The Culinary Health Center lies within an unremarkable building on an unremarkable block in East Las Vegas.

But the clinic’s beige exterior belies its well-appointed interior — a granite, concierge-style reception desk where patients are greeted, tiled columns, wood paneled ceilings, modern globe light fixtures and wall decorations shimmering with gold-colored threads. If Culinary workers spend their days laboring in some of the most glitzy casinos on the Las Vegas Strip, their union wanted them to have an equally as pleasant aesthetic experience while receiving their health care, union officials have said.

Patients can show up to the center’s urgent care at any hour on any day of the week to get treatment. If it’s a more complicated case, labs and radiology — including CT scans — can be performed on site. If they have a tooth or eye issue, the dental and vision departments on site can be called for a consult. Patients can be set up for a follow up appointment upstairs in the primary care department. Any medicines they may need are provided free of charge just down the hall in the pharmacy where the wait time is an average of nine minutes. The goal was for the urgent care to see 30 patients a day. It sees 200.

For Culinary Union members, the 60,000-square-foot health clinic serves as a physical reminder of the health plan they have fought for since the 1960s. Roughly 130,000 workers and their family members receive health insurance coverage under the Culinary Health Fund, a multiemployer benefit trust fund also sometimes called a Taft-Hartley fund. The way it works is that employers of Culinary Union members pay money into the fund for each hour worked, which is then used to pay for health care for union members and their families. Employer contributions to the trust fund are negotiated through the collective bargaining process, and the fund itself is administered by a board of trustees with equal employer and union representation.

“We went through a lot of struggle to get health care for families, and a lot of sacrifice too,” said Geoconda Arguello-Kline, the Culinary Union’s secretary-treasurer, pointing to the union’s 67-day citywide strike in 1984 in which employer contributions to the health trust was a central issue.

Health care is often named as the top issue for voters heading into the 2020 presidential election and, particularly, Democratic voters. Democratic presidential hopefuls have been eager to stake their claim on the issue, from Vermont Sen. Bernie Sanders and Massachusetts Sen. Elizabeth Warren, who support a single-payer Medicare for all system, to Vice President Joe Biden, who favors expanding the Affordable Care Act and creating a public option plan that Americans can buy into.

The union health plan, Arguello-Kline said, is working for Culinary members. But that isn’t true for many Americans nationwide. A Kaiser Family Foundation/Los Angeles Times poll earlier this year that found while most Americans covered under traditional employer-sponsored plans are largely satisfied with their coverage, about 40 percent reported health-related financial difficulties in the prior 12 months, including paying their medical bills and affording the deductibles, copays and coinsurance required by their plans.

In this debate over health care reform, unions have become a central focus. At a labor forum in Las Vegas earlier this summer, Sanders touted that Medicare for all would take the health care conversation away from the negotiating table and allow workers to purely focus on negotiating for better wages, and Warren suggested that there would be some mechanism by which to ensure that unions get “fully compensated for what they have negotiated for” — meaning finding some way to ensure unions don’t lose out on potentially decades of wage concessions they’ve made for more robust health plans.

But at that forum they were, by far, in the minority of Democratic hopefuls, many of whom have used the unions as a cudgel against Medicare for all.

South Bend Mayor Pete Buttigieg, who has slowly been climbing into frontrunner territory in the polls, has specifically mentioned the Culinary Union in making his pitch for his “Medicare for all who want it” plan, which is essentially a public option where people could buy into the government-run Medicare plan.

“If you like your private plan — I’m thinking for example about the Culinary workers who have negotiated and fought year after year for a good plan and earned it and it’s part of your compensation — I’m not going to make you give it up,” Buttigieg said at a rally in East Las Vegas on Tuesday. “We’ll let you decide whether the plan we create is better or not.”

Those who have been far less publicly vocal about their feelings about Medicare for all are the unions themselves on the ground here in Nevada. Of the more than a dozen union leaders contacted by The Nevada Independent, most expressed significant concerns about the possibility of their hard-fought health care plans going away under Medicare for all, while a smaller minority voiced support or openness toward a single-payer system.

Where there was more agreement is in how the unions are being used in the Medicare for all debate.

“One of the things that we’ve been very careful about is we don’t want candidates trying to use this union health care versus non-union health care as a wedge issue for our members because that doesn’t do anybody any good,” said Rusty McAllister, executive secretary-treasurer of the Nevada State AFL-CIO. “You can’t come out with a position that ‘unions don’t support this’ because you can’t speak for all the unions.”

Pros and cons

Unions here are generally in agreement that everyone should have access to health care. Where they disagree is what that should look like.

One primary concern unions have about Medicare for all is that establishing a single-payer, government-run health care system will wipe out years of work at the negotiating table. Every dollar unions have asked employers to put into their health trust funds is a dollar that could have gone toward wage increases. The question is what happens to that money when it is no longer needed to pay for health care: Do the employers pocket it, or does it flow to worker paychecks?

