Abby Goodnough, Thomas Kaplan and Margot Sanger-Katz

The initial bill she would seek to pass if elected would be a step short of the broader Medicare for All plan she has championed. But it would substantially expand the reach and generosity of public health insurance, creating a government plan that would offer free coverage to all American children and people earning less than double the federal poverty rate, or about $50,000 for a family of four, and that could be purchased by other Americans who want it.

Warren has long endorsed a Medicare for All bill sponsored by one of her rivals for the Democratic nomination, Sen. Bernie Sanders of Vermont. But until now, she has not specified how quickly she would move to enact a health care plan. Friday’s proposal amounts to a detailed road map for eventually establishing Medicare for All, a single government-run health insurance program under which private coverage would be eliminated.

That goal — a wholesale transformation of how Americans receive health insurance — is a big political gamble, particularly given that many of them would have to give up the coverage they get through their employers. Warren’s proposal for Medicare for All would require an estimated $20.5 trillion in new federal spending over a decade, according to a financing plan she released two weeks ago. To provide funding for it, she would impose new taxes on businesses and the richest Americans.

But under the plan she presented Friday, she would not seek passage of a single-payer system early in her presidency. The proposal would instead move people into that system gradually — in a way she hopes would build public support for full-fledged Medicare for All — while temporarily preserving the employer-based insurance system that covers most working-age adults today.

“I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for All,” Warren, of Massachusetts, wrote in her plan. “My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for all coverage is better than their private options. I believe this approach gives us our best chance to succeed.”

Though the details differ, Warren’s transition plan shares many features with health care proposals from her more moderate rivals for the nomination, including Joe Biden, the former vice president, and Pete Buttigieg, the mayor of South Bend, Indiana. For example, it would allow higher-income adults to voluntarily sign up for a new public plan. Warren’s proposal, however, would make the optional government plan more generous than those proposed by her rivals, and would allow more Americans to get it free. It would also let anyone over age 50 buy Medicare coverage, with more benefits than the program offers now.

With her interim plan, Warren is attempting to offer something attractive to both sides of the Democratic health care debate: preserving her commitment to the single-payer vision that energizes voters on the left, while offering a less disruptive set of policies in the short term to those who may be reluctant to give up their existing coverage.

But her choice to put off seeking passage of a full-scale Medicare for All plan until as late as her third year in office could draw criticism from liberals eager to put in place a single-payer system as quickly as possible.

“Now, some people say we should delay that fight for a few more years,” Sanders said Friday as he discussed Medicare for All and the opponents who would try to stop it. “I don’t think so. We’re ready to take them on right now, and we’re going to take them on Day 1.”

And on Twitter, he offered his own pledge about the beginning of his presidency: “In my first week as president, we will introduce Medicare for All legislation.”

Rep. Pramila Jayapal, D-Wash., who has introduced Medicare for All legislation in the House, praised Warren’s plan as “one smart approach” that “gets us to Medicare for all that covers everyone with comprehensive care in four years.”

Warren’s plan reflects a sense of pragmatism about the politics and logistics of passing a major health bill through a closely divided Congress. Warren says she would pass the transition plan using special procedures that would require only a simple majority in the Senate, rather than the 60 votes needed to overcome a filibuster.

But she would still rely on Democrats winning control of the Senate, where Republicans currently hold a slim majority. And she is laying out ambitious details for getting to a single-payer system even as voter support for the idea is narrowing; polls suggest substantially more Americans prefer the “public option” type of plans that Biden and Buttigieg have proposed.

Kate Bedingfield, a deputy campaign manager for Biden, said Warren was “trying to muddy the waters even further” after “having discovered how problematic her embrace of Medicare for All has become.”

“What started out as ‘mathematical gymnastics’ have been replaced by a full program of flips and twists covering every element of her plan,” she said, adding that the transition plan “doesn’t change the reality that Medicare for All will deny Americans the right to choose their insurance by eliminating employer-sponsored insurance.”

Passing a health bill could crowd out other legislative priorities. President Donald Trump’s efforts to repeal and replace major parts of the Affordable Care Act in 2017 stretched well beyond his first 100 days and ultimately failed. And given the unpredictable nature of politics, a pledge to pass comprehensive Medicare for All legislation by the end of 2023 represents a somewhat distant goal.

“I think that it’s really unnecessary and potentially dangerous to try to split up something like Medicare for All into multiple bills,” said Dr. Adam Gaffney, the president of Physicians for a National Health Program, a group of doctors that supports a single-payer health care system. But he said he was pleased Warren was still advocating Medicare for All.

When Warren laid out her plan to finance a Medicare for All system earlier this month, she said that she would not increase taxes on middle-class families by “one penny.” Among other revenue sources, Warren would require employers to pay an amount similar to what they are currently spending on their employees’ health care, and she would raise taxes on the richest Americans, including by steepening her proposed wealth tax for billionaires.

Her transition plan did not come with its own detailed financing proposal, but it said the interim program would cost the federal government less than an eventual Medicare for All system and would be funded using some mix of the revenue sources she has already identified.

The plan also spells out a long list of administrative actions Warren would take to change the health care system, even if Democrats do not retake the Senate. She would roll back Trump administration regulations that have weakened the Affordable Care Act and broaden benefits in the existing Medicare program. She would also use executive authority to allow new generic versions of expensive drugs — such as insulins taken by patients with diabetes, treatments for hepatitis C and the overdose reversal drug Naloxone — in an effort to lower their prices.

As Warren has established herself as a leading candidate for the Democratic nomination, her opponents have frequently attacked her over health care, a top issue in the primary. For much of the fall, her refusal to say whether she would raise taxes on the middle class provided an opening for some of her rivals to paint her as cagey on a key issue.

Biden and Buttigieg have also argued their public option proposals are far more realistic than Warren’s plan for Medicare for All, emphasizing that her plan would take away people’s private health coverage.

Lis Smith, a senior adviser for Buttigieg’s campaign, described Warren’s transition plan as “a transparently political attempt to paper over a very serious policy problem, which is that she wants to force 150 million people off their private insurance — whether they like it or not.”

In the longer term, Warren’s embrace of Medicare for All would provide ammunition to President Donald Trump and his Republican allies if she became the Democratic nominee. Trump is already fond of equating Democratic approaches to health care with socialism.

Warren is a co-sponsor of Sanders’ Medicare for All legislation, which includes a four-year transition. Though his legislation is best known for its endpoint, it includes a detailed plan for moving from the current health care system to that final goal.

But Sanders’ transition relies on passing his entire plan. Warren, by contrast, has suggested splitting the process in two: starting with the transition plan and only later passing a full Medicare for All bill. And Sanders, unlike Warren, has declined to specify a detailed financing plan for his proposal.

This article originally appeared in

Elizabeth Warren Vows to Expand Health Coverage in First 100 Days

WASHINGTON — Sen. Elizabeth Warren vowed Friday to pass major health care legislation in her first 100 days as president, unveiling a new, detailed plan to significantly expand public health insurance coverage as a first step, and promising to pass a “Medicare for All” system by the end of her third year in office that would cover all Americans.

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Elizabeth Warren Vows to Expand Health Coverage in First 100 Days