‘Medicare for All’ is a signature policy of Elizabeth Warren’s 2020 campaign. So, why isn’t she talking about it in Iowa?

Greg Buntz had listened for over an hour as Elizabeth Warren gave a stump speech and answered questions about her plans to force “big, structural change” when she finally made a passing reference to one of her campaign’s most well-known proposals.

“I noticed she didn’t bring up ‘Medicare for All’ until the very end, and I thought, ‘Huh, she must be worried about that,’ ” said Buntz, 78, a retired college professor and undecided voter who attended a rally this week at Grinnell College. “The reason she probably didn’t talk about it very much is she’s being cautious. It’s very controversial.”

After months of touting her plan to provide free health care to all Americans under a government-run system, Warren mostly went quiet on the big plan during recent events in Iowa -- a move that reflects the increased scrutiny she has faced not only over whether the policy is a sound one, but whether her new $20.5 trillion plan to pay for it is realistic.

Warren’s embrace of Medicare For All, first backed by fellow presidential contender Bernie Sanders, has become a signature issue of her campaign and one that has helped win wide support in the party’s left wing that favors dramatic change to the political status quo over incremental adjustments.

Her stance on that very same issue, however, has created political headwinds for Warren in Iowa where polling has suggested more voters prefer improving the existing Affordable Care Act over implementing a single-payer Medicare For All plan that would eliminate private insurance altogether.

A recent New York Times/Siena poll in Iowa found 56% of voters preferred a candidate who would improve the existing health insurance system while 42% wanted one who favored Medicare For All. Separately, the survey also found 73% of Iowa voters were open to a single-payer system while 91% supported creating an optional government plan that anyone could purchase, known as a public option.

The differing opinions reflect a larger debate within the Democratic Party that has unfolded all year, with progressives such as Warren and Sanders wanting to put an end to private insurance while more moderate candidates such as former Vice President Joe Biden and South Bend Mayor Pete Buttigieg want to allow those who like their private plans, including unions that negotiated for it, to keep their coverage.

Warren’s lack of emphasis on the plan in Iowa recently also comes after she has faced sharpened criticisms from more moderate candidates, including Biden, Buttigieg and Minnesota U.S. Sen. Amy Klobuchar, over the costs of such a massive program.

All three favor adding a public option to Obamacare, which would create a government-run program to compete with private insurance in an attempt to drive down costs without forcing people to leave their employer-based plans. That more measured and less expensive approach has proven more popular among moderate voters who make up roughly half of the expected electorate in the first-in-the-nation Feb. 3 caucuses.

While the best way to reform the nation’s health care system remains a matter of great debate within the Democratic field, the issue by far remains the most important topic to the party’s voters. A new Quinnipiac poll in Iowa released Wednesday found voters across all age groups and income levels cited health care as the most important issue they consider in deciding who to support in the caucus.

On the campaign trail, that makes Warren’s rare discussion of the topic in recent days all the more noticeable. At events in Grinnell, Vinton and Cedar Rapids, she either didn’t bring up Medicare For All or did so sparingly.

After the Grinnell rally, Warren took a break from her now-famous practice of taking selfies with supporters to talk with reporters. Asked by the Tribune why she spoke so little about Medicare For All, Warren downplayed the interest from voters, noting the three questions she took from the audience did not raise the topic.

“I didn’t get any questions about it,” Warren said. “I talked about how to restructure our democracy. I talked about structural change in our economy. I didn’t get any questions, and so far, I haven’t gotten any in the photo line either.”

On the defensive

Early on in her presidential campaign, Warren embraced Sanders’ Medicare For All proposal, and she has signed on as co-sponsor of his Senate bill to create the program. But unlike Sanders, who readily acknowledges taxes on middle-class families would go up in exchange for lower insurance costs, Warren repeatedly ducked the question, only saying middle-class costs overall would go down.

