An unlikely alliance is being formed between the administrators of the nation's public hospitals and their unionized employees, as they confront common enemies outside hospital walls.
They're fighting to preserve the role of public hospitals against new political and market forces that are challenging their traditional missions and sources of funding. Along the way, they're teaming up to influence Medicare and Medicaid legislation and other topical issues.
Newly elected AFL-CIO President John J. Sweeney delivered a clear vision of the alliance between public hospitals and labor in a speech to the California Association of Public Hospitals on Dec. 9 in San Francisco.
"I can't think of a place where management needs labor as a partner more than in public health," Sweeney said. "We must identify our common agenda. We must work together to re-establish the public's trust in public service.
"We must flex the political muscle it takes to preserve public healthcare," he added. "Our local unions here in California are ready to work with you. And our international unions and the AFL-CIO in Washington are ready to work with you."
Three-quarters of the member hospitals in the National Association of Public Hospitals are unionized to some extent. Most of those workers are affiliated with the American Federation of State, County and Municipal Employees or the Service Employees International Union, said Larry Gage, NAPH founder and president.
The NAPH tries to work with both unions because they are sophisticated about healthcare issues on the national level.
"They have what relatively few other organizations have: They have shock troops," Gage said. "They can turn out a couple hundred people, or a couple thousand people, in support."
The unions lean, of course, to the liberal Democratic end of the political spectrum. As such, their political influence has waned since the Republicans gained control of the House and Senate in the 1994 election.
Still, Gage said, "On issues related to access to care for the poor, where even Republicans are likely to have some sympathy at the local level, we've found we can work with them very well."
The response to the Republicans' Medicaid agenda illustrates this new era of cooperation. The NAPH has been instrumental in drumming up support in congressional districts to preserve the Medicaid safety net. To do that, they call on their union pals.
In Kansas City, Mo., last summer, the NAPH asked Truman Medical Center, which treats the city's poor and uninsured, to put on a news conference to push for Medicaid funding.
"They had been doing these nationally," said Connie Brockert, Truman's marketing director. "On the program would always be union people as well. They contacted some union people here to show up at ours. It was the teachers union who was here. The NAPH was working with the teachers nationwide."
The news conference generated some favorable television coverage locally.
Natural allies."We have always seen ourselves as representing the vulnerable populations on the national level," Gage said. Whether lobbying Congress or working with the administration, the unions have been natural allies of the safety net hospitals.
Gage said the tricky part is understanding that while the interests of unions and public hospitals may converge on the national level, there is "more of a potential for conflict" at the local level, depending on the economic situation of the hospital.
"Some of the things we think hospitals need to do to survive, whether it's restructure, or merge, or downsizing, rightsizing, or laying off employees, that's where things become, understandably, of greater concern to organized labor," Gage said. A union local has a primary interest in preserving jobs, or retaining public-sector jobs when a public hospital combines with a private one.
Last summer, unions staged massive demonstrations at LAC-University of Southern California Medical Center to protest the hospital's announced closure for budgetary reasons.
Meanwhile, back in Washington, the SEIU played a backstage role in persuading the Clinton administration to cast a lifeline to the sinking Los Angeles County public health system. The administration helped defuse the crisis by granting a one-of-a-kind Medicaid waiver, worth $364 million, that gives the county some breathing time to reorganize its health services.
As Sweeney put it, "We came out batting .500 with enough money from President Clinton to bail things out temporarily. Instead of losing 12,000 jobs, we lost 1,600."
In a twist showing the links between elected officials and labor, Los Angeles County supervisors actually tossed out the original recommendation for closing the hospital. An official with the Healthcare Association of Southern California commented that the supervisors were too deeply indebted to the labor unions to allow that many jobs to be eliminated.
Some of those workers may yet lose their union affiliations, though, when some county health clinics are turned over to private operators.
First principles.In his speech, Sweeney acknowledged that on the local level the unions will fight for their members' prerogatives, rights and jobs, but he stressed that they must first work with the public hospitals to preserve the healthcare safety net.
