ohio with a bull’s-eye on her back. She had just caught Mr. Biden in national polling averages for the first time, and staked out a lead in Iowa.

A final rush

The attacks began almost immediately. First came Mr. Buttigieg. Then Senator Amy Klobuchar (“At least Bernie’s being honest here,” she said). Then Mr. Biden (“On the single most important thing facing the American public,” he said, “I think it’s awfully important to be straightforward with them.”)

From a hotel room thousands of miles away, Donald Berwick, a former federal health care official, had watched it unfold with growing frustration. For six weeks, he had been stealthily working with Ms. Warren’s campaign to develop a comprehensive way to pay for Medicare for all.

Ms. Warren’s own staff had produced the initial outline of her proposal and began circulating it among a small network of economists and academics, both for input and, eventually, public validation.

“It did kick into a higher gear after the last debate,” said Mark Zandi, chief economist of Moody’s Analytics, whom the campaign has consulted on this and other policy proposals.

The Warren campaign also tipped the progressive group Data for Progress about her proposal; it rushed a poll into the field on Oct. 30 and 31, and released its favorable results on Nov. 1, the same day as Ms. Warren’s plan.

The proposal, which would cost $20. 5 trillion over 10 years, immediately came under attack from Ms. Warren’s rivals, chiefly Mr. Biden, who said “she’s making it up.” His campaign manager recently warned that Medicare for all could cost Democrats the House.

Ms. Jayapal, the Seattle congresswoman whom Ms. Warren called before releasing her plan, said it was a milestone to have a front-runner fully embrace government-provided Medicare for all.

“It was tricky political terrain because it was Bernie’s issue,” said Ms. Jayapal, who has not endorsed a Democratic candidate. “She had to figure out a way to not step on that but also make the issue her own.”

At a campaign event in North Carolina recently, Ms. Warren delivered an emphatic rejoinder to those who said it was misguided and impossible to enact.

“You don’t get what you don’t fight for,” she said.

Less than 30 minutes earlier, Ms. Warren had been asked to list the first three bills she would want to sign into law. Medicare for all did not make the cut.

Jonathan Martin contributed reporting.