That left her facing pointed attacks in the most recent televised debate last month, a moment that coincided with her rise to the top of the polls in Iowa. Biden criticized the plan as “vague,” Klobuchar dismissed it as a “pipe dream" and Buttigieg hammered her for again dodging a yes-or-no question on whether her plan would raise middle-class taxes: “Your signature, senator, is to have a plan for everything, except this.”

The next day, Warren vowed to release a plan to detail how Medicare For All would be funded. She did so just hours before the big Democratic fundraising dinner in Des Moines last week, a critical event where all the major candidates gave speeches to an arena full of Democrats before a giant throng of national media.

Warren’s $20.5 trillion proposal calls for taxing employers $8.8 trillion -- or about the equivalent to what they currently spend on health insurance; doubling her proposed wealth tax on billionaires; adding new taxes on investment gains and stock trades; increasing taxes on companies that make more money abroad and creating new fees on big banks. She also assumes the program would cost trillions less than other public estimates on Medicare For All, would save $400 billion from immigration reform and $800 billion in cuts to military spending.

In addition to the $20.5 trillion, Warren’s plan counts on an additional $6.1 trillion in funding from states, which would pay the federal government the amounts they spend now to cover insurance for state workers and low-income residents on Medicaid.

The release of the plan quickly led to a new round of criticism from opponents in Iowa, insisting its assumptions were overly optimistic, unrealistic or would result in employers passing along some of the costs to workers. In response to questions from reporters in Grinnell, Warren defended the plan, noting it will save Americans $11 trillion in anticipated insurance costs over the next decade, which she said would be the equivalent of the “biggest tax break in American history.”

“I get it. The giant insurance companies don’t like it, the giant drug companies don’t like it, because it will bite into the profits they’ve been taking out of the system,” Warren said. “But I think we can do a lot better than that, and that’s what I’m going to keep talking to the American people about.”

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Mum on Medicare

There has been little of such talk, however, from Warren on the Iowa campaign trail in recent days.

That included a stop at a Cedar Rapids fish fry hosted by freshman U.S. Rep. Abby Finkenauer and seven major labor unions. While the daylong event focused on infrastructure, all of the presidential candidates were given time at the end of a question-and-answer session with labor leaders to discuss their candidacies.

Warren spent six minutes hitting the highlights of her campaign for “big, structural change,” including enforcing antitrust laws, instituting a wealth tax, creating universal child care and pre-K, increasing wages for child care and preschool workers, increasing public school funding by $800 billion, making college tuition-free, wiping out student loan debt for 95% of Americans and spending $50 billion more at historic black colleges and universities.

The senator, however, made no mention of her sweeping health care proposal.

Perhaps she knew her audience. One of the major arguments against Medicare For All within the Democratic field has been that union members who negotiated for good health care would lose their plans. (Although that didn’t stop Sanders from professing his support for Medicare For All to a round of applause at the fish fry).

While the assembled crowd was decidedly pro-union, there were a wide array of views from those in attendance on what Democrats should do about health care.

Marilyn Gray said she had no reservations about Medicare For All, citing it as a major reason she plans to caucus for Warren.

“Almost every country in the Western world can provide that kind of care, so there is no excuse for America not to do it,” said Gray, 77, who lives in Onslow, an eastern Iowa town of 170 people. “Yeah, it will probably cost more taxes somewhere, but I think it is something we really need to do because this process we have right now is not successful for a lot of people.”

Linda Lucy knows firsthand how difficult it was to get the Affordable Care Act passed, even after Obama scrapped plans for a public option. She worked as a longtime district staffer for former Iowa U.S. Sen. Tom Harkin, who helped write and pass the landmark legislation in 2010.

“It was difficult to the point where I didn’t think it was going to pass, and it was just inching along and then it finally happened,” said Lucy, 72, who lives in Dubuque and is weighing whether to caucus for Biden, Buttigieg or Klobuchar. “It’d be a lot easier to improve Obamacare. We just need to correct some things on it, like the way the president and Sen. Harkin wanted to do in the first place."

