Early on, the Massachusetts Democrat and 2020 presidential hopeful suggested she thought of Medicare for All in more aspirational terms. During a March interview on Bloomberg television, she said her goal was “affordable coverage for every American” but that there are “different ways we can get there.” It was a variation on a line she used two months earlier, during a CNN event: “When we talk about Medicare for All, there are a lot of different pathways.”
Warren also declined for months to issue her own detailed proposal, telling questioners simply that “I’m with Bernie,” even though she was rolling out plans for just about every other issue.
In just the last three weeks, that has changed, first when she unveiled a detailed plan to finance Medicare for All and then, late last week, when she proposed a two-step process for putting such a system in place.
Step one would be a set of executive orders, along with new legislation to bolster the Affordable Care Act and create a government-run “public option” open to anybody. The goal would be to make that happen within the first hundred days. Step two would be pursuit of comprehensive Medicare for All legislation that would make enrollment in the new government plan mandatory.
Warren says that second step, the full vote, would not come until 2023. Many progressives have interpreted that as a retreat ― and confirmation Warren that lacks the conviction of Bernie Sanders, the independent Vermont senator who is also running for president and has been Medicare for All’s loudest, most consistent advocate.
Sanders responded to Warren’s announcement by reiterating his commitment to introducing Medicare for All legislation in the first week of his presidency, suggesting those progressives may be right about which candidate is more committed to the concept.
But does that mean Warren’s approach is a less reliable way to help people pay for medical bills and, ultimately, to make health care a universal right? That is a lot less clear.
Warren’s History On Health Care
The differences between Warren and Sanders are obvious to anybody who has watched them campaign. Medicare for All is dear to Sanders and a core part of his identity in a way that it simply hasn’t been for Warren, whose passion has always been more with fighting corruption and regulating Wall Street.
It is no coincidence that the first program she proposed in her presidential campaign was for a different kind of welfare state expansion, a universal child care initiative, or that health care has generally gotten less attention in her stump speeches than countless other issues.
Still, it is not as if Warren doesn’t care about health care. The academic work that first brought her national attention and got her interested in politics focused on bankruptcy, a subject in which medical bills came up frequently. And her progressive bona fides are beyond reproach, or at least they should be. Since coming to the Senate, her voting record has consistently been on the very progressive edge, surpassing even Sanders, according to the site VoteView.
When Warren finally decided to develop her own health care plan, according to recent reporting in The New York Times, she turned to two of the country’s best known Medicare for All advocates: Donald Berwick, who was chief administrator of Medicare and Medicaid during the Obama administration, and Steffie Woolhandler, who was co-founder of Physicians for a National Health Program.
Those contacts say a lot about Warren’s instincts on policy. And the first step of her two-step proposal is designed to be a lot more ambitious than it might sound at first blush.
Her proposed executive actions include threatening the patent rights of drug companies that won’t lower the prices of expensive and essential drugs. Her proposed legislation would create a public option, open to anybody, that for a large swath of the population would cover medical care with zero out-of-pocket costs.
Two Strategies For Health Care Reform
The actual details of Warren’s proposed legislation are something of a mishmash that would likely require substantial modification before Congress could take it up. As Jon Walker put it in The American Prospect, the proper way to think about her proposal is probably as a “statement ... on her legislative strategy, her priorities, and her view of what is possible.”
But that statement is precisely what many progressives are questioning.
Enacting any major health care bill would be difficult for a new Democratic president after the next election, given the inevitable opposition of industry groups and slim Senate majority Democrats would have even under the best circumstances. Warren’s smartest progressive critics recognize this.
Warren’s error, according to the progressive critique, is in conceding policy ground upfront rather than laying out an ideal vision and bargaining back from there. “It may be necessary to accept half a loaf in the negotiation stage,” The Week’s Ryan Cooper wrote on Monday, “but only then, and only because moderates wouldn’t accept anything better.”
It’s a reasonable argument. As the saying goes, there’s no point in compromising with yourself. But you can’t compromise with anybody if you never get to the negotiating table in the first place. And that is a real danger of promoting Medicare for All right away: that it will alienate voters Democratic candidates need in order to win in 2020.
The prospect of eliminating private insurance spooks a lot of Americans, as polls have shown pretty consistently. The issue isn’t so much that people love their existing coverage. It’s that they’re wary of an untested, hypothetical public insurance alternative, especially at a time when trust in the federal government is at historic lows.
In October 1964, when Lyndon Johnson was running for president on a promise to enact the original Medicare program, 77% of Americans believed the government did the right thing all or most of the time, according to the National Election Survey. Since then, NES, Gallup and Pew Research have asked versions of that question repeatedly and the number has fallen dramatically. As of this March, it was down to 17%.
Executive actions to lower drug prices and the creation of a successful, but voluntary public insurance program could help restore some of that lost faith in the federal government ― or, at the very least, it could persuade people that giving up private coverage isn’t so risky. That would likely make Medicare for All an easier political sell.
The Differences That Matter Most
Whether Sanders or Warren has the better of this argument about health care strategy is impossible to say. No Democratic candidate in recent memory has built a grassroots movement for specific legislation in the way Sanders has. It may be that such a focused, impassioned campaign on behalf of Medicare for All would persuade skeptical voters and overwhelm industry critics in a way that past reform efforts have not.
It’s also impossible to say whether Warren’s position will protect her from charges that she would take away private insurance, given her past statements and promise to pursue full Medicare for All legislation in three years. It may be that the only way to avoid that political vulnerability is to steer clear of any commitment to Medicare for All in the near future, as former Vice President Joe Biden and Pete Buttigieg, the Democratic mayor of South Bend, Indiana, have.
And finally it is impossible to say how consequential a candidate’s position on Medicare for All will ultimately prove in the general election. Other issues will be vying for attention and public perceptions about Medicare for All vary quite a lot depending on which arguments break though in the media.
But while primary voters ponder these unknowables, and watch Wednesday night’s debate, they might want to step back and consider how much the top 2020 Democratic contenders actually agree about health care.
Each one has promised reforms that would offer more financial protection against medical bills, introduce some kind of new public insurance plan, and give the federal government more power to reduce the price of medical care. That’s a pretty strong consensus for some pretty ambitious initiatives that could help a whole lot of people.
The differences among the candidates are important, and a presidential nominating race is precisely the forum in which to argue about them. But eventually the primaries will end. At that point, the debate will be between a president trying to take health insurance away from tens of millions, through repeal of the Affordable Care Act, and one trying to carry on the Democratic Party’s historic quest for universal coverage. That surely is the choice that matters most.