A cursory search of ProPublica revealed at least 200 additional union trusts and Health & Welfare funds (which administer health care, pensions, life insurance, dental, vision, and other benefits) totalling billions more in revenue.

Although not all multi-employer trusts operate their own healthcare facilities, and not all unions operate full healthcare trusts, concern over how a transition will impact union healthcare arrangements—provided through nonprofits handling staggering amounts of annual revenue—represents a hurdle for progressives courting union support.

Single payer advocates point to the trade-off between employer healthcare contributions and wages, and the potential to bargain higher wages under a single payer system. As annual revenue figures show, billions of employer dollars are diverted into providing benefits instead of worker wages. With the average employer-provided family plan topping $20,000 in annual premiums, both employers and workers bear significant costs that could otherwise go into improving compensation through wages or other benefits.

Likewise, relying on employer-provided insurance can prove a deterrent for workers considering strike action. General Motors ceased employer contributions to striking auto workers’ healthcare—a completely legal tactic often utilized by employers to place pressure on strikers—before public outcry forced them to reverse course. In the absence of employer contributions union strike funds are forced to absorb the additional cost of healthcare payments, negatively impacting the ability of workers to stay out on the picket line.

Both Sanders and Warren have proposed transition plans addressing union healthcare and Medicare for All. Paul Whitehead, a Penn State Professor of Labor Studies and Employment Relations and former general counsel for the United Steelworkers’, sees these as attempts to allay union concerns.

“Both Sanders and Warren assume, with good reason, that unionized employers would reap a savings when they move from their union-negotiated health care plan to Medicare for All,” according to Whitehead. “So each of them creates a process for the redirection of those savings.”

“Under the Sanders proposal, this would happen via NLRB-supervised collective bargaining. Under the Warren proposal, employers would be able to reduce their contributions to Medicare for All to the extent they have already spent those savings on their employees' other benefits and wages.”

In other words, under the Sanders plan, workers would go to the bargaining table to capture savings and direct them into wages and benefits. Under the Warren plan—which is funded, unlike the Sanders plan, through employer contributions—employers are incentivized to direct savings into increased worker compensation.

Ultimately, union workers would be no worse the wear under a single payer system; even in the worst-case scenario of changing health insurance with negligible immediate increase in wages, many—even most—union members would be left with significantly better health insurance and healthcare, and greater room to maneuver at the bargaining table. The reduction in out-of-pocket costs would be immediate for some; even major union healthcare plans, such as those bargained jointly by New York City public employees and the Teamsters’ TeamCare, include employee premium shares and out-of-pocket costs through deductibles and copays: all things that Medicare for All proposes to eliminate. Workers, even those with high quality plans, would suffer no decline in their level of benefit based on the plans advanced by single payer advocates.

But for union workers that fought and struck for quality healthcare—the Culinary worker that questioned Sanders walked the picket in the six-and-a-half year long Frontier strike, the longest strike in American history—the seeming uncertainty of their future under a single payer system is still an understandable source of concern. They, and unions like UNITE HERE, are intent on forcing politicians to address it.

Advocates—including union advocates that back Medicare for All—aren’t deterred. Carl Rosen, General President of the United Electrical Workers (UE)—a historically Left-wing union and key early backer of Bernie Sanders in both the 2016 and 2020 elections—says single payer healthcare would prove a game changer for union workers.

“UE locals continue to fight for the best possible employer-provided health insurance at the bargaining table, but many of our members are spending between 15 and 25 percent of their income on healthcare costs, and facing ever-greater limits on when and where they can use their benefits,” according to Rosen. “Medicare for All would save our members money and take healthcare off the bargaining table, where employers regularly hold it over our heads.”

Other union leaders agree. Sara Nelson, the President of the Association of Flight Attendants-CWA and a rising star in the labor movement, previously told Politico that Medicare for All advocates within labor have a straightforward message: “Get [healthcare] off the table.”

Given the vast sums of money bargained into multi-employer healthcare and pension trusts instead of wages, it can be a persuasive message for unions: with a universal healthcare system, think of how the horizons of what is possible change. If unorganized workers are less reliant on their employer for their health, would they be more willing to take risks and organize? Even some major unions operating multi-employer trusts—like SEIU—see the potential.

But reservations remain, and with centrists like Joe Biden and Pete Buttigieg jockeying to outmuscle the Democratic Party’s progressive wing and the Iowa caucuses months away, there’s little room for error for Sanders, Warren, and their supporters.

Healthcare policy may not be the deciding factor in who UNITE HERE endorses—or, for that matter, who other unions endorse. The prospect of an “Organizer-in-Chief” or an ally in the White House advocating “big, structural change”—intended to benefit organized labor and working families—may prove decisive; after all, Sanders and Warren were enthusiastically received by UNITE HERE members before and after they were questioned on healthcare. It’s entirely possible UNITE HERE will ultimately sit out the primary, at least before the Nevada caucuses; they didn’t endorse prior to Nevada in 2016 in spite of Hillary Clinton’s massive advantage in early union backing.

Unions uncertain of change and used to years of political attack and declining fortunes may, whether through persuasion from the movement’s Left flank, progressive politicians, or pressure from their membership and allies, come to see the benefit emphasized by Sanders and Warren. If so, it will represent a shift in posture familiar to unions like UNITE HERE, which has emphasized nontraditional political advocacy like immigrant justice: fighting for the common good, rather than solely bargaining for their members.

Amidst an unprecedented strike wave—one led by workers like the heavily immigrant UNITE HERE Local 26 strikers at Boston’s Battery Wharf Hotel, who recently won a landmark contract—what finally tips the scales may be the ethos at the heart of the labor movement, as expressed by Sara Nelson to Chicago’s Democratic Socialists of America: “[Every] step forward makes the next step possible.” The potential for a single payer system to permanently shift the balance of power toward working people and make more possible may prove persuasive—if activists can take seriously and address the concerns of those that are hesitant. No outcome is guaranteed.

In the interim, UNITE HERE and its members are banking on their solidarity to deliver for working people, regardless of the ultimate nominee. As they chanted at their town hall, “When we vote, we win.”

C.M. Lewis is an editor of Strikewave and a union activist in Pennsylvania.