WASHINGTON — If there is anything that has changed in Senator Elizabeth Warren’s remarkably consistent campaign for president, it is how intensely and specifically she now embraces Medicare for All.
She used to discuss it in broad and flexible terms, rattling off “different pathways” the country might take to an entirely government-funded health care system. By June, she said she was committed to Senator Bernie Sanders’ sweeping Medicare for All legislation, but offered few new details of her own, even when her rivals pushed her to explain how she would generate the trillions of dollars that it would cost.
Her answers came Friday, when Warren released a 20-page proposal detailing how she would raise $20.5 trillion in new funding for a massive health care overhaul that she promised would not increase taxes on the middle class “by one penny.”
But the battle over Medicare for All in the primary may only be beginning.
Warren’s decision yokes her to an issue that energizes her liberal base but that, polling shows, is less popular with Democrats overall than a more moderate health care approach. That means Warren’s plan — her first detailed health care proposal — could leave her facing new political risks as the Iowa caucuses draw closer, because she will now have to ward off attacks from both Democrats and Republicans around the issue.
“It’s core to what she believes, and what she thinks needs to happen. To go another route for her would have been a mistake,” said Jennifer Palmieri, a former communications director for Hillary Clinton’s presidential campaign. “There’s political problems either way.”
Criticism came quickly, including from former vice president Joe Biden, whose campaign said the Warren proposal amounts to ‘‘mathematical gymnastics.’’
The plan relies largely on employer contributions and new taxes on the financial sector, large corporations, and the very highest earners, and assumes cost savings from the efficiencies of running a single national health insurance program.
Relying on analyses from economists and former Obama administration officials, Warren estimated it would cost $20.5 trillion in additional federal funding from 2020 to 2029 to make Medicare universal. Over the same period, the Congressional Budget Office projects the government to spend $14.3 trillion on Social Security and $7.8 trillion on defense spending, according to an August 2019 report.
In a Medium post, a 9,275-word retort to critics who have said she hasn’t been straightforward about the cost of her plan, Warren projected a health care system that would cost slightly less than the expected cost of the current system over the same period — $52 trillion — but would cover everyone and eliminate the need for individual health care spending.
“Over the next ten years, individuals will spend $11 trillion on health care in the form of premiums, deductibles, copays, and out-of-pocket costs,” Warren wrote. “Under my Medicare for All plan, that amount will drop from $11 trillion to practically zero.”
But some analysts and Warren’s rivals said that even a funding plan of her scale understates the true costs of such a major Medicare expansion.
“She’s making it up,” Biden said in an interview Friday with PBS.
He said the cost was more likely to be between $30 trillion and $40 trillion, in line with a study from the Urban Institute. “We don’t have to go that route — all we have to do is go back, restore Obamacare, make it — provide a public option,” Biden said.
Warren stood up for her plan as she spoke to reporters before a major Democratic gathering in Des Moines — and seemed to suggest Biden was not a true Democrat.
“If anyone wants to defend keeping those high profits for insurance companies and those high profits for drug companies, and not making the top 1 percent pay a fair share in taxes and not making corps pay a fair share in taxes, then I think they’re running for the wrong presidential primary,” she said.
Warren rarely mentions her rivals on the trail, but she invoked Biden by name as she pointed out that former Obama administration officials like Donald Berwick, who was Medicare administrator, had helped develop her cost estimates .
“If Joe Biden doesn’t like that,” she said, “I’m just not sure where he’s going.”
In her policy paper, Warren said she would roll out a plan in the coming weeks that describes how she would transition the country to a Medicare for All system. Sanders’ proposal calls for a four-year runway; that could be a place where her plan departs from his.
Warren would fund Medicare for All with $8.8 trillion in employer contributions, and nearly $7 trillion in taxes on financial firms, large corporations, and a higher wealth tax on people with more than a billion dollars. Those wealthy individuals would be taxed 6 cents on each dollar above a billion. That is on top of Warren’s previously proposed “ultramillionaire tax” — a centerpiece of her campaign — that levies a 2-cent tax on fortunes above $50 million.
Warren also said her plan would generate $1.4 trillion for the system from taxes at existing rates on the additional take-home pay of Americans since many of them would no longer have health care premiums deducted from their paychecks. She also said some funding could come from immigration reform and defense spending cuts.
Some Democrats said those details, too, could become fodder for more barbs for rival campaigns, especially as candidates like Mayor Pete Buttigieg, of South Bend, Ind., or Senator Amy Klobuchar, of Minnesota, try to pull Warren’s rising poll numbers down to earth.
“What she’s managed to do here is shut the door on one specific criticism from her rivals,” said Jim Manley, a Democratic strategist who worked on the passage of President Barack Obama’s Affordable Care Act, “but it opens up a Pandora’s box of issues that not only R’s but also some Democrats are gonna hammer on as well.”
Polling shows that Medicare for All is still poorly understood by voters, but that there is significant discomfort with a system that would eliminate private insurance.
Matt Borges, the former chair of the Ohio Republican Party, said he believes a general-election focus on Medicare for All could distract voters from their concerns about President Trump and hurt Democrats in swing states.
But Allison Youngs, the chair of the Chippewa County Democrats in Michigan’s rural upper peninsula, said voters in her area are hungry for better health care coverage.
“We’re down to one insurance plan, that’s all that’s offered,” said Youngs, who was happy to hear Warren’s plan did not raise taxes on the middle class. “Having Medicare for All with everyone covered would be fantastic.”