Viewpoint: Employment-Based Health Care Is an Anchor around the Neck of the U.S. Working Class

For a generation, U.S. unions have traded wages and other benefits for ever-shrinking health care coverage from employers, or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds. Photo: National Nurses United

Last June at the House Ways and Means Committee Hearing on Medicare for All, Rep. Kevin Brady of Texas lamented, “That great health care plan that your union negotiated for you? It’s gone. Banned under Medicare for All.”

A right-wing congressman with a 7 percent lifetime voting score from the AFL-CIO crying crocodile tears for union health care plans can easily be dismissed as just another absurdity of America’s political dysfunction.

But when Sen. Joe “The Working Man’s Friend” Biden repeats the charge almost word for word, and when AFL-CIO President Rich Trumka insists—on Fox News, no less!—that “if there isn’t some way to have our plans integrated into the system, then we would not support [Medicare for All],” something is up.

Talking points, after all, don’t appear out of thin air. They’re carefully crafted and disseminated by lobbyists and publicists, often on behalf of corporate interests.

Trumka was soon joined by Teachers (AFT) President Randi Weingarten. Six months earlier she had given Medicare for All a full-throated endorsement. But in a September 23 Politico article, she walked that back in favor of a fictitious system where “employer-based insurance would be allowed to exist to the extent that plans met or exceeded the standards set by the Medicare plan.”

It’s mind-boggling to see national labor leaders defend a system that’s the biggest cause of strikes, lockouts, and concession bargaining.

For a generation, U.S. unions have traded wages and other benefits for ever-shrinking coverage from employers, or for the ever-increasing employer contributions required to maintain similarly shrinking benefits from union-sponsored health and welfare funds.


Linking health care to employment makes the U.S. unique among industrialized countries.

Our system emerged as an accident of history, when President Franklin Roosevelt’s promise to enact a post-World War II “Second Bill of Rights” was stopped dead by a resurgent employer class.

In 1946, the American Medical Association led the fight to defeat the Wagner-Murray-Dingell Bill, which would have created a publicly funded national health insurance program. The following year Congress passed the Taft-Hartley Act. This, combined with an orgy of anti-communism and race-baiting, set the powerful postwar labor movement into a long retreat.

Unable to raise the common standard of living by making health care a basic right for all, labor helped craft a “second-best” solution, linking it to employment. Corporate America piled on and offered elaborate benefits to recruit employees and to keep unions out.

This system was flawed from the beginning. It created tiers of coverage that reinforced job-based race and gender disparities. It produced massive “churn” that disrupted continuity of care even for the best-insured.

Particularly after the 1970s, when for-profit insurance and health care providers began to expand, more and more administrative inefficiency was built into the system to facilitate profits. By this century the U.S. health care system was twice as expensive as the OECD average.

Nonetheless, in the post-World War II period many unions were able to negotiate a robust “private welfare state” that provided health care security for tens of millions of people.

These benefits were almost never handed to workers. Unions had to wage tough fights to expand and defend employer-based health care.

By the 1980s, in almost every contract negotiation, employers demanded to reduce coverage and transfer more costs to the worker. Nonunion workers fared even worse.

Unlike attempts to cut Social Security or Medicare, which almost always fail due to massive popular opposition, cuts to employment-based benefits happen company by company and arouse little popular opposition.

Today, even the few union members who have been able to preserve good benefits find themselves as islands in a sea of inadequate and precarious health care coverage.


Like it or not, employment-based health care is unsustainable. The Milliman Medical Index reported that in 2018, health care costs for a family of four with decent coverage exceeded $28,000 per year.

The employer paid $15,000 of that. The other $13,000 was paid by the worker through co-insurance, out-of-pocket charges, co-pays, deductibles, and so on. The percentage paid by the worker has gone up nearly every year since it was first tracked in the 1990s.

Every worker trades wages for health care. This puts unions at a huge bargaining disadvantage. It goes a long way toward explaining why wages are stagnant despite low unemployment and rising profits.

And even the best employment-based health care is not there when we need it most: when we lose our jobs, change jobs, go on strike, or struggle with long-term illness.

What was once a source of pride in the “union advantage” has become an anchor around the necks of the U.S. working class.

That is why unions representing a majority of organized workers now support HR 1384, The Medicare for All Act of 2019. And it’s why the AFL-CIO’s 2017 convention unanimously voted to support policies to “move expeditiously to a single-payer Medicare for All system.”


Medicare for All would take health care off the bargaining table and increase union bargaining leverage in nearly every negotiation.

It would allow union-sponsored health and welfare funds the opportunity to reallocate revenues that are currently sunk into the world’s most expensive and inefficient health care system.

Savings could be applied to new “union advantage” programs, such as enhanced disability benefits, supplemental unemployment, tuition and training programs, legal services, or childcare and eldercare. Some revenues could be reallocated to shore up endangered pension plans.



