Elizabeth Warren’s health care evolution has earned her friends on the left, but foes in her home state

WASHINGTON — The 21st Century Cures Act seemed tailor-made for Massachusetts. It promised Boston’s vast ecosystem of drug and medical device manufacturers faster approvals. Harvard and MIT researchers excitedly eyed over $5 billion in new biomedical research funding. Elizabeth Warren, the state’s senior senator, helped write the bill.

When Congress brought the legislation to a final vote in December 2016, however, a once-enthusiastic Warren wanted nothing to do with it. “Big Pharma has its handout,” she declared in a scorched-earth speech, accusing Republicans of letting drug companies “hijack” the landmark legislation, which her fellow Democrats and the Obama administration nonetheless supported. Warren’s “no” vote served as an anti-corporate war cry — one that spurned one of the state’s major industries and years of her own work.

Warren’s hardline stance on the bill was the exclamation point on her yearslong health care transformation — a shift from a senator, sympathetic to her home state’s health care interests, to a national political figure with her sights on more sweeping policy shifts. That metamorphosis has bolstered her credentials as a progressive presidential candidate and leading advocate of “Medicare for All.” But her broadsides against drug companies have also angered Massachusetts health industry figures, who have accused her of “demonizing her constituents who work in biopharma.”

Warren’s journey to a more progressive posture on health care was a deliberate one. But it has still led the senator into a political quagmire. Some allies of her primary rival, Sen. Bernie Sanders, subtly question her bonafides on Medicare for All, given her relatively late arrival to the position. And more centrist Democrats are raising the alarm over her embrace of the hugely expensive plan, warning it could cost her party the election.

“It’s fine as an aspiration, but as a political issue it’s an absolute mistake,” said Jim Manley, a former top aide to Sens. Ted Kennedy and Harry Reid. “Republicans are going to have a field day with this.”

It’s an unlikely twist of fate that Warren is now at the very center of the contentious national debate on Medicare for All. For the first four years of her Senate career, Warren’s health care work was largely incremental and bipartisan.

Despite her high-profile assignment to Senate’s top health care committee, Warren only introduced a handful of health care bills in her early years in the Senate, most of them focused on bolstering research funding and working with Republicans on enacting low-profile tweaks to the health care system. When she spoke about federal science agencies, she did so in the frame of the top-tier hospitals and researchers near Boston who would benefit from added research funding. Warren’s rhetoric and legislative work also boosted the interests of medical device manufacturers, who maintain a large presence across the state. Warren also maintained an open dialogue with the local biotech industry, which employs roughly 75,000 people in Massachusetts.

Even as the rest of Congress engaged in a partisan tug-of-war over the Affordable Care Act, Warren’s bipartisan attempts to tweak the health care system included efforts on tightening the privacy of genetic data, allowing pharmacists to only partially fill large opioid prescriptions, and improving drug benefits for seniors with heart disease.

She was a surprisingly vocal advocate for repealing the Affordable Care Act’s tax on medical devices — an unusual stance for a lawmaker otherwise supportive of Barack Obama’s embattled health care law, but one that the device manufacturers in Massachusetts appreciated.

The 21st Century Cures Act — a sprawling, bipartisan bill that promised billions in medical research funds — was at first glance the type of health care effort Warren had backed in her early years as a senator. She was among the few Democrats included in early-stage negotiations around the legislation in 2015, but soon began warning that progressives might withhold support if the bill did too little to bolster taxpayer-funded research.

A year later, Senate leadership cut rank-and-file offices like Warren’s out of the process. The resulting package, Warren argued, was effectively a handout to the pharmaceutical industry: It contained myriad provisions to speed drugs to market but less new research money than envisioned and did too little to help Americans battling addiction.

Nonetheless, every other Massachusetts lawmaker, and nearly every Democrat, voted for the legislation, which former Vice President Joe Biden lobbied for aggressively and counts as his signature Obama administration achievement. Its cancer-research provisions are titled the “Beau Biden Cancer Moonshot,” a nod to Biden’s son who died of brain cancer in 2015.

“On the surface, it was a popular idea,” said Bob Blendon, a Harvard health policy professor who conducted polls on the bill’s favorability. “Having supported the Cures act wouldn’t have hurt her. From a public point of view, it was a popular move to try to speed drugs along.”

Despite the lack of public opposition, Warren cast her vote as a principled stand against corporate overreach. She painted the bill as representing everything that’s wrong with Washington.

“Let’s be clear: What the Republicans are proposing is corrupt, and it is very, very dangerous,” she said on the Senate floor in November 2016. “The American people didn’t give Democrats majority support so we could come back to Washington and play dead. They didn’t send us here to whimper, whine, or grovel.”

Warren’s allies see the change as a natural evolution for someone who has long railed against corruption on Wall Street and at large financial institutions. When she saw how business interests ultimately shaped the Cures legislation, one of the most lobbied health care bills in recent history, she lost her patience with the health industry and turned her populist, reform-focused lens in its direction.

“Part of the plan was to send a larger signal to Big Pharma that any attempts to cheat consumers by deregulating the industry would be met with loud outrage,” said Adam Green, the founder of the liberal PAC Progressive Change Campaign Committee who worked closely with Warren’s office in her early years as a senator. “To chill bad behavior, they needed more pain in their calculus — and she decided this was the place to give it to them.”

Most Democrats swallowed concerns that the Cures bill was too industry-friendly and loosened federal oversight for new drugs and devices. Warren, however, argued the bill lined up far too well with the pharmaceutical industry’s wish list, and she occasionally exaggerated the legislation’s impacts in waging her battle against it. At one point, she implied the legislation would allow drug companies to market medicines to patients for unapproved uses, though it only permitted drug companies to advertise those uses to insurers, not patients.

