Unions and Health Care Reform

...Leveraging Wall Street SEIU began the campaign hoping for voluntary recognition...

...They also helped rationalize the economy and guarantee unions' social and political role...

...Yet unions have never surged without other vibrant social movements...

...But instead of guaranteeing survival of community hospitals, the cost-plus financing of the two programs guaranteed huge profits, rapid expansion of facilities and technology, and rapid cost inflation...

...Choosing how we take care of each other is the essence of being human...

...For the past decade, organizing to scale has involved a massive effort, joined more recently by AFSCME and the California Nurses Association, which also have records of aggressive DISSENT / Summer 2004 n 71 LABOR AND HEALTH CARE organizing...

...The State Strategy for Reform There is a difference between tactical use of the politics of the welfare state in organizing and political struggle to expand the welfare 74 n DISSENT / Summer 2004 state itself...

...SEIU pumped serious iron in the legislature—enforcing and expanding existing standards—and established itself as a force that neither Kaiser nor any other system could ignore...

...health care system from one based on non-profit and public hospitals to one that is corporate driven, and the retreat of the federal government from supporting public care to fostering privatization...

...and provides subsidies to lowincome workers to buy insurance...

...Known as SB2, the legislation requires employers either to "play" by providing a minimum level of coverage to employees (including employer contribution to the premium) or "pay" by contributing to a state fund for care...

...It holds the door open for more fundamental national measures, in part by preempting right-wing measures such as medical savings accounts or vouchers...

...Without fundamental reform of the cost of drugs or medical technologies or insurance, Medicare will soon be thrown on the pyre as well...

...under its belt, SEIU applied what it had learned to the much larger turf of hospitals, an industry that makes up one seventh of the U.S...

...But labor's assumption that it can deliver its employers to support health care reform has proven wrong in the past, most recently during the failed Clinton reform...

...SEIU analyzed the power structure of the building services industry, identified owners rather than cleaning contractors, went after entire cities rather than individual workplaces, funded itself for the long haul, then launched militant and often raucous campaigns for voluntary recognition, and waited years for victory...

...The question is not only whether unions can organize on a massive enough scale to set employment standards again, but whether they can contribute to the far more difficult problem of regulating an industry increasingly beset by the same forces of privatization, globalization, competition, and budget cutting that buffet the economy at large...

...the California organizing began seventeen years ago, at least...

...Congress will remain largely unchanged...

...It was disappointed on both counts...

...By the late eighties and early nineties, private hospitals—profit and nonprofit alike—were morphing into "systems," using their consolidated market power to battle insurers for increased rates for reimbursement, creaming the best patients and leaving the sickest to the public hospitals—and the public purse...

...For progressives, the challenge is to raise expectations for reform and keep them raised...

...If the partnership was the carrot, the stick was SEIU's revival of industry organizing through its Justice for Janitors campaign, which was conceived as a way to overcome the problems of site by site National Labor Relations Board elections (which offer perfect platforms for delaying votes and terrorizing workers...

...The state strategy avoids divisive battles over single-payer...

...Markets are efficient...

...But it does represent an ideological black hole...

...Following the Industry The challenges of building a coalition between labor and progressives are illustrated by the experience of the Service Employees International Union...

...But most also require significant political capital to implement and leave key details, such as floors for coverage, to be worked out after passage...

...Governments are corrupt and only take away the chances individuals have to succeed...

...slash budgets...

...In Maine, SEIU helped elect the governor on a platform promise of reforming health care...

...DISSENT / Summer 2004 a 77...

...Securing the Base Health care is highly centralized, and SEIU's resources, like those of most unions, are highly decentralized, in 1996 SEIU began spurring locals to put 20 percent of their budgets into organizing...

...In this context, CATS, the FTAA, regional trade agreements and structural adjustment programs (SAPS) are reminders of the pressure of time, and markers of how deep political organizing will need to be to expand, or even defend, the welfare state...

...When the Reagan administration switched to flat-rate reimbursement by diagnostic groups in an attempt to limit costs without regulating the industry, incentives jumped from providing as much care as possible to providing as little care as possible...

...Nor do most address the wastefulness of our third-party-payer insurance system or inadequate regulation of technology and facilities...

...Its strategy for political reform is, therefore, to recruit health care voters for the 2004 elections, use the 2004 elections (and beyond) to bolster and focus state level demands for reform around a broad set of principles, then use successful state reforms to press for national reform...