Upon his retirement from the Senate, Harkin said Democrats should have sought “single-payer right from the get-go or at least put a public option. … We had the votes to do that and we blew it." Reflecting the continued skepticism of the Democratic establishment in passing single-payer, Hillary Clinton on Wednesday said Warren’s health care plan would never pass Congress, “but the goal is the right goal.”

Warren was asked by reporters on the Iowa trail how she would get such a massive overhaul enacted as law when many moderate Democrats, let alone Republicans, remain skeptical. She responded by invoking the old adage of a political mandate.

“I think this is the strength on running very clear ideas and showing exactly how they can be implemented and how we can pay for them,” she said. “When I win, I will turn around to all my Democratic colleagues and say, ‘This is what I ran on. It’s there, and this is what the majority of the people in the United States of America said they wanted.' "

‘Not a definitive sale’

At another town hall in a lobby of Vinton-Shellsburg High School, Warren again did not bring up Medicare For All in her 35-minute stump speech. Dee Patters, however, raised it when she had the chance to ask the senator a question.

The 40-year-old immigration attorney said she has Type 1 diabetes and was concerned about what type of coverage she might have as the country transitioned to Medicare For All under her plan. Warren didn’t address specific coverage, but emphasized that the government and employers would continue to cover their share of costs while most Americans together would save trillions of dollars.

“I wear two medical devices. They’re expensive, but they make life with diabetes so much easier, so what I’m concerned about is am I going to be able to have those advanced technologies when we’re transitioning to a Medicare For All plan," said Patters, who lives in Cedar Rapids and had yet to decide whether to caucus for Warren or California U.S. Sen. Kamala Harris.

While she has concerns, Patters said she “wholeheartedly” supports Medicare For All, because “I don’t think we’re going to get what we need with just a public option” because the country would still have a “health care system that is just looking at profits.”

Shelley Usher said she came out to see Warren because of her stance on health care. The 57-year-old former nurse said she is staying at home to care for her husband who is on Medicare and has had difficulty getting surgeries he needs. She said the couple has faced out-of-pocket medical costs they couldn’t afford.

“I think she’s absolutely on the right track with her health care for all,” said Usher, 57, who lives in the eastern Iowa town of Vinton and is considering caucusing for Warren or Biden. “I am worried about how much it costs, and I’m not sure if that’s gonna fly, but I think it’s worth a shot."

In Grinnell, Andy Schuster said Warren and Sanders are his top two candidates so far, and he backs their Medicare for All plans.

“I think if it works for every other developed nation on the earth, we should be able to make it work for us," said Schuster, 35, a chemist who lives near Searsboro, a central Iowa town of 148 people. He said he found it “a little bit surprising” that Warren talked so little about Medicare for All.

“I mean I know that’s one of the things they’re all trying to differentiate themselves on, but maybe it was a strategic reason not to push an issue that’s not a definitive sale around here,” Schuster said. “I was talking to a co-worker today who swore off Elizabeth Warren for that very reason, because of Medicare for All."

Tom Seda currently doesn’t have insurance through his job, and he said the best approach is to get more people covered as quickly as possible. He said he favors adding a public option to do so and then evaluate whether moving everyone to a single-payer system makes sense down the road.

“If something happens to me, and I have to go to the hospital, I’m worried about what kind of care I’d get,” said Seda, 53, who saw Warren in Grinnell and lives nearby in the small town of Traer. “Those who have health insurance should keep it, and get those of us who do not have health insurance covered, just the basics, and then over time maybe we can move to something bigger.”

Seda said Warren, Harris and Buttigieg are the candidates he is thinking about caucusing for, and health care will be a key issue he considers. Asked what he thought about Warren not bringing up the topic much at the rally, the veteran caucusgoer didn’t seem too surprised.

“Well," he said. “It is controversial."

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Twitter @BillRuthhart

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