Can Warren Escape the Medicare Trap?

The candidate of plans needs a really good one right now.

On Sunday, Elizabeth Warren said that she would soon release a plan explaining how she intends to pay for “Medicare for all.” Like many policy wonks, I’ll be waiting with bated breath; this could be a make or break moment for her campaign, and possibly for the 2020 election.

There are three things you need to know about Medicare for all, which in the current debate has come to mean a pure single-payer health insurance system, in which the government provides all coverage, with no role for private insurers.

First, single-payer has a lot to recommend it as a way to achieve universal health care. It’s not the only route — every major advanced country besides the United States achieves universal coverage, but many of them get there via regulations and subsidies rather than by relying solely on public insurance. Still, single-payer is clean and simple, and many health economists would support it if we were starting from scratch.

But we aren’t starting from scratch, which is the second thing you need to know. More than half of Americans are covered by private health insurance, mainly through employers.

Not many people love their insurance companies, but that doesn’t mean that they’re eager to trade the coverage they know for a new system they don’t. Most people probably would end up better off under single-payer, but convincing them of that would be a hard sell; polls show much less support for Medicare for all than for a “public option” plan in which people could retain private insurance if they chose to.

Which brings me to the third point: In reality, single-payer won’t happen any time soon. Even if Democrats win in a landslide in 2020, taking control of the Senate as well as the White House, it’s very unlikely that they will have the votes to eliminate private insurance.

Warren, who has made policy seriousness a key part of her political persona — “Warren has a plan for that” — surely knows all of this. And early this year she seemed to recognize the problems with a purist single-payer approach, saying that she was open to different paths toward universal coverage.

Since then, however, she seems to have gone all in for the elimination of private insurance.

I have no inside information about what led her to take that plunge, but my guess is that she was trying to protect her left flank — to avoid alienating supporters of Bernie Sanders, who have made single-payer a kind of purity test one must pass to be considered a true progressive. And I’m not going to criticize her for engaging in a bit of political realism; after all, the case against Medicare for all is itself basically political.

At this point, however, it’s looking as if Warren may have painted herself into a corner.

Part, but only part, of the issue involves cost.

Journalists have been badgering Warren to get specific about how much taxes would have to go up to pay for Medicare for all. She has, with considerable justice, insisted that this is a bad way to frame the discussion, since any additional taxes would be offset by savings on the huge premiums workers and their employers now pay for private insurance — on average, more than $20,000 a year for a family plan.

The right question is whether the overall costs facing U.S. families would go up or down. Warren has been claiming that for most families, they would go down, but she hasn’t offered specifics. And this vagueness, which has started to seem like evasiveness, is more of a problem for her than it might be for other politicians. As I said, Warren has made policy seriousness a key aspect of her political persona, so her fogginess on health care really stands out.

The plan in the works will presumably try to dispel that fog, but doing so will be tricky. An independent estimate from the Urban Institute (which is, for what it’s worth, left-leaning) suggests that a highly comprehensive Medicare-for-all plan, similar to what Sanders is proposing, would substantially increase overall health spending, although a more modest plan wouldn’t.

But cost isn’t the only issue — in fact, I’m not sure how important it really is, given that full abolition of private insurance remains unlikely in practice. Also, let’s get real: If Warren gets the Democratic nomination, the outcome of the general election isn’t going to hinge on dueling think tank estimates.

The election might, however, hinge on the support of people who have good private coverage and would be nervous about making a leap into the unknown, no matter how many facts and figures Warren deploys.

So what I’ll want to see is whether Warren gives herself and her party enough flexibility to assuage these concerns. I’m not sure what form that flexibility might take. Maybe something like an extended transition period, with greatly enhanced Obamacare (which might actually be politically doable) in the interim?

Whatever Warren comes up with, this is a crucial moment. There are many excellent things in her overall policy agenda; but she won’t get a chance to do those things unless she can extricate herself from what looks like a health policy trap.

A Brief History of the Warren Presidency

A crisis of legitimacy swept across American politics in the second decade of the 21st century. Many people had the general conviction that the old order was corrupt and incompetent. There was an inchoate desire for some radical transformation. This mood swept the Republican Party in 2016 as Donald Trump eviscerated the G.O.P. establishment and it swept through the Democratic Party in 2020.

In the 2020 primary race Joe Biden stood as the candidate for linear change and Elizabeth Warren stood as the sharp break from the past. Biden was the front-runner, but fragile. Many of the strongest debate performers — Cory Booker, Amy Klobuchar, Pete Buttigieg and Michael Bennet — couldn’t get any traction because Biden occupied the moderate lane. By the time he faded, it was too late.

