So long, single payer, it’s been swell. Joseph Prezioso/AFP via Getty Images

Health care has been a difficult topic for Elizabeth Warren. After some wishy-washy answers about it early in her presidential campaign, she committed herself hard to the cause of “Medicare for All,” going so far as to produce a detailed plan answering the nagging question of how she would pay for it without increasing taxes on the middle class. But the effort to simultaneously win over single-payer diehards who’d otherwise support Bernie Sanders while quieting criticism from Democratic moderates worried about cost has not paid off particularly well. Center-left types (myself included) have criticized her budget math for being unrealistic. Some on the left, who’ve long doubted her commitment to the cause, suggested her financing plan was both insufficiently progressive and politically poisonous. And as her campaign was consumed by these conversations, her poll numbers leveled off.


Now, Warren is trying a different tack: admitting that she isn’t really going to pass single payer after all. Not any time early in her presidency, at least. And maybe not ever.

That isn’t quite how Warren is framing things, of course. But I think it’s the fairest reading of the first-term plan for “transitioning” to Medicare for All that her campaign released on Friday. The candidate promises that within her first 100 days as president, she’ll use the executive branch’s regulatory powers to start bringing down health costs, push for fast-track legislation to build on the Affordable Care Act, make traditional Medicare available to everyone over the age of 50, and create a very generous public insurance option with modest premiums that Americans will be able to purchase on Obamacare’s exchanges, which she is branding as the “Medicare for All option.”

Warren argues that these reforms will eventually pave the way to pass a second bill that fully moves the United States to a single-payer system like Sanders has envisioned, by putting all Americans on a single government plan and banning private insurers from selling competing coverage. “No later than my third year in office, I will fight to pass legislation that would complete the transition to full Medicare for All,” her plan states. “By this point, the American people will have experienced the full benefits of a true Medicare for All option, and they can see for themselves how that experience stacks up against high-priced care that requires them to fight tooth-and-nail against their insurance company.”

Now, every Medicare for All plan kicking around Washington, including the one Sanders has introduced, involves some sort of transition period where the country would move off of private insurance and onto a government plan. And some left-wing Democrats, such as Rep. Pramila Jayapal, who has written her own single-payer plan in the House, have insisted that Warren is simply committing herself to such a roadmap.


But the catch is that these sorts of transition plans are usually included in the same bill as the main single-payer system. Warren is vowing something different. Her plan is to pass a big health care reform in her first 100 days, but not Medicare for All. Then she’ll give actual single payer a shot a couple of years later, supposedly, perhaps just as she’s approaching her reelection campaign.

The most generous way to read Warren’s promise here is that she’s working from the FDR/LBJ model. Both men entered the White House with ambitious, progressive agendas, which they quickly began to pass. But it took additional Democratic landslides for them to build up the sort of massive majorities in Congress that were necessary to enact some of their greatest achievements, from Social Security and the Wagner Act to Medicare and the Voting Rights Act. Perhaps Warren has something similar in mind. Even if the 2020 election goes well for Democrats, after all, the party is unlikely to have more than a one- or two-seat advantage in the Senate, and the caucus will include many, many members who say they are opposed to single payer. The chances of Warren (or Sanders) passing Medicare for All under those circumstances are next to nil. Better, perhaps, to wait and hope that after two spectacular years in office, Democrats can pad their majorities on Capitol Hill during the midterms and then pass the real deal.

The cynical, and I think more convincing, way to read Warren’s promise is that it’s really just a tacit admission on her part that single payer isn’t going to happen without a miracle. Presidents usually have their biggest legislative successes early on, and their parties tend to lose seats during the midterms. “No later than year three,” therefore, might as well mean the 12th of never—which is certainly how many on the socialist left have taken it. As the Week writer Ryan Cooper tweeted, “any idiot can see if you get majorities in 2020 they are 90% likely to be gone in 2022.” Fundamentally, she seems to be falling back on the same approach to health care reform as Pete Buttigieg, who has also framed the public option in his “Medicare for All who want it” proposal as a potential “transition” to single payer.


Either way, Warren seems to be bowing to some measure of realism here, while perhaps attempting to unyoke herself a bit from an idea that’s getting less popular the more Democrats talk about it, and so far seems to have mostly been a drag on her candidacy. On its own, the “transition” plan she has proposed would count as another historic reform of the American health care system. While conceptually similar in many ways to Buttigieg’s plan, it’s bigger and more ambitious. It promises free coverage for all Americans earning less than 200 percent of the poverty line—no premiums, no cost sharing—and caps premiums at no more than 5 percent of income for everyone else, making it far more generous than Obamacare’s current subsidies. In addition to dropping the Medicare age to 50, she would expand benefits and cap out-of-pocket costs before trying to phase them out entirely. It’s a big enough reform that, were it to pass, you could easily imagine it possibly sucking all the momentum out of single payer. After all, in a world where the poor and lower middle class pay nothing for their health care, everybody gets Medicare at 50, and most working adults only have to pay modest premiums toward their insurance, how many people are going to keep clamoring for a major health care push? The more people who have generous, affordable health care, the more resistance you’d have to further change.

In its attention to detail and detours into important niche issues that don’t often get much play on the campaign trail, the plan also just reads a lot more like the sort of proposals we’ve come to expect from Warren than her previous stabs at health care. It dwells on the role of antitrust in breaking up local hospital monopolies. There is a broad explanation for how the public option would reduce payments to doctors and hospitals over time, until they dropped to around Medicare rates. There’s a section where she promises to deal with concentration and anti-competitive practices in the electronic health records industry, which is a subject virtually no normal human being has ever thought about, but is fairly important if you want to promote competition between health care providers. This thing is thought out.

In other words, in the guise of a “transition” to Medicare for All, she’s put together a far-reaching health care plan that at least has some vague grounding in political reality. It would still require a bunch of new federal spending but far less than single payer, since it charges some premiums. It’s probably more comprehensive than anything Joe Manchin will want to pass, but you could still theoretically do it using the budget reconciliation process, which lets Congress enact spending bills with a bare majority vote, and which any health care legislation will need to rely on so long as the filibuster exists.

What’s most frustrating and baffling about the proposal, in the end, is how Warren got there. Had she offered something like this from the start, she could have saved herself weeks of awkward contortions over Medicare for All. Instead, she tied herself in knots trying to court part of the left that was never going to give her credit for the effort anyway. Instead of leading off with a bold, firm plan, she’s awkwardly backing her way into one, and leaving her opponents plenty of room to call her out for flip-flopping. Yes, it’s better for Warren to be in the position of defending a good plan than a bad one, but better still to not have to play defense at all.