Warren also charged that the bill would “cover up bribery” by exempting drug companies from reporting payments to doctors for speeches and developing educational materials. Her opposition led the Senate to drop the section, but the change wasn’t enough to win Warren’s vote.

Warren also sided with lawmakers who had included a $10 billion increase to the National Institutes of Health budget that would not be subject to yearly Capitol Hill spending battles, and suggested that the final bill’s more modest, discretionary funding increase would never come to pass. But lawmakers, with Warren’s help, have boosted NIH funding by nearly $9 billion since 2015 and funneled billions more dollars toward efforts to address the opioid crisis. In the end, Warren was one of just four Senate Democrats to vote against the legislation, leading to some criticism from addiction treatment providers at home, who had asked her to reconsider her stance.

Her public battle against the bill, which coincided with President Trump’s election and her overnight emergence as a likely presidential contender, marked the point where Warren found her voice on health care. In the two years following her fiery opposition to the 21st Century Cures Act, Warren signed onto Sanders’ Medicare-for-All proposal, introduced legislation to allow the federal government to manufacture generic drugs, and pushed a $100 billion proposal to address the opioid crisis. The work built upon Warren’s previous shot across the bow of the pharmaceutical industry in 2015: a fund called a “swear jar” that drug makers would pay into each time they settled a federal lawsuit, bolstering federal research programs.

None of the proposals has garnered any Republican support, underscoring Warren’s shift. Once a pragmatist do-gooder, she is now the only Democratic candidate willing to fully detail and defend her plans to overhaul the health industry.

Warren’s wider lens on health care has helped her win left-wing support from coast to coast, but it has left industry figures in Massachusetts, who previously found her approachable, resentful of the senator’s national political ambitions.

Bob Coughlin, the head of the local drug lobbying group MassBio, has labeled his senator’s anti-pharma jabs as “insulting and hurtful.”

“Senator Warren was once receptive to the concerns of the Massachusetts biopharma community, but in recent years her advocacy and language on drug pricing have become more inflamed, demonizing her constituents who work in biopharma,” Coughlin said. “As she’s become a national political figure she’s moved further from supporting her home-state companies, and there’s no better evidence of that than her vote against the 21st Century Cures Act.”

Despite staking out a more vocal, left-wing position on health care over the past few years, Warren did not initially appear poised to center her presidential run around the issue. Her early major policy proposals vowed to break up big tech companies and increase taxes on multi-millionaires to fund a host of domestic programs such as universal childcare and student loan debt forgiveness. Despite her rhetoric on drug companies, Warren has offered just one original legislative proposal targeting high pharmaceutical prices — a bill to allow the government to manufacture generic drugs.

“She has been very detailed in all of her other plans. But until now, Warren has just not crossed the T’s and dotted the I’s on health care, generally,” said Larry Levitt, the executive vice president for health policy at the Kaiser Family Foundation.

Warren signed on to Sanders’ Medicare for All bill years ago, but at first appeared to waver on whether she supported his timeline for it as a presidential candidate, suggesting there could be a longer “runway” to implement a government-run health care system. But, after facing pointed questions on her position, she definitively embraced the proposal in June during the first Democratic debate in Miami, saying “I’m with Bernie,” on Medicare for All.

The decision to tie herself to Sanders’ plan ultimately led to some of the toughest weeks of Warren’s campaign. Her rivals pushed the self-professed “plans” candidate to reveal how she would pay for Medicare for All, and even Sanders knocked her for saying middle class taxes would not need to go up to pay for it. Under pressure, Warren later released a plan to produce $20.5 trillion in revenue without raising middle-class taxes, which has led to a new round of attacks from Biden and other rivals who question her math.

On Friday, Warren unveiled a plan to transition to Medicare for All, pledging to dramatically expand Medicare during her first 100 days in office and moving to universal coverage later in her first term, once millions more people enrolled in the program. At that point, people “can see for themselves how that experience stacks up against high-priced care that requires them to fight tooth-and-nail against their insurance company.”

Even as Warren has quickly made Medicare for All a top priority of her campaign, Sanders’ allies have been indirectly questioning her commitment to his signature issue. His campaign has suggested that he is the candidate with real “credibility” on Medicare for All, and is running ads emphasizing how long he has worked on progressive issues — a not-so-subtle dig at Warren’s more recent arrival to the scene.

“We’ve always benefited as a campaign from the credibility of being the ones who wrote the damn bill,” said Sanders’ campaign manager Faiz Shakir. “There’s no event you can go to where Bernie Sanders won’t talk about this.”

Warren’s campaign also believes she has credibility on health care, and a campaign aide who declined to comment on the record stressed that the senator spent much of her career as a law professor studying why families go bankrupt, finding that medical crises, even for insured people, was a leading cause.

Embracing Medicare for All may still be the only way Warren can lock down the progressive base and secure the nomination. It would have been difficult for Warren, who frequently calls health care a human right, to take a more centrist position without alienating supporters who are attracted to her message of combating corporate greed.

“It’s Bernie Sanders’ main cornerstone of his campaign, it’s his signature piece, and the fact that she supported it for so long, I think, already helped her pick up Sanders’ supporters from 2016,” said Mary Anne Marsh, a Boston-based Democratic strategist.

Warren’s allies point out she’s now released a more detailed funding plan than Sanders, which should rebut any questions about her commitment to Medicare for All. Her plan to split the legislation in two to boost its chances of passing Congress also goes beyond what Sanders has offered. But that’s exactly what others warn about — Warren is now wedded to the pricey proposal for the general election, which could hurt Democrats unless more voters come around to the idea.

“I was very enthusiastic about her, hoping she’d get herself out of this box,” said Elaine Kamarck, a Brookings Institution fellow in governance studies and former aide to President Bill Clinton. “Instead she seems to have jumped in with both feet.”