Shane Goldmacher, Sarah Kliff and Thomas Kaplan

One was Paul Krugman, the Nobel Prize-winning economist and New York Times columnist, who had written skeptically days earlier that her plan to pay for “Medicare for All” was a “make-or-break moment” for her, if not the whole 2020 race. Another call was to Rep. Pramila Jayapal, the lead sponsor of Medicare for All legislation in the House and a leading liberal as the co-chair of the Congressional Progressive Caucus.

“Pramila,” Warren told her, “we’re gonna do this.”

She would soon need every ally possible: Warren’s announcement of her Medicare for All financing package is perhaps the riskiest political bet of her campaign. Her Democratic rivals have attacked her plan as unfeasible and some voters worry that it is too radical. Warren would guarantee government health coverage to every American for the first time, erase the existing system of private insurance that currently covers more than 170 million people and pay for it with huge new taxes on corporations and the wealthy but not, her campaign claimed, with “one penny” from the middle class.

The sprawling plan is the culmination of Warren’s yearslong journey toward a full embrace of Medicare for All and a clear sign that she believes her path to the Democratic nomination, and her party’s to the White House, is through full-throated liberalism.

And yet the politics of health care have always been thorny — they powered the Democratic takeover of the House in 2018 and the Republican wave in 2010. Warren appeared to nod to that reality on Friday, announcing a two-step transition plan that would give her up to three years to try to pass Medicare for All.

The twist is that health care was never supposed to define Warren’s candidacy. That was Sen. Bernie Sanders’ signature issue. Warren had entered the race and gained momentum with a populist agenda focused on breaking up Big Tech, tackling corruption in Washington and on Wall Street, and making corporations and the wealthiest Americans pay more in taxes.

But her decision to remake the health care system is now a major part of the 2020 debate, and Warren’s upward momentum in the polls has stalled as her opponents have assailed her. Political strategists say the sheer scope of her plan and her support for ending private insurance threaten to subsume her candidacy.

“She took most, if not all, of her chips and put them on this — and I do think it took a lot of political guts,” said Chris Lehane, a veteran Democratic strategist who worked in the Clinton White House. “By going big on health care, she will either go to the White House on this issue or go home because of it.”

How Warren came to put together her blueprint, including her determination to avoid middle-class tax increases, offers a revealing window into the methodical way that she operates, her approach to political balancing acts and how she might govern as president. It is a story that begins with Warren researching medical bankruptcies at Harvard nearly two decades ago and ends with her as a front-runner for the Democratic nomination, rolling out a plan while under siege from her rivals for more specifics.

Throughout, Warren has kept one eye trained on policy and the other on realpolitik: protecting her aspirational brand of liberalism and robbing Republicans (and her Democratic rivals) of a potent talking point about middle-class taxes. She ignored those in the Democratic establishment who had warned her against eliminating private insurance, and ultimately settled on a proposal whose math loosely adds up but that many, even within her party, see as mostly a values statement.

The transition she announced Friday focuses her first 100 days on a public health insurance plan closer to what her more moderate rivals have championed — drawing instant condemnation that she was trying to have it both ways. “We’re not going to beat Donald Trump next year with double talk on health care,” Kate Bedingfield, a deputy campaign manager for former Vice President Joe Biden, said Friday.

The backlash seemed to ensure that Warren will face even more pressure to explain her stance in the Democratic debate in Atlanta on Wednesday.

“Up until putting a price tag on Medicare for All she had imposed her will on the primary and dictated the tempo on her terms,” Lehane said. “This is first time that she is having to react and not follow her campaign script.”

Warren had a plan for everything. That was her calling card almost from the start of the race. But health care was conspicuous it its absence, all the way back to her first trip to Iowa, when she barely mentioned Medicare for All. In June, Warren simply tucked into the slipstream of her liberal rival, Sanders, on his signature issue.

“I’m with Bernie on Medicare for All,” she said at the first debate.

But by fall, health care was emerging as the No. 1 issue in the campaign, and the absence of a plan was increasingly untenable. She was dogged for weeks by questions about whom she would raise taxes on, saying only that total costs for the middle class would go down.

“Your signature, senator, is to have a plan for everything,” Mayor Pete Buttigieg took aim at the last debate. “Except this.”

What few people knew then was that Warren and her Boston-based team had been privately crunching numbers since at least late August, working with the internal imperative to craft a package without hiking middle-class taxes, according to interviews with people directly involved in the process.

The onslaught at the debate accelerated the timeline. One academic described working so hard with Warren officials in late October that he was distracted from his teaching duties; another said she made final edits on a letter endorsing Warren’s math in her car at her child’s school during a Halloween parade.

“Syria is easier compared to this,” said one Warren adviser, granted anonymity to speak about the process of crafting a plan.

Kristen Orthman, Warren’s communications director, said the campaign had not been and would not be buffeted by “the cable news flavor of the week.”

“We are running a campaign on identifying what’s broken, presenting big ideas to fix it, and building a grass-roots movement to make it happen and that’s exactly what we did here,” Orthman said.

Now Warren, who declined to be interviewed for this article, must sell her plan to a Democratic Party deeply concerned about ceding any political advantage to Trump next fall.

Skeptics of Medicare for All have ranged from Hillary Clinton to House Speaker Nancy Pelosi to former President Barack Obama, who on Friday night issued a warning of his own about disrupting people’s existing insurance. “Eighty-five percent of the country has health care,” Obama said. “They may not love it, but it roughly works for them.”

At a campaign event in North Carolina recently, Warren delivered an emphatic rejoinder to those who said it was misguided and impossible to enact.

“You don’t get what you don’t fight for,” she said.

Less than 30 minutes earlier, Warren had been asked to list the first three bills she would want to sign into law. Medicare for All did not make the cut.

This article originally appeared in

How Warren Got to 'Yes' on Medicare for All

Two days before Sen. Elizabeth Warren rolled out a fundamental reimagining of America’s health care and tax system — a $20.5 trillion package that would dwarf all her previous plans combined — she was working the phones to personally preview her proposal and sell it to a select group of political influencers.

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Shane Goldmacher, Sarah Kliff and Thomas Kaplan

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How Warren Got to 'Yes' on Medicare for All