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Warren’s Medicare-for-All Dodge Is Wearing Thin

It's a mystery why the Massachusetts senator won't plainly state the truth about single-payer health care.

Win McNamee/Getty Images

Tuesday’s debate offered Elizabeth Warren the opportunity to feel what it’s like to be the Democratic field’s clear frontrunner, a prospect that recent movement in the polls has brought to the point of likelihood. Throughout the night, her rivals forsook Joe Biden as their main target and instead took pointed jabs at her. Warren fended them off with sturdy aplomb, save for one criticism: how she reckons with middle class taxes in a world with Medicare for All. It’s clear that she has a plan for dealing with these attacks; it’s also clear that her plan is not as effective as she believes it to be. What’s more, she’s missing out on a chance to reframe the terms of the debate in a way that might benefit her candidacy and improve public opinion of Medicare for All.

It’s been a running gag throughout the debate cycle: The moderators enjoin an argument over the candidates’ various health care plans, giving the field’s Medicare for All opponents the opportunity to ask but how will you pay for it. Warren, called to account for how she’ll prevent middle-class taxes from rising, shifts the topic from taxation to health-care costs. Tuesday night, when pressured, she retreated time and again to a simple set of talking points: “Costs will go up for the wealthy. They will go up for big corporations. For middle class families, they will go down. I will not sign a bill into law that does not lower costs for middle class families.”

As rejoinders go, it’s simple enough, but it nevertheless resonates poorly in the room. Her constant repetition of this thesis is one of the few occasions in which she sounds like a conventional politician, enunciating the same sentence in a Marco Rubio-esque ostinato. It’s especially glaring in contrast to Bernie Sanders, the proverbial author of “the damn bill,” who is forthright on this point: Middle class taxes would go up.

It’s not impossible for a reasonable person to grasp what Warren is saying about health-care costs. Medicare for All purports to eliminate a slew of household expenses. Routine health care costs—from premiums and co-pays and deductibles, to pharmaceutical mark-ups and coverage gaps, to the surprise costs that can be incurred from emergency care or out-of-network providers—would either be zeroed out or drastically reduced. When these savings are laid against the increased taxes needed to cover single-payer government health care, middle class Americans come out ahead on their balance sheet.

Or so Warren seems to be implying. The problem that Warren faces—the reason moderators and rivals will keep pressing this question—is that, for whatever reason, she wants to skip over the explanation. This is a puzzlement, given that Warren has an inordinate amount of experience offering sound personal financial advice. There’s not much more to be done once the matter is explained through the lens of a household budget. Maddeningly, in this instance, she wants to attest to solving the Medicare for All equation without showing the work. In so doing, she forces voters to fill in these gaps for themselves.

Warren is also missing a golden opportunity to make an important point about the various costs that the health care industry imposes on the middle class. These costs are taxes, broadly defined. They may not be the literal taxation that the Internal Revenue Service levies on an annual basis, but this is a distinction without a difference. Just as American society imposes a series of taxes to build a world of public goods and services—from roads to schools to an unbridled war machine that operates without any accountability—the health care industry makes similar extractions as individuals travel its labyrinthine architecture.

This is not some trick of rhetorical prestidigitation or a leap of logic. Many Americans pay for their insurance in the form of a deduction from their paycheck; it’s right on their pay stubs, alongside the deductions made for federal and state withholdings and Federal Insurance Contributions Act. The Affordable Care Act, as it was originally conceived, was also founded on the notion that health care expenses are taxes: Americans who were required to obtain insurance on health-care exchanges either paid an insurance premium or sent an additional chunk of money to the IRS. This is not difficult to explain to voters. To the extent that there are people who don’t currently conflate the health care industry’s predations as a type of taxation, there is a big “Eureka!” moment to be had, to which Warren could point the way.

Why Warren doesn’t do so is a mystery. Perhaps she’s anxious that her primary opponents—or President Donald Trump—will feature her in a campaign ad saying that taxes will go up on the middle class. Avoiding such a prospect would be a thin victory. Some of her Democratic opponents have already proven willing to mischaracterize Medicare for All as a plan to throw millions of people off their private insurance. Trump is going to spin bigger and gaudier lies about Warren than her position on health care. Besides, Sanders has already given away the game—so why not just admit that middle class taxes will increase under Medicare for All, and explain why this doesn’t mean their overall household costs will go up?

That Sanders is the mastermind behind the Medicare for All bill may go farther in explaining Warren’s reluctance to provide a more compelling answer. When she has the opportunity to defend her own plans, she does so with the firmness and specificity she’s eschewed in the Medicare for All debate. (Her defense of her wealth tax provides a good contrast.) But Warren doesn’t really have her own health care plan. She has piggybacked onto Sanders’s plan, but done so without fully embracing its implications. Instead, she has hemmed and hawed. She seems to want all of the political simplicity of Medicare for All without owning any of the risk of it.

This is the wrong footing for proponents of any kind of single-payer health care plan. Medicare for All promises numerous benefits to a nation in the grip of a health care crisis, including an end to the fear that getting sick could lead to intractable debt. But it also guarantees a wrenching change to the health care status quo, and to our lives. It is therefore incumbent on Medicare for All proponents to be as forthright as possible. Should Warren win the presidency and push the plan in Congress, she may come to regret not shooting straight with voters when she had the chance. They could well turn on her, damaging not only her own political prospects but the fate of an ambitious proposal that could well transform American life.