In early February, as the momentum of the primaries gathered behind Bernie Sanders, the senator’s universal health care plan took center stage in Las Vegas, promising working-class Nevadans comprehensive access to health care and relief from soaring medical costs. Nonetheless, one of Medicare for All’s biggest critics in the lead-up to the Nevada caucus seemed to come from one of Sanders’s key constituent groups: organized labor. The Culinary Union, UNITE HERE Local 226, circulated a flier that warned that Medicare for All would “end Culinary Healthcare.” The flier argued that the plan to give everyone in the U.S. good health care would mean an end to the “good health care” that powerful unions have fought for over the years.

A few days of social media mayhem ensued, with pro-Sanders critics accusing Local 226 — which represents roughly 60,000 hospitality workers, mostly women and people of color — of sowing division with a reactionary stance on the left-most health care reform proposal in Washington. Then came another twist: On caucus day, many union members broke with their leaders and voted for the candidate who would supposedly end their union health plans.

The drama around Medicare for All in Nevada reflected an evolving debate on single-payer health care in the labor movement: Although a public, universal health care system would potentially prevent thousands of needless deaths as well as eliminate the hefty medical bills, premiums and copays that plague many workers and their families, leaders of unions — which collectively represent about 1 in 10 workers nationwide — are divided on Medicare for All. Many labor organizations have deep economic and political stakes in the health insurance industry, often because they help provide health care to members under multiemployer insurance plans. Local 226 is one of several unions that run their own health centers, financed through a so-called Taft-Hartley trust fund, a jointly managed benefits fund established through collective bargaining that supports workers in multiple firms. Overall, affordable health insurance is one of the keystone benefits that union contracts typically provide, for which unions have historically bargained as a form of compensation. Over time, labor advocates say, unions have been compelled to effectively prioritize long-term health care over other bargaining issues, as negotiations on insurance tend to crowd out discussions on take-home pay and other components of a compensation package.

But over the past several decades, collective-bargaining agreements have become so backloaded with costly health care programs that the benefits that union members guard so jealously are precisely what’s making their contracts unsustainable. As Truthout has reported, transitioning to a public universal health care system would liberate unions from having to haggle over insurance co-pays at the expense of demands on wages or pensions.

Mark Dudzic, national coordinator of the Labor Campaign for Single Payer, says that, as health care reform has become a central issue in Washington, the politics around it have changed. “People like Bernie [Sanders] have injected it into mass political consciousness, and more and more unions are convinced that there’s a political path to win this,” he told Truthout. Dudzic estimates that, based on public support for single-payer legislation in Congress, organized labor groups representing the majority of the union workforce support a universal, national health plan.

Dudzic sees universal health care as a path to dismantling the power imbalance intrinsic to a collective-bargaining dynamic, which holds workers hostage to employer-based insurance plans. “[W]hen we go into the bargaining process,” he said, “employers know that they can hold that as a sword over our heads, on every other issue that we’re bargaining over, and we can’t walk away from that table with huge concessions on health care, so when that sword disappears, we have more power. Just like an individual worker has more power if she knows that she can leave her job and not lose her health care.”

Many labor organizations have deep economic and political stakes in the health insurance industry because they help provide health care to members under multiemployer insurance plans.

While hundreds of unions and labor federations have broadly endorsed Medicare for All legislation, not all unions are actively campaigning for single-payer. In 2017, the AFL-CIO conference unanimously passed a resolution aiming “to move expeditiously toward a single-payer system, like Medicare for All, that provides universal coverage using a social insurance model, while retaining a role for workers’ health plans.” The conservatively worded statement seemed to endorse some form of universal health care, but not as a replacement for existing union benefits. In recent months, AFL-CIO and American Federation of Teachers leaders have apparently waffled on earlier support for Medicare for All.

Last September, the Massachusetts AFL-CIO convention went further than the 2017 resolution by pledging to make their presidential endorsement conditional on support for Medicare for All. California’s single-payer legislation, which would implement a Medicare-for-All-type system statewide, has been endorsed by more than 30 unions and labor organizations, including the Los Angeles Federation of Labor, several municipal workers unions and UNITE HERE Local 11.

Health care workers, who are on the front line of the health care crisis as providers and patients, have been leading the charge for single-payer.

National Nurses United (NNU) points to recent nurses’ strikes as an illustration of the cruel intersection of health care and labor crises: nurses have recently gone on strike in Vermont and Minnesota both to protect their own health care and advocate for better working conditions — and thus better care — for their patients.

“If we didn’t have to fight so hard for that one aspect of our union contract, we would have more time to fight for other protections, like better wages, and for nurses — better patient care conditions,” said NNU President Deborah Burger via email. “As union workers in the healthcare industry, nurses see every day how our patients, working people in America, are suffering and dying unnecessarily in this profit-based system, where coverage is tied to employment. Guaranteed single-payer health care is a more permanent, humane solution, proven to work in every other industrialized nation on earth.”

