× Expand Manuel Balce Ceneta/AP Photo Senator Bernie Sanders introduces the Medicare for All Act of 2019, on Capitol Hill in April.

In an attempt to assuage union concerns about his Medicare for All plan, presidential candidate Bernie Sanders added a section to his new “Workplace Democracy Plan.” The problem is that it is difficult to square this new talking point with his others on health care. From the plan:

[T]he plan will ensure that union-sponsored clinics and other providers are integrated within the Medicare for All system, and kept available for members. Unions will still be able to negotiate for and provide wrap-around services and other coverage not duplicative of the benefits established under Medicare for All.

Either these are mostly meaningless promises without actual policy implications, intended to trick voters, or Sanders's past statements about banning duplicate insurance don't really hold up.

Sanders's Medicare for All bill is entirely comprehensive, fully covering everything. It is also meant to aggressively focus on equality by denying everyone, except the rich who can afford concierge medicine, a way to pay for faster treatments by banning duplicate insurance. Those are big moral and practical selling points for the law, but inconsistent with these union promises.

Sanders's bill is so comprehensive that there is no possibility for “wrap-around services and other coverage” that Medicare for All wouldn't cover. For example, one of the only theoretical additional pieces of coverage Sanders even mentions is plastic surgery insurance, but that does not exist in the real world and won’t ever make sense. The whole point of Sanders’s argument up until now is that there would be nothing for unions to negotiate on health care, since the government would do it all.

More importantly, there is also no way to really square keeping “union-sponsored clinics” open for members with the principles behind his ban on duplicate insurance. If union-sponsored clinics need to treat everyone equally, regardless of union status, they effectively would become community health clinics, offering nothing special for union members. If, on the other hand, employers can pay for union-sponsored clinics where union members get special privileges for faster appointments, that would be for all intents and purposes duplicate insurance.

This is what duplicate insurance is in many European countries: an employer-provided perk for workers to get certain medical testing, non-emergency surgeries, or elective treatments faster at special clinics. In such countries, this duplicate insurance is often primarily for union members, covers only a limited number of faster services, and makes up a very small share of total health spending. Regardless, if Sanders insists on calling it “employer-provided, union-sponsored clinics” instead of employer-provided duplicate insurance, such an arrangement would meet the definition of duplicate insurance.

There is nothing wrong with allowing such an arrangement, and there is a reason why so many countries with single-payer health care systems have this element. Union insurance tends to have quality networks and fast appointments, an important perk that is understandably hard to give up. There is even a strong policy argument that certain high-risk/high-value professions might uniquely benefit from aggressive testing/treatment, but that is not how Sanders has been selling his bill so far.

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It's somewhat strange that Sanders even feels the need to pander to unions at all in this fashion. Since the last debate, when Sanders was challenged multiple times about “taking away good union benefits,” unions have actually rallied to his side and condemned the attackers. SEIU president Mary Kay Henry said she resented union workers “being pitted against millions of Americans struggling to get healthcare coverage.” Sara Nelson of the Association of Flight Attendants said that presumed union anger over everyone getting benefits as good as they have reflects “a great failure of understanding how unions work.” While a few union members have expressed concern about their health care benefits, over 20 unions have endorsed Medicare for All.

Moreover, unions would be in the best position after Medicare for All to ensure that savings reaped by employers from no longer providing health insurance is converted into higher wages for their members, because they already collectively bargain with employers and can ask for higher wages and better working conditions contractually.

As Sanders has sold his plan up to now, there practically can't be any union-negotiated “wrap-around coverage,” and whether or not a clinic technically remains “union-sponsored” would have no impact on any union member. So either these promises are meaningless claims to placate confused voters, or Sanders has effectively endorsed in all but name the duplicate insurance we see in countries like Norway, Sweden, and New Zealand.

If it is the former, it is strange that Sanders doesn't just make the simple argument that health care shouldn't be tied to your employment at all and unions will have nothing to do with health care. If it is the latter, it makes Sanders's rhetorical insistence that he is “banning private insurance,” while allowing duplicate insurance in all but name, a strange political decision given how poorly banning private insurance polls.