Vision for Health Care
With A New Vision for Health Care, We Need A New Vision for Health Care Workers
This book will be controversial in the health care workers' union movement and in the broader labor movement. It examines the experience of the union long known as Local 1199,
Ducey interviews 1199's members about their lives, aspirations, working conditions, their interactions with each other, and their relationship to the union structure. Her focus is the ground-breaking 1199 Training and Upgrading Fund, which for many years was funded by a percentage of the employer hospitals' gross payroll, but which was hugely expanded in the 1990s through government grants and funding streams.
The book investigates the Labor-Management Cooperation program launched in the early 1990s, and how this program supported the hospital industry's workforce re- design goals, and then how these goals were reflected in the Training and Upgrading Fund's programs.
The author takes a sharply critical stance toward the decisions of 1199's leaders. She states, 'the elaborate and extensive training and education system established for health care workers in New York in the 1990s.largely failed to address, and in some instances, reinforced, key problems in health care work and the health care system more broadly.' On the relationship between the training programs and working conditions, Ducey asserts, 'Some training programs even cajoled workers to accommodate the market-driven health care reforms that produced and aggravated the aspects of their working conditions they found most frustrating.'
Later she says, 'A training and education superstore under de facto union control was the primary achievement of 1199's decision to form an alliance with hospital leaders in the 1990s. This achievement, however, entailed costs for the frontline health care providers and patients.'
Health Care Worker Training and the Interests of Patients
Nowhere are the contradictions discussed in this book more clear than in the example of the new hospital worker classification called Patient Care Associate in 1199's hospitals (and given different titles around the country) - a nursing assistant with some amount of additional training and given expanded responsibilities for a variety of new tasks formerly performed by nurses.
Ducey might have examined the impact of this new job in a more comprehensive manner by interviewing registered nurses, licensed practical nurses, and the PCAs more thoroughly and through direct observation of nursing care in acute care hospitals. However, she nonetheless grasps the impact of this new job - one of the Training and Upgrading Fund's major programs - on the interests of patients.
Ducey contends that the new multiskilled jobs which were the result of the collaboration of 1199 and the hospital industry represented health care worker speedup and not real upgrading for the workers. Those knowledgeable about the nursing profession will recognize that the new PCA position does not afford a 'step up the ladder in nursing', and it might be interesting to study how many of the nurses' aides actually viewed it as such, or whether the union presented it as such to the nurses' aides, even if in a subtle way.
The fact that the union negotiated a $40 a week salary increase for the PCAs was important for these workers, and cannot be belittled. However, 1199's leaders made a major mistake in not taking more seriously the impact of this new job on patients. In the experience of this writer, 1199's leaders did not heed either those RNs who were members of 1199, nor nurses outside the union, who immediately grasped the dangers to patient care of this fragmentation of hands-on nursing care. PCAs were now being substituted at the patient bedside for RNs, who are the only nursing workers trained to make assessments of patients, which can have life or death importance.
Ducey states, 'It may seem that the potential negative consequences of re-engineering could have only been known with hindsight - and therefore that 1199's only choice in the mid-1990s was to cooperate with and thereby try to mitigate the effects of restructuring.' But she later writes, 'The dangers and limitations of restructuring could have been predicted from the angry letters that nurses around the country wrote to their professional journals (until they burnt out and quit).' Furthermore, another major nurses' union - the California Nurses Association - fought this re- engineering of nursing militantly and effectively during the same period.
Ducey points out that a '1998 study of twelve New York City hospitals found that none of the hospitals is attempting a comprehensive evaluation of the impact of redesign on quality of patient care and patient outcomes.' The Registered Nurses Division of 1199 did begin to dabble in meeting with nursing researchers who were beginning to look at these issues (this writer was directly involved), but as a powerful and well- resourced union, 1199 had the responsibility to push for or to sponsor such research itself, but it abdicated this role in the interest of not rocking the boat with its partner, the hospital industry.
The question must be asked: if unionized hospitals in a state whose health industry is more regulated than many others are not being overseen for workforce changes which could be detrimental to patients, what could be going on in the majority of US hospitals which are not unionized?
Thankfully, responsible nursing and medical researchers in the decade since re-engineering began have discovered and publicized the fact that re-engineering of nursing and the too high ratios of patients to nurses are resulting in thousands of deaths of hospital patients in the United States every year. A growing national movement of nurses is fighting for recognition of this unnecessary and reversible epidemic of 'failure to rescue' hospital patients.