...Theoretically, singlepayer national health insurance is already prohibited under GATS, Under NAFTA's provisions for investor-to-state suits, single-payer could be challenged either by a foreign insurance company or a U.S...

...As more jobs have become part time or temporary, the stability of the system of privately paid, job-based benefits has crumbled...

...SB2, for example, followed fourteen years of efforts with other initiatives, including a single-payer initiative that crashed and burned in the wake of the Clinton debacle...

...The question is what the reforms accomplish and whether the momentum they create is more likely to be harnessed by the left than the right...

...Insurers—which now included health maintenance organizations and other managed care systems—consolidated and fought back, inventing "capitation" or a flat rate per patient—an even worse incentive to ration care...

...The globalization of health care will transform the leverage points for organizing once again...

...Federal Reserve chair Alan Greenspan has used the deficit to call for cutting Social Security...

...So far, SEIU's health care organizing has taken place in a national context...

...The result was alternating rounds of cost inflation, profit 72, n DISSENT / Summer 2004 squeezes, and further acquisitions...

...economy...

...In the thirties, forties, and fifties unions raised employment standards by organizing on such a massive scale that they dominated labor markets for union and non-union workers alike...

...In the absence of any similar social movement today, what makes SEIU's ambitions possible as well as necessary are the same forces that make reform essential— the transformation of the U.S...

...Workers were now "cost factors" of production that hospitals had to minimize...

...Hard work leads to success and to global competitiveness...

...insurer incorporated off-shore that wanted to recapture a share of the U.S...

...The push to organize grew out of the plummeting market position of SEIU's flagship health care employer, Kaiser Permanente, as freestanding hospitals in California—nonprofit as well as profit—went through a massive wave of amalgamations in the late eighties...

...Organizers worked with Catholic activists to hold CHW accountable to Catholic social teachings...

...More, employers see other DISSENT / Summer 2004 n 75 LABOR AND HEALTH CARE employers in the same market and same industry felled by multi-year campaigns that unions fully fund, prepare for, and stick with...

...Hospitals became more dangerous for patients and workers alike...

...SEIU is one of a handful of unions that have seriously focused on the changing shape of their industry and that have continued to grow...

...It leads to greed...

...With half of its 1.5 million members in health care, SEIU is also the largest health care union in the country...

...Even at this stage, it would be a mistake not to push John Kerry...

...Its goals are expansive: "Organizing to scale," meaning organizing enough workers to set employment standards in the industry, and taking on the issues of universal access, quality of care, and health care financing...

...Apart from the treaties, structural adjustment programs of the International Monetary Fund and World Bank are already prying open Latin American markets, and health maintenance organizations have begun to export managedcare operations...

...Non-union employers began providing family coverage...

...Any and all information that can be electronically transmitted across borders will be...

...A decade later, with successful campaigns from Los Angeles to Washington, D.C...

...Then it takes off...

...And getting a good contract ceased to be a matter of simple militancy and holding out longer against an employer who could pass on wage increases...

...For unions, it is to deepen the political understanding and commitment of members and build a base that will stick to and demand reform, whether today or ten years from today...

...WITH HEALTH CARE the numbertwo priority of voters—behind jobs but still before terrorism— hopes are riveted on the 2004 election for reform that would extend coverage to forty-five million uninsured and safeguard the care of those lucky enough already to have coverage...

...Tenet Hospital Corporation, the second largest for-profit system in the country, the largest provider in southern California, and an almost entirely nonunion chain, would be the second...

...Local 250 had a density of 80 percent to 90 percent in the Bay area and contracts with three CHW facilities, but was losing leverage as CHW expanded to include more and more non-union hospitals, and had taken strikes in 1988, 1994, and 1996...

...And although the reforms can add revenue for the providers at the margin, they do little to alter the overwhelming calculus of a federal financing system-60 percent of hospitals' budgets are LABOR AND HEALTH CARE paid by Medicare and Medicaid—that continues to feed privatization, acquisitions, and consolidations that will further squeeze patients, workers, and unions...

...No one expected its passage when it finally came...

...Non-union workers began calling the union...

...The right tells a story about the national and global economy and individual virtue, and it's been polishing the details since Barry Goldwater ran for president in 1964...

...Medicare and Medicaid greatly expanded access...

...So did a plan...

