Elizabeth Warren's choice: 'Medicare for All' purity or a path to beating Donald Trump?

Elizabeth Warren is increasingly less of a long shot to win the Democratic presidential nomination, as a new Iowa poll shows. She now has a window to either expand her appeal to millions of voters who are uncertain about her candidacy, or make sure they write her off.

It all comes down to health care.

The Massachusetts senator portrays herself as the candidate of dreaming big and fighting hard. That is working well when it comes to her signature promise of fixing what she calls a rigged economic system that favors rich people and corporations at the expense of much of the rest of America.

Financial struggles and insecurity are problems that know no party, after all. And polls show 6 in 10 believe that wealthy people aren't paying their fair share. The same large majority favors raising their income taxes or (as Warren has proposed) imposing a wealth tax. An even larger 69% say corporations aren't paying enough.

Warren's support for "Medicare for All" and the phaseout of almost all private insurance, however, is working much less well. In fact, it’s scaring people off.

People want choices on health care

Warren won predictable applause at the last Democratic debate when she declared, “I've actually never met anybody who likes their health insurance company.” They like their doctors, nurses and pharmacists, she said, and they’d be able to keep them — the only difference would be the bill would go to the government, not an insurance company.

That tremendously oversimplifies an intensely personal, complicated issue.

A few months ago, a friend told me over dinner that he liked his health insurance and would oppose any plan or candidate that forced him to give it up. That came as an utter shock, but then I considered the sources of our respective plans. He has excellent insurance through a top university. I have expensive, skimpy insurance in an industry that has fallen on hard times.

There are lots of people with marginal insurance or no coverage at all. But there are also lots of people like my friend. That has become increasingly clear as unions, a core Democratic constituency, defend the private health insurance plans they have negotiated, sometimes giving up higher wages in exchange.

Polling reflects this reluctance to throw out the existing patchwork of private insurance and public plans like Medicare and Medicaid. Most people prefer to build on the current system, the premise of the Affordable Care Act (ACA), rather than move to Medicare-only. Seven in 10 like the idea of giving everyone a choice between private insurance or a public, government-run option (like Medicare, for instance). Even a majority of Democrats favor that approach over Medicare for All.

Medicare for All as 'goal' to fight for

Former Vice President Joe Biden, Minnesota Sen. Amy Klobuchar and South Bend, Indiana, Mayor Pete Buttigieg, who all oppose eliminating private insurance companies, make arguments tailored to those numbers. Buttigieg at the debate framed Sen. Bernie Sanders' Medicare for All plan as “my way or the highway” versus trust and choice, as in Buttigieg's proposal for Medicare for all who want it: “I trust the American people to make the right choice for them.”

Warren's health plan is headlined “Health care is a basic human right” and says that while we must defend the ACA from damage, “it’s time for the next step.” That step is Medicare for All, "a goal worth fighting for." There are no specifics about costs, transitions, structure or timing. There are, however, details on other ways Warren is trying to improve health care.

She has introduced bills to make drugs more affordable, expand mental health coverage and help communities fight the opioid epidemic. She has several proposals to ensure that rural areas have the health care facilities and workforce they need. And while she co-sponsored Sanders' Medicare for All bill, she has also co-sponsored a State Public Option Act to let states sell Medicaid plans to anyone, regardless of income.

When you've lost Mia Farrow ...

So Warren is not as all-or-nothing as her rhetoric suggests. She has plenty to talk about besides taking away private insurance. If she wanted to, she could sound more like New Jersey Sen. Cory Booker, also a Medicare for All backer. “There is an urgency right now in this nation. Everybody feels it," he said at the Sept. 12 debate. "And as a person who has an ideal, I know we cannot sacrifice progress on the altar of purity.”

This may be a matter of trying to keep the focus on the highest, most aspirational goal, much as Republicans did when they ran on killing the ACA while Obama was in the White House with a veto pen. The difference is that their rallying cry mobilized the GOP base. Warren’s runs the risk of alienating even many liberal Democrats. Mia Farrow is hardly an average American or a swing voter, but she spoke for many when she tweeted after the last debate, “Love @ewarren but if people like their pvt healthcare, taking it away is too extreme.”

If that's what Farrow says, imagine what President Donald Trump would say.

Warren's Medicare for All emphasis may be part of why she is surging (apparently at the expense of Sanders) in Iowa, which kicks off the nominating season Feb. 3. But as the Democrats' 2020 standard bearer, a prospect not out of the question, she’d be saddled with a position making it much harder to achieve the overarching goal of more than half the country: beating Trump.

Jill Lawrence is the commentary editor of USA TODAY and author of "The Art of the Political Deal: How Congress Beat the Odds and Broke Through Gridlock." Follow her on Twitter: @JillDLawrence

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This article originally appeared on USA TODAY: 'Medicare for All' purity or beating Donald Trump: Warren 2020 choice