Although specific nurse to patient ratios were written into the collective bargaining agreements for 1199 RNs during this period, the union did little to train the nurses in how to actively enforce the ratios, and they became worse to the point where they were no different from the ratios in non-unionized hospitals by 2003.
Impact of Labor-Management Cooperation on Working Conditions
In the direct experience of this writer, conditions for hospital workers other than nursing workers deteriorated as a result of 1199's cooperation program with the hospitals. Hospital worker conditions are inseparable from patient conditions - at the hospital which pioneered the 1199 Labor-Management Cooperation program, one third of the housekeeping staff was laid off and the hospital became unacceptably dirty much of the time. Workers were required to work - and came to need economically - high levels of overtime. A goal of the cooperation program was a decrease in the number of grievances and arbitrations, but whether legitimate grievances were being discouraged by union stewards and staff members in the name of cooperation was the subject of constant debate among the union's membership.
A focus of this book is how health care workers feel about how their work is valued, and a major factor in this is how workers feel about their treatment by their frontline supervisors. This is an area where the 1199 Labor Management Cooperation program failed. Union members complained that the program was having no impact on the arbitrary and often harsh discipline they continued to experience, despite the participation of the hospital 'higher ups' in the cooperation program. Furthermore, as soon as the union-friendly CEO of the first hospital to enact the cooperation program left the hospital, a much harsher group of management personnel arrived, and the program became more of a tool against the union's membership.
1199, Health Policy and Politics in New York
This book examines a little-studied aspect of the life of 1199 - how its policy decisions and political choices (sometimes endorsing Republicans over progressive Democrats) affected the health care of New Yorkers. Public health activists were angered when 1199 fought for the conversion of the not-for-profit insurer-of-last-resort Blue Cross to for-profit status. Ducey reveals other instances of 1199's failure, in her view and that of others, to fight for the health interests of the poorest New Yorkers.
One labor commentator is quoted, 'Deals that are good for the members of one union are not necessarily good for the members of other unions, let alone working people in general. A governor (Republican George Pataki - endorsed by 1199) who slashes welfare, cuts taxes, cuts and privatizes public services, locks people up, blocks efforts to redress the state's unequal education funding, campaigns for an anti-union President and can't even be bothered to raise the minimum wage in an election year is not likely to help the labor movement in the long run.'
1199 and SEIU's direction, Labor's Future, and the Future of Health Care Workers
In October, 2008, a majority of the members of the 42 year old Teachers' Federation of Puerto Rico (FMPR), voted to reject representation by SEIU, following 1199's ex-President Dennis Rivera (a native of Puerto Rico) making a deal with Puerto Rico's Governor to decertify the union so that SEIU could take it over. So strongly did the teachers feel about Rivera's role and SEIU's record, that they voted to weaken their own bargaining position and to become an uncertified union. (This Governor has since been voted out of office, and the teachers have new hope for re-certification, and vow to continue their militant struggle as a rank-and- file controlled, independent union.)
Meanwhile, SEIU's second largest health care 'local' - United Healthcare Workers West, is fighting for its democratic life under the threat of trusteeship by International President Andrew Stern.
What many labor activists consider to be the pro- corporate approach of SEIU over the past several years is being rejected by growing numbers of the union's members. We must hope that SEIU's members change the direction of their ship.
As the election of President-elect Barack Obama opens new possibilities for new kinds of jobs and as the movement for health care justice girds itself for a fight once again, health care unions willing to oppose the dictates of the hospital industry could promote new kinds of health jobs which are badly needed - such as community health workers, multi-lingual hospital translators, and infection control workers. 1199's training program could pioneer in creating these new jobs.
A small minority of health workers are unionized. Labor journalist David Bacon has written, 'An organized health care industry in alliance with consumers could create the strength to win a single-payer health system benefiting every person in the country.'
But this can happen only when health care unions are prepared to take on corporate health care and fight for the inseparable interests of workers, patients, and consumers and to play the critical role of uniting these powerful forces into one winning movement.
[Marilyn Albert, RN, was a shop steward and organizer for 1199 from 1974 to 2003 and was personally involved in 1199's Labor Management Cooperation program. She now lives in Cleveland, Ohio and is an organizer for the National Nurses Organizing Committee.]