The relationship between the workforce that treats America's patients and the health systems that employ them is fraying, and the more than 75,000 Kaiser Permanente workers on strike this week are just the latest example.
The year started with 7,000 NYC nurses across two hospital systems going on strike. Now, as autumn sets in, 10 times that many health care workers are striking in one of the best-known health systems in the country — one that had, until now, been something of a model for successful labor-management relationships in the health care industry. The striking workers have said this will be a three-day action, though as of Thursday morning, there was little evidence of a resolution between the unions and Kaiser Permanente.
Medical doctors and registered nurses are not among those on strike. But other support staff upon whom patients' care depends — including licensed practical nurses and nursing assistants — are walking out because they, like many nurses since the beginning of the Covid-19 pandemic, find their work conditions intolerable.
The workers say they are overworked and underpaid. According to the New York Times, the unions had asked for a minimum wage of $25 per hour plus annual raises of 7 percent over the next two years. The company had countered with a base wage of $21 to $23 per hour and slower wage increases.
At the same time, lab assistants described their offices shrinking. One who was hurrying to finish tests before the strike began said a team of formerly five was now only three. A longtime nursing assistant described the growing burden of burnout on the health system's workforce.
The strike could lead to delays in patient care because while nursing assistants and lab techs may not have the same clinical responsibilities as an MD or an RN, their work is necessary for a functional health system. They bathe and feed patients, run samples through tests, and perform other tasks necessary to the successful treatment of the people in the hospital.
How did we end up here, with another major hospital system paralyzed by another health workforce strike, over the same issues that have been cited for years, dating back to before the pandemic?
It's the same problem that led to the NYC nurses' strike, which followed at least eight major work stoppages involving health care staff in 2022, and the same problem I wrote about in June last year, describing the way we pay nurses as "broken."
Hospitals don't make more money if they pay nurses or nursing assistants more money, or hire more of them to better distribute the burden, or invest in other things to improve their work environment. Because of the way the US pays for health care, those outlays are exclusively expenses that do not help bring in any new revenue. The result is that the people who do much of the patient care are persistently undervalued.
"The same problems apply to support staff insofar as they are costly to organizations and don't bring in reimbursement, so they are perpetually understaffed, underpaid, etc.," Olga Yakusheva, a health economist at the University of Michigan who has written extensively on the economics of the hospital sector and how it affects staffing, told me.
US hospitals generally depend on a fee-for-service system: They make money by billing for individual services. Doctors, in this universe, are revenue generators. They order tests to be run, imaging to be taken, medications to be administered. They conduct surgeries and exams. The hospital can charge for each of those individual services, and patients see them on their bills.
Nurses, nursing assistants, and LPNs are all essential to caring for the patients who receive those services. But because hospitals do not bill insurers for the labor that those workers provide to support a doctor's orders, they end up on the other side of the hospital balance sheet as a labor cost. Patients are charged for their work in the same way they are for Jell-O, as part of the cost of the hospital room. The work they do is not considered a billable service under the fee-for-service payment model.
Betty Rambur, a professor of nursing at the University of Rhode Island, ticked through the other ways in which the work situation for medical support staff has become increasingly untenable, many of which also apply to nurses. Some patients can be violent. Facilities are putting more responsibilities on a smaller number of people.
These workers can often make similar wages at other non-health care businesses that do not carry the same risks (such as getting sick yourself). The cost of living is going up. The structural problems that contributed to an exodus of medical workers during the pandemic are only getting worse.
"The intangible 'soft rewards' of the work are evaporating," Rambur said. "The nation has systematically underinvested in health professions outside of medicine."
There is one detail that is distinct to the Kaiser Permanente strike: Bianca Frogner, who leads a program on the US health care workforce at the University of Washington, told me support staff are typically not unionized at other health systems across the US. This strike may be "a canary in the coal mine" signaling wider discontent across an oft-ignored part of the health system.
"These workers going on strike are among the lowest paid workers in any health care system," Frogner said. "Many are working behind the scenes in important roles, and they are living in areas of the country with high cost of living."