Warren triumphed over the other progressive populist, Bernie Sanders, because she had what he lacked — self-awareness. She could run a campaign that mitigated her weaknesses. He could not.

Biden was holding on until Warren took Iowa and New Hampshire. He or some other moderate could have recovered, but the California primary had been moved up to March 3, Super Tuesday. When Warren dominated most of the states that day, it was over. The calendar ensured that the most progressive candidate would win.

Many pundits predicted that Warren was too much the progressive regulator in chief to win a general election. Indeed, her personal favorability remained low. But the election was about Trump — his personal disgraces but also the fact that he told a white ethnic national narrative that appealed only to a shrinking segment of the country.

Warren won convincingly. The Democrats built a bigger majority in the House, and to general surprise, won a slim Senate majority of 52 to 48.

After that election, the Republicans suffered a long, steady decline. Trump was instantly reviled by everyone — he had no loyal defenders. Only 8 percent of young people called themselves conservatives. Republican voters, mostly older, were dying out, and they weren’t making new ones. For the ensuing two decades the party didn’t resonate beyond its white rural base.

The American educated class celebrated the Warren victory with dance-in-the-street euphoria. In staffing her administration, she rejected the experienced Clinton-Obama holdovers and brought in a new cadre from the progressive left.

The euphoria ended when Warren tried to pass her legislative agenda. One by one, her proposals failed in the Senate: Medicare for all, free college, decriminalizing undocumented border crossing, even the wealth tax. Democratic senators from red states, she learned, were still from red states; embracing her agenda would have been suicidal. Warren and her aides didn’t help. Fired by their sense of moral superiority, they were good at condemnation, not coalition-building.

When the recession of 2021 hit, things got ugly. The failure of two consecutive presidencies had a devastating effect on American morale. It became evident that the nation had three political tendencies

  1. conservative populism,
  2. progressive populism and
  3. moderate liberalism.

None of them could put together a governing majority to get things done.

Before Warren, people thought of liberals and progressives as practically synonymous. After Warren, it was clear they were different, with different agendas and different national narratives.

Moderate liberals had a basic faith in American institutions and thought they just needed reform. They had basic faith in capitalism and the Constitution and revered the classical liberal philosophy embedded in America’s founding. They inherited Abraham Lincoln and Frederick Douglass’s millennial nationalism, a sense that America has a special destiny as the last best hope of earth.

Progressives had much less faith in American institutions — in capitalism, the Constitution, the founding. They called for more structural change to things like the Supreme Court, the Electoral College and the basic structures of the market. Trump’s victory in 2016 had served for them as proof that racism is the dominant note in American history, that the founding was 1619, not 1776. They were willing to step on procedural liberalism in order to get radical change.

With the Republicans powerless and irrelevant, the war within the Democratic Party grew vicious. Progressives detested moderate liberals even more than they did conservatives. The struggle came to a head with another set of Democratic primaries in 2024.

The moderate liberals triumphed easily. It turns out that the immigrant groups, by then a large and organized force in American politics, had not lost faith in the American dream, they had not lost faith in capitalism. They simply wanted more help so they could compete within it.

By 2030, progressive populism burned out as right-wing populism had. The Democrats became the nation’s majority party. This party ran on a one-word platform: unity. After decades of culture, class and demographic warfare, moderate liberals defined America as a universal nation, a pluralistic nation, embracing all and seeking opportunity for all.

In a wildly diverse nation, voters handed power to leaders who were coalition-builders not fighters. The whole tenor of American politics changed.

Dare We Dream of the End of the G.O.P.?

In a new book, the pollster Stanley Greenberg predicts a blue tidal wave in 2020.

Toward the end of his new book, “R.I.P. G.O.P.,” the renowned Democratic pollster Stanley Greenberg makes a thrilling prediction, delivered with the certainty of prophecy. “The year 2020 will produce a second blue wave on at least the scale of the first in 2018 and finally will crash and shatter the Republican Party that was consumed by the ill-begotten battle to stop the New America from governing,” he writes.

It sounds almost messianic: the Republican Party, that foul agglomeration of bigotry and avarice that has turned American politics into a dystopian farce, not just defeated but destroyed. The inexorable force of demography bringing us a new, enlightened political dispensation. Greenberg foresees “the death of the Republican Party as we’ve known it,” and a Democratic Party “liberated from the nation’s suffocating polarization to use government to advance the public good.” I’d like to believe it, and maybe you would too. But should we?

