Healthcare unions have scored major contract wins amid a wave of labor action across the U.S. and used their muscle to push beyond priorities such as pay and staffing and secure guarantees that their employers will take action to promote health equity.
Workers at Oakland, California-based Kaiser Permanente, New York-based Mount Sinai Health System and Bronx, New York-based Montefiore Health System, for example, negotiated new collective bargaining agreements after striking this year. While those contracts include pay boosts and similar provisions, they went further by creating power-sharing arrangements, accountability structures, and policies and programs related to racial justice and community health.
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“It is really common for healthcare unions to seek changes through collective bargaining that not only impact working conditions but also improve patient care," said Laurel Lucia, director of the health care program at the University of California Berkeley Labor Center.
In New York, 7,000 nurses engaged in a three-day strike this January demanding more investment in low-income communities and accusing executives at nonprofit Montefiore and Mount Sinai of prioritizing finances over patient care. The New York State Nurses Association won sizable wage increases and updated staffing ratios with stronger enforcement mechanisms.
In the highest-profile healthcare labor action this year, nearly 75,000 Kaiser Permanente nurses and other workers from several unions staged what may have been the largest healthcare strike in U.S. history last month. The final agreement brought union employees substantial compensation gains and job outsourcing protections.
Staffing and equity
Healthcare workers are eager for solutions to nationwide staff shortages and their adverse effects on patient care, especially in underserved communities. In response, unions are actively advocating for stronger commitments to recruitment and professional development that would reduce wait times, meet staffing ratios and foster workforce diversity.
In New York City, where limited access to healthcare services compels patients to use emergency departments, the New York State Nurses Association won new staffing ratios and an arbitration provision to give Mount Sinai and Montefiore nurses a means to hold the health systems accountable for shortages. This month, Montefiore nurses accused the health system of understaffing 27 shifts over a two-month period and won the arbitration—the first using this mechanism. The health system had to pay $17,000 under the ruling.
Vanessa Weldon, a home health nurse at Montefiore Medical Center, said it’s a new power the union has to ensure there are enough nurses to properly care for patients.
“Our fight is not about money. It’s about providing adequate care to our community," Weldon said. "Our fight is about better health equity for our patients and our community. Montefiore was not going to do that, and we had to take a stand for our community. We need the same type of community health equity that is afforded to other, more affluent communities.”
Nurses from the New York hospitals also secured additional funding for apprenticeship programs in underserved neighborhoods. The companies are expected to launch recruitment initiatives in nearby high schools to create a pipeline for a workforce that mirrors their communities.
Similar initiatives among Kaiser Permanente workers led to a 40% funding increase for the Coalition of Kaiser Permanente Unions’ education trust fund, which is used for professional development and recruitment to alleviate staffing shortages. The coalition is also working with the nonprofit integrated health system to establish paid trainings and externships to encourage low-income people to apply for open jobs.
Recruiting workers that reflect the community being served is a vital component of equitable care, said Caroline Lucas, executive director of the Coalition of Kaiser Permanente Unions. The coalition comprises locals from the Service Employees International Union, the Office and Professional Employees International Union and the International Federation of Professional and Technical Engineers.
Kaiser Permanente and the unions are also creating career development pathways to promote greater diversity in the management and executive ranks, Lucas said.
“Our frontline workers and unions are the most diverse set of employees they have. Kaiser tends to get more white and male as you go up, just as any other corporation does,” Lucas said. “Being able to develop the folks who are coming in the front door for employment—who tend to be lower income, less educated and more diverse—so that they are able to advance their skills and potentially end up in leadership roles will very much have an impact on health equity,” she said.
"We are always open to hearing from our employees, physicians, leadership or our unions on opportunities to better live out this foundational commitment," a Kaiser Permanente spokesperson wrote in an email. "Our multicultural, multiracial workforce is truly one of our greatest strengths."
Investment, decision-making power
A Montefiore program that provided preventive and social care to pregnant mothers and their children ran out of grant funding last year and the health system planned to shut it down. The nurses union negotiated a solution in the collective bargaining agreement in which the health system will finance the initiative while it seeks long-term grant funding.
“We know that within New York state, the mothers and the babies of the Bronx have the highest mortality rates out of all the counties,” Vanessa said. “This program was vitally important to them.”
Kaiser Permanente workers utilize a nearly 20-year-old power-sharing arrangement with the health system to advance health equity, Lucas said. Union members from across the health system come together in multidisciplinary focus groups to discuss projects and undergo training. The unit-based teams help distribute power across union members to enact change in the health system, she said.
For instance, employees are working to reduce hypertension in Blacks in the District of Columbia and manage diabetes among Native Hawaiians and Latinos in Southern California. The unit-based teams have also helped expand appointment times for people who need interpreters and added pronouns as a demographic element within electronic health records so patients are identified properly.
“It's one of the structures created under our national agreement and it's really the premise that frontline healthcare providers and frontline teams can best design workflows and practices to support their patients,” Lucas said.
The union also negotiated a performance-sharing program focused on blood pressure control through which workers earn bonuses if they close disparities in outcomes. That encouraged employees to conduct outreach to Latinos within a diabetes program to ensure they were getting routine maintenance and access to preventive care.
Some demands were left on the table. For example, the Kaiser Permanente unions failed to win contract language related to racial justice after the health system maintained its own activities, such as an internal diversity, equity and inclusion program, are sufficient, Lucas said.
“Our interest was: [DEI] has been around for a while, but it can tend to be a flavor of the month. Right now, it's high profile, but what happens 10 years from now?” Lucas said. “If Kaiser decides that isn't a focus of the organization, we want contract language that codifies the work. That wasn't something that we, by and large, were able to get.”