The Democratic primary debate on Wednesday night had an element of health care deja vu. For the ninth time, the candidates mostly rehashed the same talking points about the relative benefits of a public option and Medicare for All, as proposed by Senator Bernie Sanders.

One of the few exchanges that stood out and might have an impact on Saturday’s caucuses in Nevada focused on the effect of various plans on unions. On Feb. 13, the state’s powerful Culinary Workers Union declined to endorse a candidate. The union has nevertheless been vocal in its opposition to Sanders’s proposal. Several candidates assailed Sanders on that issue at the debate, accusing him of threatening hard-won coverage. The Vermont senator and current front-runner responded by contending that he would never sign a bill that would cut into current benefits.

Both sides are arguably telling the truth, though that may seem contradictory. Sanders’s plan would get rid of union plans built with decades of effort. It would replace them, however, with coverage that is even more generous, at least according to his plan. Several unions explicitly back Sanders. Picking a side isn’t straightforward, even for groups with a good deal under the current system. 

Steady membership and the ability to bargain collectively helps unions negotiate generous health benefits. The Culinary Workers Union plan is particularly strong: It charges no premiums to full-time workers, operates clinics and keeps out-of-pocket expenses low. It’s understandable why members might be reluctant to give that up.

Employees who belong to smaller unions especially aren’t immune to the world’s least cost-effective health care system, however. Health premiums paid by both workers and employers, deductibles and co-payments have been rising for years as provider and drug prices increase at an unsustainable rate. Rising costs put a significant financial strain on many Americans to the point where many delay or avoid needed care. The time, energy and money unions spend on health benefits come at the expense of efforts to improve wages and working conditions. 

Medicare for All offers a potential improvement for even Nevada’s culinary workers. Their current plan would be replaced by one that has no out-of-pocket cost for care. At least some of the money employers now spend on providing expensive health coverage would go to employees, and union members would most likely come out better than most. A single-payer would be able to reduce prices in a way that the current system can’t. None of the public option plans proposed by more moderate candidates would do as much on any of these issues. 

Still, Medicare for All represents a smaller step forward for many union members, so its trade-offs will matter more. The plan’s generous coverage will require significant tax increases, which could erode the benefit of the plan for unions and their members. Cost- and price-control efforts could have a mixed or disruptive impact on the availability and quality of care. The proposal also wouldn’t make it through the Senate in the near term; any effort is just as likely to derail beneficial health reform entirely as it is to lead to a more progressive compromise down the line.

Unions have bargained hard for decent medical benefits for their members. They are going to be hard-pressed to surrender them for the promise of a government-run plan, which complicates the equation for choosing a Democratic nominee. 

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Max Nisen is a Bloomberg Opinion columnist covering biotech, pharma and health care. He previously wrote about management and corporate strategy for Quartz and Business Insider.

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