Elizabeth Warren's BRILLIANT Medicare For All Plan.

"Sen. Elizabeth Warren says paying for "Medicare for All" would require $20.5 trillion in new federal spending over a decade. That spending includes higher taxes on the wealthy but no new taxes on the middle class.

WASHINGTON—Senator Elizabeth Warren on Friday laid out an ambitious plan to transform the nation’s health insurance system to Medicare for All in just four years, using a budgetary maneuver in Congress to create a “Medicare for all option” at the outset of her presidency before finalizing the transition through regular legislation in her third year.

The aggressive timeline would require Warren to spend a significant amount of political capital on health care early in her term, and comes as the thorny issue has become increasingly central Warren’s presidential candidacy with the Iowa caucuses approaching.

“Every step in the coming fight to improve American health care — like every other fight to improve American health care — will be opposed by those powerful industries who profit from our broken system,” Warren wrote in a Medium post outlining her plan. “But I’ll fight my heart out at each step of this process, for one simple reason: I spent a lifetime learning about families going broke from the high cost of health care.

In recent months, Warren’s support for Medicare for All, a system of single-payer health insurance prominently supported by Senator Bernie Sanders, another Democratic presidential contender, has made her a target for criticism on both the left and the right.

Two weeks ago, following weeks of pointed questions from her rivals, Warren released a plan to fund a $20.5 trillion Medicare for All plan without raising taxes on the middle class, but it was immediately derided by rivals who said the plan was not realistic.

Presidential candidates like former Vice President Joe Biden and South Bend Ind., Mayor Pete Buttigieg have proposed plans that would expand public health insurance options while leaving more room in the system for private insurance.

On Friday, Warren seemed to attempt to head off criticism of her transition plan by pointing out that any plan that expands public coverage will be a heavy lift.

“Any candidate who believes more modest reforms will avoid the wrath of industry is not paying attention,” Warren said.

Warren’s plan is essentially divided into two phases. In the first, which she says would play out during her first 100 days in office, she would use the budget reconciliation process — which requires only 50 votes in the Senate — to create a Medicare for All “option” that would be available for anyone to buy into, and which would be free for Americans under 18 and families living under twice the poverty line. Americans over 50 would be able to enter an expanded version of the traditional Medicare plan.

During that time, she also says she would dramatically lower the prices of drugs like insulin and EpiPens; protect people with pre-existing conditions; expand enrollment in the Affordable Care Act; and prohibit Medicaid restrictions like work requirements.

Warren has built her presidential campaign on a series of ambitious policy proposals, and she has advocated for the elimination of the Senate filibuster to get it all done. Her decision to turn to the budget reconciliation process to expand Medicare at the outset of her presidency, however, may be an acknowledgement that will not be possible to do that right away.

“ I’m not going to wait for this to happen to start improving health care – and I’m not going to give [Senate Majority Leader] Mitch McConnel or the Republicans a veto over my entire health care agenda,” Warren wrote.

The second phase would come by the third year of her presidency. Warren said she will “fight” to pass legislation that would complete the transition to Medicare for All, which is when private insurance companies would be mostly eliminated. Only 742 words of the more than 8,900 word proposal deal with that phase of the effort, which would probably be very complex.

In the post, Warren acknowledges private insurance would have some role in her new system. Sanders’ plan, she points out, allows for it to cover services that aren’t covered by Medicare for All. “For unions that seek specialized wraparound coverage and individuals with specialized needs, a private market could still exist,” she wrote.

Warren also said “private employer coverage that reflects the outcome of a collective bargaining agreement” could be “grandfathered” into the new system so workers receive full benefits of a bargain before they move into the new system.

“But the point of Medicare for All,” Warren wrote, “is to cut out the middleman.”