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Medicare for All would also provide better coverage than any employment-based plan in existence today.

Don’t confuse the constricted benefits offered under today’s Medicare program—after more than 50 years of underfunding and privatization attempts—with the greatly expanded and improved benefits that we’re proposing under Medicare for All.

HR 1384 would cover hospital services, prescription drugs, mental health and substance abuse treatment, reproductive, maternity, and newborn care, oral health, and more—all without a single co-pay, deductible, or out-of-pocket cost.

Nonetheless, too many national labor leaders continue to sing the praises of employment-based benefits. Too many others give merely rhetorical support for Medicare for All; they pass resolutions to please union activists, but devote most of their mobilizing and legislative efforts to incremental and defensive fixes.

Only a few national unions have begun to commit the kind of resources and organizing needed to defeat the concentrated power of the medical-industrial complex.


As momentum for Medicare for All builds, we are witnessing more backpedaling—and even outright opposition—within the labor movement.

What is driving this opposition? In union-dense states, some union leaders still think they have a seat at the table. They may sincerely believe that they can bargain better, more secure benefits that won’t be vulnerable to annual budget debates.

Many union leaders may also believe that “the members aren’t ready” to support Medicare for All. Behavioral scientists have observed that people are more motivated by the fear of losing something than by the prospect of gaining something. Fear of losing health insurance is a major driver of working-class insecurity.


The debate within the labor movement over Medicare for All has drawn headlines over the past week, after Nevada’s politically powerful Culinary Union distributed a flyer to members warning that the Medicare for All plan backed by Senator Bernie Sanders would “end Culinary health care.”

The Culinary Union is the largest UNITE HERE local, representing 60,000 hotel, casino, and restaurant workers in Nevada, where caucuses will take place on February 22. Its multi-employer health fund provides medical, dental, vision, and pharmaceutical benefits for 130,000 participants. The union is seen as a kingmaker in state politics.

Meanwhile, seven UNITE HERE locals with members in California, Arizona, and Texas have endorsed Sanders.

In a USA Today op-ed, the co-presidents of UNITE HERE Local 11 in Southern California, which jointly endorsed Sanders and Senator Elizabeth Warren, wrote, “If health care were treated as the basic human right that it is, unions like ours could get back to fighting for the other needs of working people, such as organizing the unorganized, winning wages that can keep up with soaring rents, securing a pension to enable a retirement with dignity, and ending discrimination of all kinds. That is what we think a movement that represents all workers should stand for.”

Yesterday the Culinary Union announced it would not make an endorsement in the Nevada caucus.

Lobbyists and publicists for the medical-industrial complex focus on this theme. Some of the same fear has infected union members. But anyone who’s ever been through an organizing campaign knows you have to confront such fears and articulate a vision that will inspire and unify workers.

In the wake of the Janus decision, which made public sector union membership completely voluntary, many leaders are convinced that the best way to keep membership up is to show workers how the union adds “value.”

Negotiating health benefits is one way to do that without necessarily having to engage in risky internal organizing and mobilizing that may end up undermining existing union leadership.


Some unions have raised the specter of job loss as a reason to oppose Medicare for All. This is a legitimate concern. Studies have shown that close to 2 million workers will be displaced by new administrative efficiencies.

While both the House and Senate bills include funding for transition benefits for these workers, people are rightly skeptical of promises, after decades of the working class bearing the cost of environmental-, trade-, and automation-related job losses.

We must center these worker concerns in the political and legislative battles to come. Failing to do so will give our opponents the opportunity to divide workers against each other.

Unions have also expressed concern that employers will get to keep all the wages that unions have traded away over the years to maintain decent private insurance coverage. This assumes that, in the transition to Medicare for All, unions will be so weak or incompetent that they can’t recapture those already bargained monies.

A number of institutional factors can also discourage union support for Medicare for All. Union health and welfare funds often have substantial investments in union facilities and provide a range of member services. There’s a vast web of relationships between union officials and health care vendors, brokers, intermediaries, attorneys, and various hangers-on.


However, the biggest factor by far is many union leaders’ fear of disrupting their own relationships with the establishment politicians who oppose Medicare for All.

Unions are multi-issue organizations. Many of their bargaining and organizing goals are affected by local and national political concerns. So unions routinely pull their punches to maintain these relationships.

This political practice engenders cynicism and apathy among members, and provides the space for right-wing populism to take root in some sections of the working class. Medicare for All can be an important wedge issue in building out an independent working-class politics.

As Washington State Labor Council President Larry Brown put it, “Unions do not serve their members well by trying to circle the wagons around an unsustainable model of employment-based health care.” Our labor movement will thrive when we express the aspirations of all workers and speak on behalf of the entire working class.

Mark Dudzic is the national coordinator of the Labor Campaign for Single Payer. A longer version of this article was originally published in New Politics—read it at

A version of this article appeared in Labor Notes #492. Don't miss an issue, subscribe today.