“If we didn’t have to fight so hard for that one aspect of our union contract, we would have more time to fight for other protections, like better wages, and for nurses — better patient care conditions.”

Sal Rosselli, president of the National Union of Healthcare Workers (NUHW), recalled that in the 1980s, when he organized with SEIU Local 250 in California, the union bargained hard to secure quality health plans for health care workers and their families. But as health care became increasingly corporatized, union leaders got mired in “a defensive fight, every contract cycle” with tight-fisted employers. NUHW, representing 15,000 hospital and clinical personnel across California, champions Medicare for All not only as a basic public good, he says, but because it would help unions pursue stronger benefits and protections beyond just health insurance. “Single-payer will accomplish taking health care off the bargaining table so that economic gains — wages, pensions, childcare, elder care, training — can be prioritized, because employers will no longer have to put their profits or their budgets into health care,” Rosselli told Truthout.

NUHW acknowledges reasonable concerns among some Medicare for All critics about the potential loss of health care industry jobs under the transition to single-payer. While there will be economic disruption when replacing the health insurance bureaucracy with a leaner, state-run program, Rosselli noted that NUHW members would be able to gain new jobs from a health care system that provides more comprehensive coverage and includes more people.

“When we accomplish Medicare for all,” Rosselli said, “and have comparable access to care for all people that live in this country, there is going to be a demand for hundreds of thousands of jobs in the health care field — there’s already shortages…. So, there will be tremendous opportunity in all kinds of ways.”

Sanders’s Medicare for All legislation also has built-in safeguards for workers through the transition process. Union employers would be mandated to pass any health care savings from Medicare for All down to workers in their contracts — for example, by providing the equivalent value of their old health insurance plans in the form of wages and other benefits. His bill also pledges to support health care workers affected by the transition with up to five years of compensation and aid for displaced workers. (The Political Economy Research Institute at the University of Massachusetts, Amherst, estimates that within the five-year timeframe, the government could effectively implement a “just transition” to include retraining, relocation assistance and wage replacement for about 746,600 workers, for about $61.5 billion annually for two years — roughly 2 percent of total operational spending.)

Union employers would be mandated to pass any health care savings from Medicare for All down to workers in their contracts.

The divisions around single-payer within the labor movement attest to a history of unions embedding themselves in the employer-based insurance industry, for reasons both practical and political. During the early 20th century, the American Federation of Labor joined with industry groups to oppose a proposal by social reformers for a universal health care plan, preferring instead to maintain labor’s status as a welfare provider to union members. From the 1950s through the Obamacare era, employer-based health plans solidified as part of the social contract that unions offered members, becoming entrenched as part of a standard collective-bargaining package.

According to Anand Singh, president of UNITE HERE Local 2, shifting health care responsibilities to the government could help expand unionization in the long term, because currently, fear of high insurance costs is one factor that ramps up employers’ union-busting campaigns and staunch opposition to workplace organizing. “Workers have a lot of reasons to join a union: a voice on the job, respect on the job. But [with respect to] employers, right now, health care is an impediment for workers really having that voice and exercising the right to join a union,” Singh said at a recent media conference.

Carl Rosen of United Electrical Workers, a left industrial union that has long championed a broad social welfare agenda including single-payer, said that he understands why some unions argue that they want to maintain the benefits that they fought hard for. Workers in his union have had the same fights, he said, but “you’d be hard-pressed to find any members in our union — the ones who’ve actually been involved in those fights, who’ve had to go on strike in order to preserve their health care, who have had to take lesser wage increases than they want, etc. — you won’t find any of them saying, ‘Therefore I want to keep exactly what we have right now, because I had to fight to get it.’”

Shifting health care responsibilities to the government could help expand unionization in the long term.

If private health insurance were replaced by a state-run system, Rosen adds, unions would be challenged to shift the value of their contracts into other types of compensation, “and any union that doesn’t have the confidence that they can do that — that’s an issue that they’d better do some soul searching on: why they don’t think they’d be able to bargain to move that money into other parts of their package.”

In other words, making health care a state responsibility would expand the horizon of possibility in collective bargaining. Whether workers want better wages, training and education benefits, or childcare, both employers and unions would be pushed to become more creative in their demands and more responsive to workers’ aspirations.

For now, as Dudzic put it, “When we bargain for health care, we bargain against ourselves.”

Labor advocates increasingly see Medicare for All as an imperative for health care justice for working people, and unions must grapple with the prospect that the health care that they have bargained for as a union advantage could become a universal public entitlement. While single-payer would disrupt how they negotiate contracts, union workers might see it as a fair trade for enshrining health care as a right, not a bargaining chip.

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