“Medicare for all comes along, what does — in our case the contractor who we work for — and the union, how do they sit down and have a conversation about what to do with that money?” said William Stanley, executive secretary-treasurer of the Southern Nevada Building Trades. “There’s $10 or $15 an hour going to a trust fund for health care that’s no longer required because there’s Medicare for all. How does that contribution get divided? How is there a decision made, or are you just going to let the employer and the union fight it out and whoever is in the position of power wins and somebody walks from the table mad?”

Most of the building trades unions secured their health care provisions back in the 1960s and 1970s, Stanley said, which means that there have been six decades of making concessions at the negotiating table to get those health care benefits.

“How do you now go back and divide up those contributions?” Stanley said. “It’s a mess.”

But proponents argue that removing the health care conversation from the bargaining table would allow them to focus on other issues such as better wages and safer working conditions.

“Every time workers are going to the bargaining table, the employers are constantly trying to figure out how to put more and more cost on employees, and the insurance companies are trying to get more out of the employers. For us, they’re trying to figure out how to pass that along to the employee,” said Brian Shepherd, chief of staff for SEIU Local 1107. “Taking that off the table means we could focus on safer staffing levels, caseloads, better working conditions, which is what our members want to negotiate over.”

The union, which represents health care workers at major hospitals across the state as well as county employees, has gone so far as to explicitly endorse the mission of fighting for health care for all in its local constitution and bylaws.

“We are advocates for health care for every single person,” Shepherd said. “Now, I think where I think there are some differences is how do you get that done. If everybody has to have health care, we’re not just talking about insurance, we’re talking about actual health care.”

One primary difference between SEIU and other unions in Nevada wary of Medicare for all is that SEIU members here have employer-sponsored coverage, with the union bargaining for how much of the cost employees should pay and any changes in coverage, instead of running its own nonprofit health plan or, like the Culinary Union, a health clinic.

The Laborers Local 872, which represents construction workers in Las Vegas, has run its own clinic for more than a decade.

“Our clinic does fantastic for us. No copayments, there’s no out of pocket money, it’s free for our members and their spouses and their children,” said Tommy White, secretary-treasurer and business manager for the union. “It’s saved our health plan a ton of money and it isn’t that expensive. The cost of building the clinic and having it there for our members was a lot cheaper than having our members go to the emergency room or wait a month to see a doctor.”

Running a clinic has also given the union significant control over the health of its members in a way that it wouldn’t if its members were covered under an off-the-shelf private plan or a government plan. White said that after his brother-in-law overdosed on Christmas Day 2005, he got serious about cracking down on opioid prescribing — years before it was identified as a national epidemic.

“I started monitoring doctors. When I found doctors that were overprescribing members, we threw them out of our plan. No one wants to be proactive that way,” White said. “I had to take some heat from my members — ‘What did you do? He was a good doctor. He took care of my mom.’ He might have been doing the right thing for your mother, but he was doing the wrong thing for your sister or for somebody else’s family member.”

It comes as no surprise, then, that the Laborers are staunchly opposed to Medicare for all.

“We’re against it, and if there’s a candidate that’s going to come in and start saying, ‘We’re going to push Medicare for all,’ we’re not going to endorse them,” White said. “I speak it the way it is. I might get my ass in a jam every once in awhile for doing that, but I’ve got to protect what my members want. We’re more than willing to put in our fair share to help people, but we don’t want people telling us how much our deductible is going to be, our copayment is going to be, what we can prescribe.”

That’s another key issue for many unions that run their own health plans. A Medicare for all plan likely won’t cover some of the specialized, industry-specific benefits they have included in their plans. For the building trades, that might be more extensive chiropractic and orthopedic coverage. For police and fire, better mental health coverage to help with post-traumatic stress disorders. For the laborers, acupuncture and lasik surgery.

“It was cheaper to do lasik than it was to issue glasses every year or two years,” White said. “Medicare isn’t going to cover lasik.”

A cautionary tale

But not all self-funded plans come the same.

Teachers in Clark County are covered under the Teachers Health Trust, a teacher-run nonprofit health plan beset by problems in recent years. With the school district hit hard by the recession and stagnating premium contributions, the trust slashed benefits from its once robust health plan in 2014 and shifted costs toward employees. That gave way to complaints from teachers about insurance hassles and even a class-action lawsuit against the trust.

In 2018, an arbitrator sided with Clark County School District teachers in a contract standoff with the district, requiring the district to increase its contributions to the health trust per teacher from about $538 to $583 a month.

John Vellardita, the executive director of the Clark County Education Association, said that the trust is “on the road to recovery” now with the increased contributions, but the plan is no longer what it once was. He blames, in part, the skyrocketing costs of health care.

“To the extent that the economy is good and your employer has that kind of money where you can bargain those increases, then it’s going to be great,” Vellardita said. “But the risk, the exposure you have is when there is a downturn in the economy and the employer is facing financial difficulties in that economy, it’s going to impact what goes on at the table. The table does not control health care costs. The market controls health care costs.”

Vellardita acknowledged the concerns that other unions voiced on Medicare for all — that their health plans are built on years of collective bargaining and that having purview over their plans lets them tailor benefits to their members’ needs — but he said that conversation can’t be separated from the economic realities that shape the deals hashed out at the bargaining table.

