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Joe Biden and other moderate Democratic candidates opposed to “Medicare for All” have cast the plan as anti-labor, arguing it would leave union members worse off by stripping them of the health care benefits they painstakingly negotiated.
But not all labor unions agree.
Only a few major unions have come out against the single-payer system that would all but eliminate private insurance, while many others remain undecided and some of the biggest labor groups in the country have embraced the plan.
Those supporting Medicare for All — or at least not yet ruling it out — say health care increasingly dominates contract battles, consuming bargaining power that could instead be directed toward raising wages and improving working conditions.
“When we’re able to hang on to the health plan we have, that’s considered a massive win," Sara Nelson, president of the Association of Flight Attendants, told POLITICO. “But it’s a huge drag on our bargaining. So our message is: Get it off the table.”
It's true that union workers are wary of giving up hard-won benefits, even when promised a plan that covers more services for less money. That’s why Biden, Sen. Kamala Harris , former Rep. Beto O’Rourke, Rep. Tim Ryan , Sen. Michael Bennet and former Rep. John Delaney, among others, have invoked organized labor in recent debates and candidate forums to argue against mandatory single-payer health insurance.
"I've been listening to a lot of folks in labor who have said to me, 'Look, we negotiated contracts where we've given up wages for these health care benefits, and under the Medicare for All plan, we would lose them or we would be certainly in fear of losing them," Harris said days after the debate at a forum in Nevada hosted by the American Federation of State, County and Municipal Employees.
But backers of single-payer health care have hit back, asserting that union members would benefit from a government system that effectively guarantees comprehensive benefits and takes health care out of labor negotiations.
“We will do what every other major country on Earth does — guarantee all of you health care so you can sit down and negotiate decent wage increases,” Sen. Bernie Sanders (I-Vt.), who wrote the Senate Medicare for All bill and made the policy the centerpiece of his 2016 presidential bid, said at the AFSCME forum.
It’s an argument that resonates with many labor leaders.
“Wouldn't it be great if we had a single, universal access point for health care and we could instead spend our time bargaining for lower class sizes and wrap around services and increases to people’s pay?” said Randi Weingarten, president of the 1.7 million-member American Federation of Teachers, which endorsed Medicare for All earlier this year. “Wouldn’t it be great it if it wasn’t always dominated by health care fights?"
In addition to representing teachers, the AFT is the second-largest union of nurses and other health care workers in the country. The biggest, National Nurses United, has been on the front lines fighting for Medicare for All. The American Federation of Government Employees, which has more than 300,000 members, including thousands of medical workers at the Department of Veterans Affairs, is also a supporter.
“Not only have health insurance premiums risen every year for the 30 years I've been involved with the union, there’s also been steady cost-shifting from the government to the workers,” said Jacqueline Simon, the AFGE’s public policy director. “We recognize that the enormous premiums federal employees are required to pay are far higher than what they’d pay in new taxes under Medicare for All. They would come out ahead, unequivocally.”
Leaders of unions that have signed on to Sanders’ Medicare for All bill and its House counterpart say the benefits of a reshaped health system would extend far beyond their membership and that they have a duty to advocate for the broader population. But some have also endorsed more incremental coverage expansions — keeping their options open while arguing that any expansion of government coverage is better than the status quo.
“We are supporting any policy proposal or legislation that moves us in the direction of universal coverage,” Leslie Frane, executive vice president of the Service Employees International Union, told POLITICO.
Nelson, who is leading contract negotiations with 10 airlines, said any candidate who invokes unions to argue against Medicare for All "doesn’t understand how labor works."
"I find it offensive that candidates would pit union members against non-union members on this issue," she said.
But even leaders of unions on the record as supporting Medicare for All have voiced qualms about the sweeping proposal.
“While we would like to see universal health care, we want to make sure that there is a role for employer-bargained plans in that plan,” AFL-CIO President Richard Trumka told reporters after the second Democratic debate. Though the union voted in 2017 on a resolution to "move expeditiously toward a single-payer system, like Medicare for All," Trumka recently endorsed a much narrower coverage expansion plan: lowering Medicare’s eligibility age to 55.
Still others who haven't yet taken a position say they're wrestling with the question of who the winners and losers would be under a single-payer plan as the gig economy continues to envelop the workforce.
"There’s a concern that an ill-executed Medicare for All plan could be a step backward for a lot of union members, who sacrificed a lot in negotiations to bolster their own benefits," Lowell Peterson, the executive director at Writers Guild of America, East, told POLITICO. “But many of our members work in more precarious gigs where the employer-sponsored benefits aren’t all that great, where people are being forced to pay enormous premiums for crappy high-deductible plans. So we certainly shouldn’t spend any political capital defending that stuff."
Far fewer labor groups have openly criticized Medicare for All, with opposition to such policies largely confined to the state and local levels. For example, several major unions in New York joined hands with business groups in 2018 to rally opposition to a single-payer proposal for the state.
On the national level, the International Association of Fire Fighters has been the loudest labor voice against Sanders’ bill, arguing that it would deprive workers of plans that meet their significant and specific health care needs.
“We’ve spent a lot of time and effort developing plans that recognize the uniqueness of our members’ profession, the health consequences and exposures related to our work, including behavioral health issues like PTSD, drug addiction and alcohol abuse,” IAFF General President Harold Schaitberger told POLITICO. “We question whether a governmentwide, government-run plan for everyone would ever be able to recognize those unique circumstances.”
The IAFF endorsed Biden in April, and Schaitberger said the union would have difficulty supporting a Democratic candidate who ran on Medicare for All.
“We are not going to cut our nose off to spite our face, but we’d be very troubled with any nominee who advocates for the elimination of private-employer or negotiated plans,” he said.
Other labor leaders have expressed similar misgivings and warn that policies like Medicare for All appeal more to progressive activists than rank-and-file union members.
“A lot of union members are happy with their health plans, and of course there’s a fear of the unknown,” said Steven Greenhouse, who was a labor correspondent for The New York Times for nearly 20 years. “They say the devil we know is better than the devil we don’t. But a lot of members aren’t so happy with their health plans. And one of the major reasons for wage stagnation in this country is that so much money has been going to health care.”
Greenhouse, who just published a book on U.S. labor history, said this split in the labor community is nothing new and that unions have been fighting over the question of national health insurance for decades. While leaders like legendary United Auto Workers President Walter Reuther were calling for government-sponsored coverage in the 1930s and 1940s, others saw single-payer proposals as a threat to their recruitment efforts that would remove an incentive to join unions.
Nelson, president of the flight attendants union, brushed off such concerns.
“There’s no reason to say unions couldn’t negotiate something over and above whatever floor is established [by Medicare for All] just like they do in other countries and like we do now for retirees under Medicare Advantage,” she told POLITICO. “And there is no shortage of issues people want to address in their workplace. There will always something for unions to fight on.”