John Locher/AP Photo
Democratic presidential candidate Senator Elizabeth Warren of Massachusetts speaks during a fundraiser for the Nevada Democratic Party in Las Vegas, November 2019.
Presidential candidate Elizabeth Warren’s recently unveiled plan to transition to Medicare for All is better understood as a roadmap to how, if elected, she will run her entire administration. It shows what her priorities will be, what her congressional strategy will be, and what her political theory of change is.
The plan lays out in broad strokes numerous actions she will take on health care right away without Congress, and a reconciliation bill to expand public insurance that she will try to pass in the first 100 days. Reconciliation bills cannot be filibustered in the Senate, so they can pass with simple majority support. Only later, at the end of her term, does she plan to push for the full Medicare for All bill.
If you look at the reconciliation bill she proposes as an actual piece of legislation, it’s a horrible policy mess—a Frankenstein of a half dozen other bills and sections awkwardly sewn together. Many of the provisions make no sense to include together and some even directly contradict each other. It seems to include:
- The Medicare Transition plan Senator Kristen Gillibrand (D-NY) wrote for Sanders’s Medicare for All bill. This is a really good Medicare buy-in that covered 90 percent of all medical costs, with individuals paying only up to 5 percent of their income for it.
- An optional expansion of Medicare to people age 50 that in part mirrors a bill from Senator Debbie Stabenow (D-MI). But such an option makes little sense if everyone can buy into the affordable transition plan.
- A section just like Representative Ro Khanna’s (D-CA) bill to make it easier for states to apply for waivers to do state single payer. This move wouldn’t make much sense for states to invest time in if the Warren campaign actually expects federal single payer to pass in a few years.
- Most perplexing, it seems to include Warren’s entire bill to strengthen the Affordable Care Act exchanges. It would increase ACA subsidies and peg them to private insurance plans, which cover 80 percent of medical expenses instead of the current 70 percent.
This is truly incoherent on multiple policy levels.
First, it creates two inconsistent ways of calculating subsidies. Exchange subsidies would be based on the price of the second lowest-cost private “gold” plan, but the Medicare buy-in also on the exchange would only offer “platinum”-level coverage with a completely separate and more generous formula for determining subsidies. Even with expanded subsidies, private exchange plans would still end up being a much worse deal than the Medicare buy-in. Second, Warren claims that the point of the Medicare transition is that by her third year, “the number of individuals voluntarily remaining in private insurance would likely be quite low.” This is meant to make the final passage of full Medicare for All much easier. Including a provision to make private insurance more appealing undermines this goal.
The reconciliation bill cannot be seen as an actual proposal, because there is no way anyone would pass such a conceptual mess. The plan is more like a laundry list of every option to improve health care being considered by Democrats, regardless of whether the bills can work together. On top of that, Warren adds every executive action that any progressive group has pushed for, including enforcing anti-corruption and antitrust laws, reducing drug prices through compulsory licensing, increasing mental health treatment, adding dental benefits to Medicare, boosting Medicaid eligibility, creating an advisory commission of workers on the transition, closing regulatory loopholes in the current system, and reversing Trump administration actions to damage the ACA .
The correct way to view this document is as a statement from Warren on her legislative strategy, her priorities, and her view of what is possible. Given that primary debate questions heavily focus on abstract goals and not specific legislative realities, we only seem to learn about these things indirectly.
She seems to have taken several lessons from the Affordable Care Act saga. First, trying for bipartisanship is a fool’s game. Slow congressional negotiations always undermine popular support. An array of specific actions beats allowing one issue to dominate for a year. Finally, you need to deliver as much as you can immediately. The ACA’s Medicaid expansion eventually turned out to be a political win for Democrats in 2016 to 2018, but due to the incredibly long delay in the rollout, that was too late to help many of the members who voted for it. Almost every item in her plan could be rolled out in a matter of months.
Warren is all but directly saying she will use reconciliation to try to quickly pass whatever immediate improvements to health care she can with only Democratic votes. She is only interested in already formed and vetted bills that deliver something immediately to supporters. If she has the votes, she will do A. If not, she will try for B, and then option C or D, and if she doesn’t have a Senate majority (or even if she does in some cases) she will take a broad set of executive actions. She is heavily prioritizing getting something positive done quickly over taking the hardest possible negotiation position. She is going for the bird in the hand. This is an attitude she will likely adopt in many other policy areas.
This plan, combined with her plan to fund Medicare for All, makes clear that Warren thinks a lot of groundwork still needs to be laid before Medicare for All can even be considered. For example, one of her funding sources is comprehensive immigration reform, which is convenient since immigration reform offering legal status to most undocumented immigrants is very popular. But providing government insurance to undocumented immigrants until their status is addressed is not.
Warren is signaling here a vision of movement-building that is all about momentum, with quick victories each leading to more victories. If she can provide immediate, tangible improvements to regular people in 2021, she seems to believe can win big in 2022, and have the support to pass even bigger improvements. The idea is to steadily build credibility with voters and with members of Congress about her ideas being political winners. She has been the candidate of big detailed plans, but now we get real insight into her plan to make these proposals a reality. Warren is prepared to cut deals, scale back, or use aggressive executive action to quickly move the ball forward, even if only inches.
Whether or not this will work, and whether or not it will appeal to voters, is yet to be seen. But we now know her strategy. It would likely have been better for her if she had found a way to articulate it months ago instead of as part of a rather muddled health care message.
