Harold Schaitberger wants nothing to do with Medicare for All.

Schaitberger, head of the Firefighters union, said firefighters deal with high rates of cancer and post-traumatic stress, and have fought to make sure their health insurance plans have good coverage for those conditions.

“Our health-care plans are absolutely critical,” Schaitberger said. “Any thought of having a government-wide, single-payer Medicare for All plan, we would never support.”

But Jean Ross, a registered nurse from Minnesota and president of National Nurses United, called Medicare for All a cornerstone of her union’s values. Nurses have a front-line view of the problems with the health-care system, Ross said.

“Medicare for All is the only solution to guarantee health care for everyone,” she said. “People shouldn’t have to choose between rent, food, and health care. This violates our values as nurses.”

The firefighters have endorsed for president former Vice President Joe Biden, who wants to preserve private insurance. The prospect of single-payer government health care is a key reason the nurses endorsed Vermont Sen. Bernie Sanders last week.

The divide among labor unions mirrors how, more than any other issue, Medicare for All is cleaving the Democratic presidential primary, serving as a demarcation line between a liberal wing pushing for bold structural change and more moderate voices urging pragmatic incremental change. All of the Democratic primary debates so far have featured the fight, and it’s almost certain to come up again in the fifth debate on Wednesday night.

Labor unions represent about one in 10 U.S. workers and form a crucial part of the Democratic electorate. The stance individual unions take on Medicare for All depends on various factors, including the type of work its members do, the strength of the union’s insurance plan, whether out-of-pocket costs are increasing, and even ideology

Two of the three front-runners, Sanders and Massachusetts Sen. Elizabeth Warren, support a single-payer plan that eliminates private insurance policies, including those unions have negotiated. Warren said last week she would phase in her plan over several years. Sanders has said his administration would introduce single-payer legislation in the first week of his presidency.

Their more moderate rivals, including Biden, Mayor Pete Buttigieg of South Bend, Ind., and Sen. Amy Klobuchar of Minnesota, have blasted those plans as expensive and unrealistic.

Biden pitches his approach — which would allow people to keep their private insurance while also letting Americans join a government plan if they chose — before union audiences, who have often made concessions to hold on to quality health care through their employers.

“You’ve broken your neck to get it,” Biden said at a labor convention in Philadelphia this fall. “You’ve given up wages to keep it. And no plan should be able to take it away.”

“Health care is nothing but deferred wages,” Rick Bloomingdale, president of the Pennsylvania AFL-CIO, said recently. “Employers don’t just give you health care — it costs, and it comes out of their pockets.... That’s why it’s a concern of our members.”

He worried that Medicare for All might not live up to campaign promises once it meets the congressional sausage grinder.

Those concerns are particularly prominent among building trades unions, such as those representing plumbers, electricians, and ironworkers, whose members tend to have generous health benefits. But the view isn’t universal.

“You might expect unions to oppose it,” said Laura Bucci, an assistant professor of political science at St. Joseph’s University who studies labor and politics.

Many do, but Bucci also noted the “solidarity” philosophy guiding much of the labor movement: “Historically, there has been the bigger push toward broader thinking about what’s going to happen for all people.”

Union supports signs are left behind following the first-ever "Workers' Presidential Summit" at the Pennsylvania Convention Center Sept. 17.
Tom Gralish / File Photograph
Union supports signs are left behind following the first-ever "Workers' Presidential Summit" at the Pennsylvania Convention Center Sept. 17.

‘To us, it’s a no-brainer’

The Nurses union is one of more than a dozen labor organizations to endorse Medicare for All, including the Association of Flight Attendants, which represents 50,000 workers for 20 airlines. The union’s president, Sara Nelson, said negotiating health care takes up 75% of the time at the bargaining table.

“And the fight is always around trying to retain what we already have, it’s not about improving it,” Nelson said.

While union members may have better health insurance than some workers, Medicare for All would help bring solid coverage to family members not always covered, said David McMahon, 55, a film stagehand in Philadelphia and New York who is part of a labor coalition backing Sanders.

Similarly, Tom Townsend, an electrician who is president of the AFL-CIO in Dubuque, Iowa, said he worries about members who get laid off and workers who aren’t in his union. “There’s a lot of holes in health care right now that could be fixed with a universal health-care system,” he said.

Jed Dodd, chairman of the Pennsylvania Federation BMWED, which represents rail workers, is on the steering committee of the Labor Campaign for Single Payer Health Insurance. “To us, it’s a no-brainer,” Dodd said. “Before I get out of bed in the morning, I pay $4,000 a year in cost-sharing, and if I start to use it, it quickly jumps to $7,000.”

Dodd argued that nothing about Medicare for All would prevent a union from negotiating supplemental insurance for specific needs, as in the case of the firefighters. Sanders and Warren both have single-payer plans that require employers to pay back the money they save on health care to employees in other benefits.

“I think it’s just fear, and you can’t say fear is not valid, but I don’t see the reasoning behind it here,” Dodd said.

But leaders of Dodd’s national union, the Teamsters, oppose a single-payer system.

A union member reacts as U.S. Sen. Bernie Sanders speaks during an interview at the "Workers' Presidential Summit" in Philadelphia in September. Retired Philadelphia TV journalist Vernon Odom (left) was the interviewer.
Tom Gralish / File Photograph
A union member reacts as U.S. Sen. Bernie Sanders speaks during an interview at the "Workers' Presidential Summit" in Philadelphia in September. Retired Philadelphia TV journalist Vernon Odom (left) was the interviewer.

‘I’d be a fool to do that’

Two leaders of the largest unions, Richard Trumka, president of the AFL-CIO, and Randi Weingarten, president of the American Federation of Teachers, have opposed a single-payer plan that would ban private insurance.

Weingarten, however, worries the Democrats are at risk of tearing themselves apart over the debate. She commended Warren’s plan to phase in Medicare for All gradually.

“Virtually every Democratic candidate wants universal health care as a right, not a privilege, and has proposed things that would [have been] viewed in the Obama administration as really on the left,” Weingarten said. “Let’s stop killing ourselves about what’s pure and not pure.”

Overall, a small majority of adults still say they support putting all Americans on a single national health plan, with 51% in favor and 47% opposed, according to an October poll by the Kaiser Family Foundation, a nonprofit focused on health-care policy. But the margin of support has shrunk from the beginning of this year, when as many as 57% backed such a proposal and only 37% were opposed. Several surveys show that support drops once people learn more details.

Among Pennsylvania swing voters, a separate poll by Kaiser and the Cook Political Report released in November found 56% opposed banning private insurance.

The topic comes up often as the candidates campaign in the early-voting states. When a group of New Hampshire trade union leaders met with Rep. Tulsi Gabbard in September, the first questions for the Democratic candidate were about Medicare for All.

What if they face higher deductibles? Or more limitations on choice of doctors? They all agreed that every American should have access to good health care, but didn’t want to give up the insurance they know and like.

Wendell Young heads the Pennsylvania local of the United Food and Commercial Workers, which represents 35,000 food, retail, and slaughterhouse employees. In a union poll, a majority of members favored endorsing Biden, in large part due to his health-care stance. “They trust that there’s going to be gradual change and improvement,” Young said.

Steven Tolman, president of the Massachusetts AFL-CIO, said the trades, in particular, would not want to give up their health insurance: “I’d be a fool to do that.”