“The assumption built into that argument is that somehow health care can, in this day and age, be divorced from any kind of economic impact when you’re bargaining with your employer and I don’t see how that exists,” Vellardita said.

He’s also pragmatic about developing a national health care system based around the needs of unions, when only about 11 percent of workers are union members.

“Ninety percent of the population does not have the luxury of collective bargaining for health care,” Vellardita said.

The debate on Medicare for all, he believes, has been framed around a false dichotomy between a universal health care system and protecting union rights to collective bargaining.

“I think we’re at a passing moment in history where both of those solutions are not the solutions we’re going to land on,” Vellardita said. “The first thing that has to be answered is [health care] a right and then, once it’s answered, what’s the role of the government — to be the delivery system or regulate the private sector delivery system?”

On this, the Nevada State Education Association — and, by extension, the National Education Association — and the Clark County Education Association, which broke away from the state and national affiliates last year, are in relative agreement.

“The National Education Association believes that affordable comprehensive health care is a right,” said Chris Daly, a lobbyist for the NSEA. “The association supports a national health care policy that mandates universal coverage with the highest quality health care at the lowest possible cost. The NEA also advocates for incremental reforms to improve the health and health care of children, students, and communities as well as their members.”

There’s one final element that plays into the discussion. Teachers, like the nurses, have been invested on the national level in the Medicare for all debate not just as consumers of health care but as people who work in a profession devoted to the individual wellbeing of humans. If their students aren’t healthy, teachers can’t teach them.

“Health care goes beyond our immediate self interest. It goes to the population we serve in our profession and that’s these kids. When we see these kids not having access to health care and coming into the classroom with the effects of that, you can’t walk away from the issue,” Vellardita said. “You cannot close your classroom door and walk away from this issue because it’s in your classroom."

The politics of health care

The question now is to what extent union’s positions on Medicare for all will shape who they ultimately decide to endorse — if they decide to endorse. Unions are an important constituency for Democrats, and their support could help tip the balance in the presidential nominating contests early next year.

But many unions have kept their powder dry so far, waiting to see how the crowded Democratic field thins out and giving union members time to consider their options.

The politically powerful Culinary Union — whose support is much coveted by Democratic presidential hopefuls — is no different. Arguello-Kline said the union has met with several candidates but that leaders aren’t making any decisions yet. She wouldn’t rule out the possibility of the union endorsing a candidate that backs a single payer system, but she stressed the difficulty of selling a candidate like that to her members.

“How am I going to go and talk to the members and say, ‘You have to support a member like that?’ I don’t think so,” Arguello-Kline said. “The members are really smart, and they want to protect their family first. They understand they have the right to protect their own health care too. How are you going to go and tell the members you’re supporting a person who is going to take away their health care?”

As far as what the union does need to hear from a candidate if they want to have any shot at its endorsement, Arguello-Kline said it’s simple.

“They need to say that they’re going to protect the Culinary Union health care,” she said. “All the union members, not only the Culinary Union.”

For its part, SEIU would like to see candidates keep talking about Medicare for all or any other solution that works toward the goal of universal coverage.

“If we start from the place that health care is a human right, then that means you have to have everybody in and nobody gets left out,” Shepherd said. “As a union that is the largest nurses union in the state, we want more people going to the doctor. We want more people getting the treatment they need so that health care workers can do what they were hired to do, not worried about having to turn away folks because they’re not eligible.”

Jeffrey Proffitt, business manager of the Sheet Metal, Air, Rail and Transportation (SMART) Workers Local 88, said that the union is in no “way shape or form” ready to endorse a candidate yet. However, he said the plan he believes that most suits union households right now is Biden’s, which he said would “take care of the folks that need the health care” but not “unravel the whole system over here for the unions.”

Right now, the union provides health care to its members through a trust fund that spans three states, but Proffitt said that they’re trying to transition to a more localized health plan similar to the one the Culinary Union has.

“It’s not working for my members right now, but I wouldn’t swing the pendulum the other way and say we need to go to strictly Medicare for all,” Proffitt said.

At the same time, he said that union workers have known Sanders “for years and years and he’s a strong union guy” but he’s “dead set on what he wants to do” on Medicare for all. With Warren, he believes there might be more wiggle room. The Massachusetts senator is expected to soon release a more detailed Medicare for all plan, including how to pay for it.

“What we do like about Elizabeth Warren is she says, ‘Let’s have a discussion.’ We’ve sat in the room with her and it’s about how can we do this. I don’t think that she’s dead set on everything she talks about because they’re ideas,” Proffitt said. “If Medicare for all can weave in with these systems where we can have our own [union] doctors and doctor’s offices, then I think you’ve got something special.”

They’re not the only ones who are open to listening to the arguments for a single-payer system, either. McAllister said that many AFL-CIO affiliates are supportive of something like a single-payer system. It’s more a question of how to get there, he said.

“One of the things I’ve found in this position here is labor’s all on the same mission but often they have a different idea of the best way to get there. That’s kind of where I think a lot of them are right now,” McAllister said. “We’re willing to listen to all options, but let’s make sure that the solution isn’t pitting one group against another.”