...Charity care was the main recourse for the uninsured...

...Maine and California are cases in point...

...Taming the health care industry today means solving the problem of universal access and skyrocketing costs...

...The civil rights movement boosted the last wave of hospital and public sector organizing...

...The bulk of CHW's non-union facilities were in southern California, where Local 399 had organized only one hospital in the past decade...

...So are the growing trade and budget deficits...

...movements and popular movements abroad...

...Germany and France, with mixed privatepublic systems, have found ways to provide care for all...

...The Election, and After The Tenet campaign is far from over, but SEIU would say it demonstrates what it calls the "big bang" theory of organizing...

...The story says that none of us can fully be valued except in community...

...Lessons Learned If the left is to persevere for the long haul and avoid being coopted, as happened with the Medicare drug benefit and as Republicans are trying to do now with the issue of coverage, we need first to reconsider some of the lessons the left believes it has learned from the Clinton debacle...

...With Kaiser paying higher wages than its non-union competitors, the stage was set for a bitter 1987 strike that left Kaiser workers with a two-tier pay system and leaders vowing to organize the competition until it met or surpassed Kaiser's standards...

...The effect in Los Angeles was electric...

...Both locals now embarked on aggressive campaigns to educate members about the corporatization of health care and why contracts with Kaiser couldn't improve until CHW was organized...

...And density in a global economy is a different calculus than density in a national economy or industry...

...When Eliseo Medina, executive director of a San Diego local that had quintupled in five years, was elected international vice president and appointed to the western region, he started building the local support and groundwork needed to get through the "dark days" before winning new members, a period that many unions don't survive...

...Third, and most important, is the larger story in which the facts about health care are embedded...

...And half of California's union members walked into it...

...SEIU's support of Howard Dean's antiwar candidacy made complete sense from the point of view of safeguarding the field for domestic reform...

...But at higher density, the incentive is reversed...

...Progress is gradual up to a point...

...Regional decision-making structures were formed to deepen organizing decisions as well as to increase leadership positions for women and people of color...

...When the union lost several of the elections, it established a Fair Election Commission, headed by State Assembly Speaker Antonio Villaraigoso, to expose CHW's election conduct and used the report to maintain momentum with workers and the community...

...Now on the verge of taking Los Angeles union, SEIU believes that if it can succeed, then repeat its success nationally, it can do for the hospital workforce—largely women and people of color—what the Congress of Industrial Organizations did for white males in the thirties, as well as raise political expectations and build a base for reform...

...SEIU's vision took shape as it swung into action with a controversial labor-management partnership with Kaiser, aimed both at freeing resources for organizing and demonstrating to non-union employers just how beneficial a collective bargaining relationship could be for LABOR AND HEALTH CARE quality of care...

...Union density is at less than 13 percent...

...We can, too...

...The bottom-up approach of GATS allows countries to commit sector by sector to its provisions...

...Locals responded with an assortment of organizing drives...

...Just as market share mattered for the hospitals, density mattered for the unions...

...Sympathetic priests were asked to sponsor "labor in the pulpit" on Sundays so workers could tell congregations about their working conditions and CHW's resistance to organizing...

...In the thirties, movements of the unemployed, the homeless, and the left boosted labor militancy and made possible gains in collective bargaining that would have been impossible without their political pressure...

...Density matters, and both bargaining and organizing are political...

...There were rallies in front of hospitals and a prayer vigil in Sacramento...

...Few knew of its passage, and a hard-fought referendum this coming year will now determine its survival...

...A 1997 joint research project shared by SEIU International, Local 250 in Northern California (based in Oakland and a strong single-payer advocate), and Local 399 in Los Angeles, deepened commitment...

...In the wake of these technological innovations are the General Agreement on Trade in Services (GATS), the North American Free Trade Agreement, the proposed Free Trade Agreement of the Americas, and the various hemispheric trade agreements...

...creates a state insurance pool for individuals, small businesses, and the self-employed...

...expands private financing of coverage...

...Strategies such as those SEIU used to organize home care workers—winning creation of a public employer of record for privately contracted home care workers—might be considered an illegal monopoly and outlawed...

...In larger movement terms, the question is how to forge a more enduring coalition between labor and progressives...

...If the dollar tumbles as the international reserve 76 n DISSENT / Summer 2004 currency, the unparalled freedom the United States has enjoyed from the pressures of financial markets in setting domestic policies will be gone...

