America was in a health care crisis before Covid, and the stresses of the pandemic have made it worse. Since the pandemic began, the health care work force — the country’s largest industry by employment — has shrunk by nearly 2 percent. That may seem like a small amount, but historically, the health care work force doesn’t shrink; it only grows. Now, with astronomical turnover and rising demand as patients seek care that they may have put off during the height of the pandemic, hospitals, clinics, nursing homes and home care agencies across the country lack sufficient staff members to adequately care for patients.
The health care system, before it is anything else, is a work force — that’s the “care” part. Without enough nurses and aides, patients in skilled nursing facilities cannot be bathed when they need it, or have their pain relieved or wounds dressed in a timely manner. Patients who can’t feed themselves may not eat enough because no one has the time to help them. Hospital nurses coordinate care by dispensing medications, prepping patients for tests and scans and, most important, quickly intervening when serious problems develop. Respiratory therapists in hospitals manage the ventilators that keep many Covid patients alive, and without enough pharmacists, medications cannot be efficiently and safely prepared for patients.
Most hospitals might be private companies in their formal legal identity, but the reality is that government has shaped the health care system every step of the way of its modern existence. That shaping dates back to the 1940s, when tax policy and labor market regulation led to the establishment of private employment-based health insurance. Medicare and Medicaid account for more than one in three health dollars, and Medicare has absorbed hospital capital costs since it was established in 1965, meaning that the federal government paid to create much of the existing facilities and equipment used by hospital systems today.
American health care is a public system in the sense that the government paid for much of it and gave it its current shape, but it’s divvied up for administration across private owners. This means that savings often take the form of holding down wages and, if that becomes difficult, suppressing staffing levels relative to patient needs. If the government doesn’t step in to stabilize the health care labor force, patients suffer and overworked and underpaid health care workers quit or go on strike, which drives up costs further and will likely hurt patients.
Unionized health care workers all over the country are fighting back against untenable conditions in the health care industry, and they are often met with harsh treatment by employers for doing so. Recently, thousands of nurses in the California Sutter Health system were barred from returning to work for five days in retaliation for a one-day strike. Workers at Howard University Hospital in Washington, D.C., struck last month, protesting pay and benefit changes imposed unilaterally during negotiations. A unit of some 1,600 nurses at Providence St. Vincent in Portland, Ore., recently voted to authorize a strike to protest retaliation against nurses for union activity. Nearly 5,000 nurses at Stanford University Hospital this month ended a strike during which the administration threatened to cut off their health insurance. This behavior by management pushes health care workers out the door faster and degrades the health care system further.
The labor movement, and some cities and states, have come up with one way to stabilize the system: requiring health care employers to make what are known as labor peace agreements with their unions. Under these deals, employers and employees must work together to prevent strikes, which means finding mutually agreeable paths for workers to have a voice. Employers are generally restrained from retaliating against employees or from refusing to respond to their grievances, since doing so would generate labor disputes. And if the sides cannot reach agreements, they must go to arbitration.
Peace agreements are popular with unions because they help prevent the type of devastating reprisals that drive many workers out of their jobs, but employers often refuse to accept them.
That’s where policymakers come in. In Pennsylvania, Gov. Tom Wolf’s administration is proposing to require Medicaid contractors — virtually all major providers of health care services — to guarantee labor peace, on the grounds that this would prevent disruption to patient care. Illinois is looking at a similar provision. New York City recently imposed a labor peace requirement on social service and health providers that contract with the city.
These agreements can face opposition from hospitals. The Hospital and Healthsystem Association of Pennsylvania is suing the state to prevent Governor Wolf from carrying out the labor peace policy. But these policies reflect a long history of governments stepping in to ensure stability when an industry suffers from disruption due to frequent or bitter strikes and high turnover.
Research shows that in health care facilities, patients fare only as well as the nurses, and by extrapolation, the entire staff. By giving weight to workers’ on-the-job needs, while eliminating strikes, labor peace policies in health care facilities benefit patients because they give workers more power to manage their work environments. They also make establishing unions easier for workers, and data suggests that unionization in health care improves patient care. One recent study found that unionized nursing homes in New York State had a significantly lower rate of resident deaths from Covid-19 than nursing homes where the work force lacked unions.
Labor peace policies could build on a legacy of regulating health care labor relations. States already oversee the staffing of nursing homes directly through Medicaid, for example. And before the extension of federal labor law to health care in 1974, states sometimes treated health care workers like de facto public employees. In 1970, Pennsylvania put hospital workers under the protection of a new public employee labor relations system in the name of labor peace. This was legally possible because of the state’s role in financing health care, and the legislature was clear about the purpose of these protections: “Unresolved disputes between the public employer and its employees are injurious to the public.”
A large body of research has shown that when health care staff members are overworked, patients die who would not have otherwise. But more than that, patients deserve to be cared for as human beings — to be fed, safely medicated and attentively watched over. Labor peace regulations help bring much-needed security and serenity to patients and caregivers alike. If widely imitated, they would lead to a more humane health care system for all of us.
Gabriel Winant is an assistant professor of history at the University of Chicago and the author of “The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America.” Theresa Brown is a nurse and the author of “Healing: When a Nurse Becomes a Patient.”
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