How Elizabeth Warren Misread the Politics of Health Care

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Charlie Neibergall/AP Photo

Elizabeth Warren speaks during a town hall meeting at Grinnell College in Iowa, November 4, 2019.

Consecutive Democratic presidencies have been thrown into upheaval over the early promise and subsequent political peril of health care. It’s rare to see a primary candidate go through that entire cycle and suffer the same fate before a ballot has been cast. But Elizabeth Warren has managed it. A campaign that was defining the contours of the race has now become tied completely in knots over health care, a bruising political subject that topples virtually everyone who comes into contact with it.

Warren’s troubles spring from a signature mistake: believing that she could hide in the weeds on health care, and highlight other progressive issues where she had more fluency on the road to the nomination. Like a cluster of other presidential hopefuls, Warren endorsed Bernie Sanders’s Medicare for All Act the day he introduced it in 2018, and she seems to have thought that was the sum total argument she’d need to make. “It wasn’t really clear that we were going to be spending the fall drilling down on the details,” an unnamed source close to the campaign told The Washington Post.

This reflects a lack of understanding of the centrality of health care within activist circles on the left, and even among the public at large. Health care was the dominant issue in the 2018 election. Voters, unnerved by attempts to unravel the Affordable Care Act and discouraged by rising insurance premiums and drug prices, wanted to know how the political parties would respond. Democrats’ soaring trust on the issue powered them to victory in the midterms.

This didn’t end for the 2020 cycle, for the rather simple reason that nothing has been done about it. Health care remains the top policy issue for voters in the Democratic primary, as it was in the last contested primary in 2008. That’s because it’s about living and dying, about who we are as a society, whether we’ll care for the least among us. It’s not an issue that can be finessed.

Move further to the left, toward the zone of the electorate Warren hoped to capture in the primary, and the interest in health care rises even further. Groups like Progressive Democrats of America have been leading with health care for years and years. It is seen as the unfinished business of the welfare state, and Obamacare did not close the deal. If you’re going to be a serious candidate from the left in 2020, you’d better have something to say on health care.

For months, Warren had nothing much to say beyond, “I’m with Bernie.” Each debate has led off with a laborious segment on health care, where blow-dried media figures try to bait candidates into saying they will raise taxes, because apparently you only pay taxes with money, not insurance premiums or deductibles. Warren understood how to make the arguments—that we pay twice as much per capita as the industrialized world for worse coverage that isn’t even universal, that we can extend better coverage to everyone while bringing costs down—but she sought to deflect on the details and stay latched to Sanders. That was never going to be tenable. And Warren was late to recognize that everyone else ditched Medicare for All rhetorically and then formally, putting her in a squeeze between Sanders’s hardcore supporters and the rest of the field.

With media noise over paying for Medicare for All peaking in the October debate, Warren accelerated her proposal on financing, which first took flight in late summer. Her plan, with its focus on lowering costs as well as a mishmash of funding sources to cover the balance, seemed like a way out of the rhetorical box, a way to pivot and challenge rivals on how they would control runaway health care costs and cover everybody.

Personally, I don’t think the form for which the tax incidence should be expressed on the employer Medicare contribution, as a payroll tax or a head tax, was enough to induce cries of being a neoliberal sellout. But Sanders and his supporters jumped onto that aspect of the financing to label her plan regressive. The bigger problem was that Warren remained mired in a technical debate about a plan she didn’t prepare for earlier in the year. To her left, she was hit for the wrong kind of taxes; to her right, Joe Biden and Pete Buttigieg took shots about aspects of the funding, despite never having to answer for their own plans on this point.

Then on Friday, a brand-new Warren plan dropped, proposing a transition that split the process into two separate bills: a reconciliation effort to lower the Medicare age to 50 and create a comprehensive public option that’s free up to 200 percent of the poverty line (that also cleverly federalizes Medicaid and gets states to kick in their share to pay for it) and affordable for everyone else who wants it; and then a second bill, two to three years later, to complete the transition to a single-payer system.

If this were an opening bid delivered in January, plenty on the left wouldn’t have liked it, but it would still have been the most aggressive plan in the field save for Sanders, and one that, if it managed to work, would complete the transition in the same four-year timeline that Sanders envisions in his bill. If you take each one of Warren’s proposals out individually, you could easily make a case for them—including a strong public option with better benefits, executive actions on prescription drugs that mirror the Prospect’s Day One Agenda proposal, rollbacks of Trump’s health care sabotages, adding dental benefits to Medicare, and breaking up excessive concentration in health care markets that has been the primary driver of cost increases.

But combining the parts into a whole reveals a bit of a mess. After putting forward a comprehensive cost control and financing bill, Warren split that apart and asked people to accept two bruising fights to get to her purported end goal. It’s reasonable for people to see that as a bait and switch. Flooding the zone with plans after months of relative silence gives the appearance of a lack of commitment. And given the initial reaction, there’s every reason to believe Warren is going to have to spend even more precious time a couple months from the Iowa caucuses deliberating over technical health economics arguments.

Warren had a way out of this box if she had just let health care proceed from her core premises about American politics. Our health system is deeply corrupted, with concentrated corporate interests and endless middlemen sucking up mounds of cash without delivering decent care. The core reason that we don’t have a single-payer system today, alone among developed nations, has to do with our historical accident of deferring to employer-based coverage after World War II, allowing the health sector to balloon in size and influence.

Warren could have reframed the entire issue around corruption, and positioned her fixes to the system in Washington as a necessary precondition to getting everyone coverage. She could have used the moral argument as well, drawing on her research into bankruptcy that shows the debilitating presence of health costs swamping middle class finances.

Would that have worked? I don’t know. But the somewhat contradictory policy papers and the deep dive into the quicksand that is health financing isn’t getting the job done. The policy people clearly run the show in the Warren campaign, when they needed some good old-fashioned politics.

Warren has been damaged by this episode. She got suckered into a policy duel with herself, and lost sight of what drove her rise in the polls. The idea that she would ever be allowed to skate on health care was absurd, necessitating this scramble to find some sweet spot that, in the politics of health care, simply doesn’t exist. Maybe this week’s debate will reveal an ability to counterpunch, to tell a different story. Because this trajectory goes only one way—back to being the senior senator from Massachusetts.