...The second is that the argument for reform can't be made without facts, particularly since the right so frequently dispenses with them or makes them up...

...Unfortunately, defeating George W. Bush, even if it can be done, won't correct course...

...While CHW took five years and millions of union dollars to reach a contract, it took only eighteen months for Tenet, SEIU's next organizing priority, to agree to fast and fair elections and a guarantee of first contracts that would include joint patient care committees with binding arbitration to settle disputes, fully paid health care, and raises of between 5 percent and 8 percent a year for four years...

...At low levels of union density, employers have every reason to resist unionization because competitors are non-union...

...Harnessing Politics to Organizing SEIU had the ability to develop that plan: an insistence (now rare in the labor movement) on "industry organizing"—organizing entire hospital systems rather than isolated work sites, a willingness to tackle the problem of "time" with long-range commitment of energy and resources, the harnessing of members' health care purchasing power to the cause of organizing, and the systematic mobilization of a mammoth public sector base in California...

...For employers who engaged constructively, SEIU would lend its political muscle to common objectives, particularly funding...

...Four years later, SEIU successfully refocused the resources it had unleashed into "unity funds"—money for massive industry campaigns, supported by locals across the country...

...Conceived as one-way streets to privatization, the treaties commit governments to open domestic markets to global competition by eliminating "barriers to trade" (for example, licensing standards, safety standards, higher reimbursement levels for public providers), even when the "barriers" treat foreign corporations exactly the same as domestic corporations...

...Movement building, of course, takes time...

...This past January, citing the twin deficits, the IMF issued a report calling for extensive "reform" of Social Security and Medicare...

...When CHW pursued expansion plans by buying and closing community hospitals to increase its own market share, staff researched CHW's legal responsibility to provide charity care and asked the California attorney general DISSENT / Summer 2004 n 73 LABOR AND HEALTH CARE to enforce the hospitals' charitable trust obligation to the community...

...All this will aid in efforts to privatize Medicare, resist regulation, and fend off taxation, in other words, complete the neoliberal agenda within the United States as well as in the third world...

...Finally, most reforms—including SB2—leverage Medicaid payments to expand financing and are vulnerable to Medicaid's being turned into block grants—another defensive battle that will either be fought simultaneously with Medicare or after it...

...In an industry where 60 percent of costs are labor costs, raising capital for acquisitions and consolidations meant systematically squeezing staffs and reducing nurse-patient ratios...

...The radical right hasn't hesitated to push its commanders in chief...

...And the moral imperative for unions organizing health care workers lies as much in the linkage between safeguarding jobs and winning adequate financing for the uninsured as it does in bargaining...

...The United States hasn't agreed to open professional health care services to global competition, but it has opened management of hospitals and other health care facilities as well as health insurance...

...Cost control measures can be creative, but limited...

...the need to squeeze workers decrease...

...The battle will be uphill all the way...

...On a practical level, the reforms significantly expand coverage...

...Markets alone foster inequality...

...Governor Gray Davis signed SB2 into law in an attempt to cement labor support just before his recall...

...market...

...In 2001, feeling pressures from Catholic activists, facing extraordinary expenses from a California law requiring retrofitting of public facilities for the disabled, and fearing the consequences of dropping bond ratings from its overexpansion, CHW capitulated and signed a fair-election agreement similar to organizing rights Local 250 had bargained for CHW hospitals in the Bay area...

...The election doesn't represent an ideological shift—Schwarzenegger didn't run on cutting services...

...Without community, there is no real prosperity, either domestically or globally...

...As late as the sixties, seventies, and even early eighties, doctors and hospitals directly controlled the price of their services...

...On the other hand, SEIU's proposition that union density is the basis of both economic and political power for unions is less straightforward...

...Brothers in the hospitals held captive prayer meetings, organizers were told unions were nowhere to be found in the Bible, workers were surveilled...

...Because spreading risk helped safeguard profits, market share, or size, suddenly mattered, and hospitals began pouring their huge accumulation of capital into mergers and acquisitions...

...And greed—most specifically, the unchecked greed of the corporations and transnationals—leads to less for all, not more...

...The first is that single-payer may be off the table, but the task should be putting it—or some equivalent—back on...

...system of care, they'll harness privatized Social Security funds to the cause of transnational capital accumulation and concentration, undermine politically conscious public sector health care unions in Latin America, and increase the global and national political influence of the industry...