This is not the first time that experts have predicted the inevitable triumph of progressive politics. Seventeen years ago, John Judis and Ruy Teixeira published “The Emerging Democratic Majority,” which argued that the country was on the cusp of a liberal political realignment driven by growing diversity, urbanization and gender equality. In sheer numerical terms they were right; between then and now the Republican Party won the presidential popular vote only once, in 2004. But Republicans still have more power than Democrats, and in 2017, Judis disavowed his book’s thesis, arguing that only populist economics could deliver Democratic victories.

As it happens, Greenberg, who became famous as Bill Clinton’s pollster in 1992 and consulted for Hillary Clinton in 2016, told me he used to “shudder” at the “Emerging Democratic Majority” analysis. “I’m used to campaigns in which you impact what’s going to happen,” he said. “The idea that it’s just going to happen because of trends is dangerous. And it was dangerous with Hillary.”

There’s a fascinating tension in “R.I.P. G.O.P.” Greenberg is scathing about the failures of the Hillary Clinton campaign, accusing it of “malpractice.” Yet he believes that at least some of the political assumptions that were mistaken in 2016 will be sound in 2020.

Stanley Greenberg
Credit Tom Williams/CQ Roll Call/Getty Images

Greenberg suggests that Clinton erred by focusing too much on multiculturalism at the expense of class, and by trying to discredit Donald Trump as a vulgarian rather than a plutocrat. As Clinton wrote in “What Happened,” her post mortem of her shattering loss, Greenberg “thought my campaign was too upbeat on the economy, too liberal on immigration, and not vocal enough about trade.”

Yet going into 2020, Greenberg believes that what he calls the “rising American electorate” — including millennials, people of color and single women — will ensure Democratic victory, almost regardless of whom the party nominates. “We’re dealing with demographic and cultural trends, but we’re also dealing with people that are organizing and talking to one and another and becoming much more conscious of their values,” he said.

In his polling and focus groups, he’s seeing that the reaction to Trump is changing people. “The Trump presidency so invaded the public’s consciousness that it was hard to talk to previously disengaged and unregistered unmarried women, people of color and millennials without them going right to Trump,” he writes. A few months after the election, he realized he could no longer put Clinton and Trump voters in focus groups together because indignant Clinton voters, particularly women, so dominated the conversations. “This turned out to be an unintended test of the strength of their views and resolve to resist,” he wrote.

That resolve to resist has led many voters to define their own beliefs in opposition to Trump’s. On immigration, for example, “every Trump outrage increased the proportion of Americans who said, ‘We are an immigrant country,’” writes Greenberg. Indeed, according to recent Pew data, 62 percent of Americans say that immigrants strengthen the country, while 28 percent, a near record low, see them as a burden.

Yet rather than modulating their anti-immigrant politics in response, Republicans have little choice but to double down, because so many of their voters are driven by nativism. In this way, Greenberg sees an omen for the Republican Party in California. It’s hard to remember now, but the state was once the heartland of conservatism, nurturing the political careers of Richard Nixon and Ronald Reagan. From 1968 to 1988, it voted Republican in every presidential election, and regularly elected Republican governors.

But in 1994, California Republicans, fearful of changing demography, campaigned for Proposition 187, a ballot initiative meant to make life miserable for undocumented immigrants. It won — though courts blocked its implementation — but it also turned expanding constituencies in California against Republicans. Today the party has been reduced to an irrelevant rump faction in state politics.

The specter of California haunts the modern right; many conservatives see it as a portent of what demographic change will do to Republican power nationally. But California can just as easily be seen as a sign of how a political party can drive itself to ruin by making a cruel, doomed stand against the coming generation. If Greenberg is right, national Republicans, fearful of going the way of those in California, may have ensured precisely that fate.

But is he right? Unlike in California, you can’t win power in the United States just by getting the most votes. The political analyst David Wasserman has argued that Trump could lose the popular vote by as much as five million and still prevail in the Electoral College. Greenberg, however, is convinced that the 2018 midterms prove that mass turnout can overcome the Democrats’ structural disadvantages. “Every piece of data I have, the trends have moved to be more Democratic since 2018,” he said.

His confidence will not be enough to lessen the insomnia that has plagued me since the cursed night when Trump was elected. But his book should be a corrective to the media’s overweening focus on the mulish devotion of Trump voters. Trump hatred is a much more potent force in this country than Trump love. There is one way, and one way only, that Trump may surpass Barack Obama. Though Obama was a community organizer, Trump could turn out to be much better at mobilizing progressives.