"I can't think of a place where management needs labor as a partner more than in public health," Sweeney said. He then outlined for the public hospital administrators "what the men and women of the AFL-CIO are doing to preserve Medicare and Medicaid."
The unions set up toll-free telephone numbers that connect to the Capitol Hill operator. In summer and fall they spent $4 million on media in targeted House districts and generated 270,000 phone calls, and 200,000 postcards to the president.
The week of his speech they sent a million pieces of mail and bought radio and television time. They staged events and news conferences in 22 House districts.
Robert Sillen, executive director of the Santa Clara Valley Health and Hospital System, San Jose, Calif., liked what he heard. "I couldn't be more pleased that John Sweeney is the new president of the AFL-CIO. As former president of the SEIU, he has a long background and familiarity with the healthcare industry. I'm looking forward to working with labor to preserve what we all want to preserve."
Sillen's public health system has 4,000 employees, of whom 3,500 are union, most with SEIU Local 715. "The attitude of labor, the performance of labor, is absolutely critical for the future of public hospitals," Sillen said. Unions, management and governing bodies have to share responsibility for the good and bad fortunes of public hospitals, he believes.
"The survival of the institution and the services it provides is the preeminent concern," Sillen said. "We have to work together to preserve the jobs, but maybe not all of the jobs. Protect workers rights, but change the definition of what those rights are."
Workers need to understand that public hospitals have to enhance their service and customer satisfaction to compete in the new environment. "Public hospitals can't continue to have extremely long waits, or this attitude that people have nowhere else to go," Sillen said. Without union cooperation and flexibility, these improvements don't have a chance.
Santa Rosa battle.Unions also realize that if public hospitals fail, or are sold or leased to private entities, the new operator won't necessarily recognize the union.
This scenario is being played out now in a public hospital about 50 miles north of San Francisco. The Sonoma County Board of Supervisors is negotiating to lease out Community Hospital in Santa Rosa to Sutter Health Foundation of Sacramento. The supervisors specified that Sutter must give hiring preference to existing county hospital employees.
However, SEIU Local 707 points out that the supervisors aren't requiring Sutter to assume the labor contracts.
The lease allows Sutter to set "the terms and conditions of employment subject to negotiation with the unions," said Michael Allen, general manager of 707, which represents 800 workers at Community Hospital.
In the private sector, many union contracts contain successorship clauses, which embeds the union contract in the sale. In the public sector, Allen said, few contracts have successorship clauses, because no one imagined that whole sectors of county services would be sold off or leased.
"It puts us in a difficult position," Allen said. "But many of us felt it was a victory because we at least got them to recognize us. They could have put us through a National Labor Relations Board certification election."
Nevertheless, the union opposes the lease. Local 707 has banded together with other community groups to organize the Campaign to Save Community Hospital. They have gathered almost 30,000 signatures on a petition, enough to force an initiative election on leasing the hospital.
The union says it thinks the deal with Sutter is the first step in an attempt to tear up the county's integrated healthcare system for the indigent.
"It's been on that basis that we've joined forces with the community," Allen said. "It's a public policy issue-who's going to take care of the indigent-that's created this strong coalition."
In the union's view, the public shouldn't trust a nongovernmental hospital operator to make the same commitment to indigent care that the county does.
But Sweeney, in his speech, pointed to a third way: developing public health authorities to avoid privatization or outright closure.
Denise Martin, president of the California Association of Public Hospitals, said this could prove a constructive alternative.
"If the county hospital is taken out from under control of the board of supervisors (and given to a private company), the unions fear they lose too much in that transition," she said.
A public authority, by contrast, would remove direct control and oversight of the hospital from county supervisors. That would make the hospital or health system more independent, eliminate bureaucracy and trim costs.
"It doesn't mean supervisors have lost all interest," Martin said. "It just takes it one step away from the inefficiencies of government."