...In the meantime, the recall has left the new governor, Arnold Schwarzenegger, free to freeze enrollment in public health programs...

...In addition to the hospital organizing, results in California include a ground-breaking campaign for 74,000 publicly financed but individually contracted Los Angeles County home care workers, a successful financial rescue of L.A...

...and it's not just Republicans who are loath to take on the insurers and pharmaceuticals, or who share a weakness for privatization and deregulation...

...The following year, 2002, SEIU won a contract—with paid family health care for workers with more than twenty hours a week, no-subcontracting clauses, and patient care committees with binding arbitration—that raised the roof on standards for the industry...

...and care would improve, along with the providers' reputations...

...We spend more per capita on health care than any other country in the world, yet we're the only industrialized nation where not only the poor but the working and middle classes, even those with health care coverage, regularly face ruin if they get sick...

...When SEIU's campaign for voluntary recognition stalled after a year and a half, organizers reacted flexibly and petitioned for NLRB elections in hospitals where they thought they could be successful...

...Nor has real reform taken place without the tailwind of a movement...

...No industrialized society has successfully mitigated the effects of for-profit health care or won national health insurance without a vibrant labor movement...

...The left must tell its own story, one that talks about valuing work and workers...

...LABOR AND HEALTH CARE Competition is efficient...

...In California, additional political contradictions have already surfaced...

...and increase contracting out— moves that hurt most workers and force unions into defensive battles...

...Although the global factory is a familiar concept, most health care workers, unions, and consumers haven't focused yet on the global hospital: importing nurses, outsourcing reading x-rays, back office data handling, tele-medicine...

...Organizing the Church...

...The result, Dirigo Health, expands state programs for the poor...

...It also identified Catholic Health Care West— a newly formed system of Catholic hospitals that was also California's largest system—as the first organizing priority...

...and provides a floor for benefit costs for union employers competing against the likes of Wal-Mart, while still allowing unions to bargain for extended benefits and employer-paid premiums...

...Labor chose not to push Clinton during his health care reform—and to rely on support from its employers for reform as a way to rationalize costs...

...unions failed to win national health care, but they won employer-paid insurance for many and helped safeguard Social Security...

...Local 250 upped the size of its bargaining teams from two to as many as one hundred members for each hospital...

...The last major market to go union was New York City, in the wake of the upsurge of the civil rights movement...

...The reason is our failure to control our third-party insurance system and medical-technology establishment...

...The "big-bang" lesson is applicable to political organizing as well...

...SEIU knows that without reform it may soon find itself an island in a sea of shrinking coverage...

...However, although the National Conference of Catholic Bishops supported the dignity of workers and their right to organize, the order of nuns that owned CHW hospitals didn't reflect that position in their management practices...

...Inequality isn't efficient...

...SEIU countered with a campaign that dissected CHW's roles as a provider of health care services, employer, corporate citizen, organ of the church, and recipient of tax subsidies...

...Higher wages and benefits helped tame industries, redirecting them away from deflationary wage competition and toward productivity growth and rising consumer incomes...

...Choosing how we live together, choosing justice, is the essence of being human...

...The views expressed in this article are her own...

...in Dirigo, cost controls are voluntary for the first year...

...KATHERINE SCIACCHITANO teaches at the George Meany Center-National Labor College...

...It will also expand the potential for alliances between labor and anti-globalization movements, grown more distant since 9/11, as well as between U.S...

...In California, SEIU helped enact "pay or play" legislation and brought both Kaiser and CHW into the coalition for its passage...

...Resources would increase...

...These operations will not only globalize the U.S...

...The legislation keeps employers from taking themselves out of the health care equation...

...Under any of the pacts, the state attorney general's charitable trust authority that SEIU relied on in the CHW and Tenet campaigns might be severely restricted...

...There is no such thing as active citizenship—there is no such thing as democracy—without a guaranteed level of security for basic human needs such as food, housing, and medical care...

...The Global Hospital The trip wire for change may turn out to be global rather than local...

...Local 399 went from no member organizers in 1993 to 118 in 2003...

...County public hospitals, and the nation's first "pay or play" legislation to extend employer based coverage to uninsured workers...

...In the long run, reform depends less on the results of any election than on the reinvigoration of the organizational resources, numerical strength, and moral force of labor...