After Neoliberalism

For the past 40 years, the United States and other advanced economies have been pursuing a free-market agenda of low taxes, deregulation, and cuts to social programs. There can no longer be any doubt that this approach has failed spectacularly; the only question is what will – and should – come next.

The neoliberal experiment – lower taxes on the rich, deregulation of labor and product markets, financialization, and globalization – has been a spectacular failure. Growth is lower than it was in the quarter-century after World War II, and most of it has accrued to the very top of the income scale. After decades of stagnant or even falling incomes for those below them, neoliberalism must be pronounced dead and buried.
Vying to succeed it are at least three major political alternatives:
  1. far-right nationalism,
  2. center-left reformism, and the
  3. progressive left (with the center-right representing the neoliberal failure).

And yet, with the exception of the progressive left, these alternatives remain beholden to some form of the ideology that has (or should have) expired.

The center-left, for example, represents neoliberalism with a human face. Its goal is to bring the policies of former US President Bill Clinton and former British Prime Minister Tony Blair into the twenty-first century, making only slight revisions to the prevailing modes of financialization and globalization. Meanwhile, the nationalist right disowns globalization, blaming migrants and foreigners for all of today’s problems. Yet as Donald Trump’s presidency has shown, it is no less committed – at least in its American variant – to tax cuts for the rich, deregulation, and shrinking or eliminating social programs.

By contrast, the third camp advocates what I call , which prescribes a radically different economic agenda, based on four priorities. The first is to

  1. restore the balance between markets, the state, and civil society. Slow economic growth, rising inequality, financial instability, and environmental degradation are problems born of the market, and thus cannot and will not be overcome by the market on its own. Governments have a duty to limit and shape markets through environmental, health, occupational-safety, and other types of regulation. It is also the government’s job to do what the market cannot or will not do, like actively investing in basic research, technology, education, and the health of its constituents.
  2. The second priority is to recognize that the “wealth of nations” is the result of  – learning about the world around us – and social organization that allows large groups of people to work together for the common good. Markets still have a crucial role to play in facilitating social cooperation, but they serve this purpose only if they are governed by the rule of law and subject to democratic checks. Otherwise, individuals can get rich by exploiting others, extracting wealth through rent-seeking rather than creating wealth through genuine ingenuity. Many of today’s wealthy took the exploitation route to get where they are. They have been well served by Trump’s policies, which have encouraged rent-seeking while destroying the underlying sources of wealth creation. Progressive capitalism seeks to do precisely the opposite.
  3. This brings us to the third priority: addressing the growing problem of concentrated . By exploiting information advantages, buying up potential competitors, and creating entry barriers, dominant firms are able to engage in large-scale rent-seeking to the detriment of everyone else. The rise in corporate market power, combined with the decline in workers’ bargaining power, goes a long way toward explaining why inequality is so high and growth so tepid. Unless government takes a more active role than neoliberalism prescribes, these problems will likely become much worse, owing to advances in robotization and artificial intelligence.
  4. The fourth key item on the progressive agenda is to sever the link between economic power and political influence. Economic power and political influence are mutually reinforcing and self-perpetuating, especially where, as in the US, wealthy individuals and corporations may spend without limit in elections. As the US moves ever closer to a fundamentally undemocratic system of “one dollar, one vote,” the system of checks and balances so necessary for democracy likely cannot hold: nothing will be able to constrain the power of the wealthy. This is not just a moral and political problem: economies with less inequality actually perform better. Progressive-capitalist reforms thus have to begin by curtailing the influence of money in politics and reducing wealth inequality.3

There is no magic bullet that can reverse the damage done by decades of neoliberalism. But a comprehensive agenda along the lines sketched above absolutely can. Much will depend on whether reformers are as resolute in combating problems like excessive market power and inequality as the private sector is in creating them.

A comprehensive agenda must focus on education, research, and the other true sources of wealth. It must protect the environment and fight climate change with the same vigilance as the Green New Dealers in the US and Extinction Rebellion in the United Kingdom. And it must provide public programs to ensure that no citizen is denied the basic requisites of a decent life. These include economic security, access to work and a living wage, health care and adequate housing, a secure retirement, and a quality education for one’s children.

This agenda is eminently affordable; in fact, we cannot afford not to enact it. The alternatives offered by nationalists and neoliberals would guarantee more stagnation, inequality, environmental degradation, and political acrimony, potentially leading to outcomes we do not even want to imagine.

Progressive capitalism is not an oxymoron. Rather, it is the most viable and vibrant alternative to an ideology that has clearly failed. As such, it represents the best chance we have of escaping our current economic and political malaise.