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nurses union
It’s Too Late for Me, But These 6 Healthcare Reforms Could Save Your Life
Unfortunately, they metastasized. I am receiving palliative care right now. But only 20% of patients with similar diagnoses make it through a year. Sooner or a bit later, I will have to go into hospice. Throughout this entire journey, I learned several lessons about our healthcare system that underscore the need for major policy changes that would greatly improve the quality, efficiency, and affordability of care delivered to patients. It is too late for me but not necessarily for you and those you love.
Our healthcare system has produced amazing strides in medical care. However, it is also too expensive and inefficient. The primary principle for a healthcare system should be predicated on placing the patient’s health as its defining feature. Instead, the current system is based on maximizing profits and revenue for the corporate elites in the healthcare and financial industries while healthcare workers and patients suffer.
It is long past time to create a different equation in which patient well-being takes precedence over profits.
This entire system is supported and protected by the elites who run or own the insurance companies, pharmaceutical corporations, hospitals, and private equity firms as well as industry lobbying organizations such as the American Medical Association. And let’s not forget the role played by those politicians who serve the interests of these institutions in return for campaign contributions or the promise of lush jobs after their “public” service. The current system is a case study in placing profits before people with incentives to increase revenue and minimize costs, which have combined to decrease the quality of patient care.
It is long past time to create a different equation in which patient well-being takes precedence over profits. The first policy reform in this article, Medicare for All, addresses the problem of the tens of millions of people who are uninsured or underinsured and the overall cost of and access to insurance. The other five policy reforms address problems associated with the actual delivery and quality of healthcare that are not addressed by Medicare for All: stopping the increasing corporatization of healthcare; mandatory nurse staffing ratios; moving from the current fee-for-service reimbursement structure to “value-based” payments based on the well-being of patients; unionizing all healthcare workers; and creating an effective process for patient advocacy. These policy recommendations are supported by numerous research reports and by my informal discussions with dozens of healthcare providers.
These reforms would not only improve patient well-being but also cut long-term costs. However, the reforms can only be instituted through a broad progressive movement which can take on the entrenched interests of the big healthcare corporations, Wall Street, and their paid political agents. It will be tough, but it can be done. After all, progressive mass movements and progressive politicians led the fight for Social Security, Medicare, and Medicaid in the face of bitter opposition by the healthcare corporate elite and their political allies. Major healthcare reform happened before, and it can again, but only through the concerted and sustained efforts by progressive activists and politicians.
1. Medicare for All
Sen. Bernie Sanders (I-Vt.) speaks alongside Rep. Pramila Jayapal (D-Wash.) during a news conference to announce the re-introduction of the Medicare For All Act of 2023, outside the U.S. Capitol May 17, 2023 in Washington, D.C.
(Photo: Drew Angerer/Getty Images)
It is well known that the U.S. is the only advanced economy in the world without a national health insurance program. It is also the most expensive and inefficient in terms of delivering comprehensive quality care. Medicare for All would save tens of thousands of lives and hundreds of billions of dollars in healthcare spending each year.
On May 17, 2023, the “Medicare for All Act” was introduced in the U.S. Senate by Sen. Bernie Sanders (S. 1655) and Representatives Pramila Jayapal and Debbie Dingell in the U.S. House (H.R. 3421). These bills would establish a four-year transition to a fully universal health insurance program. Patients would have the freedom to choose their doctors, hospitals, and other health providers without worrying about whether that provider is “in-network.” Everyone would be covered whether they were employed or not. Instead of wasting hundreds of billions of dollars trying to administer an enormously complicated system of hundreds of separate insurance plans, there would be one insurance plan for the American people with one single payer.
Medicare for All would cover many more services than currently available from almost all private insurance plans and current Medicare. These services include the following: inpatient and outpatient hospital services; ambulatory services; primary and preventive services; prescription drugs; mental health and substance use treatment; laboratory and diagnostic services; reproductive care; maternity and newborn care; gender affirming healthcare; dental health, audiology, and vision services; rehabilitative services; emergency services; pediatric services; necessary transportation; services provided by licensed marriage and family therapists and counselors; home and community based long-term services; and any item or service described above that is furnished using telehealth, to the extent practicable.
Many studies have concluded that Medicare for All would save tens of thousands of lives and hundreds of billions of dollars each year.
Importantly, the act would prohibit private insurers from offering coverage for any of the services provided by Medicare for All. In this way, health insurance companies with their bloated profits and high administrative costs would be taken out of the process. They would no longer be the arbiter of who can get health insurance and no longer be raising premiums, copays, and out-of-pocket expenses while minimizing claims and benefits to patients. In this way, access to affordable healthcare will no longer be determined by the profits of private insurance companies.
Many studies have concluded that Medicare for All would save tens of thousands of lives and hundreds of billions of dollars each year. A review of 22 analyses of both national and single-payer proposals made over the past 30 years found that Medicare for All type programs would save money over time and likely during the first year. Nineteen of the studies found that Medicare for All would save an average of 3.5% of total healthcare spending. The greatest source of savings would come from reduced administrative costs, with further savings from lower drug costs.
Of special note is a report by Yale epidemiologists which estimated that Medicare for All would save $450 billion and 68,000 lives a year. Medicare for All would save lives by providing coverage to those tens of millions of people who currently do not have insurance and, often, refrain from going to doctors due to cost. The study authors wrote:
“Universal coverage removes barriers to accessing existing primary and preventative care, and a single-payer system incentivizes the expansion of preventative programs. Preventative care reduces the incidence of myriad diseases, including diabetes, heart disease, and osteoporosis, all of which erode quality of life even in cases that do not result in death. For example, prompt diagnosis of prediabetes combined with provider recommendations about diet and exercise can reduce the risk of progressing to diabetes.”
The Yale epidemiologists also estimated that Medicare for All would save hundreds of billions of dollars a year—with substantial savings for both employers and households:
“…We predict that a single-payer healthcare system would require $3.034 trillion annually, $458 billion less than current national healthcare expenditure. Even after accounting for the increased costs of coverage expansion, our data-driven base case includes $210 billion savings on hospital care, $111 billion on physician and clinical services, $224 billion on overhead, and $180 billion on prescription drugs.”
Currently, employers spend $536 billion on healthcare expenditures which amounts to 11.29% of payroll. Medicare for All would save employers $100 billion a year by imposing a tax equivalent to just 10% of payroll. Similarly, the average household expends $5,847 on healthcare premiums and out-of-pocket expenses, which amounts to an equivalent tax of 9%. Medicare for All would impose just a 5% tax on households, which would cost $3,478 per household for an overall savings of $2,369 per household.
The insurance companies go to great lengths to rip-off the system, i.e., patients, Medicare, and providers. For example, a recent ProPublica exposé found that “internal documents and former company executives reveal how Cigna doctors reject patients’ claims without opening their files. ‘We literally click and submit,’ one former company doctor said.”
This process bypasses insurance laws and regulations that require company doctors to review claims, examine patient records, and use their expertise to decide whether to approve or deny claims. “Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers healthcare plans for 18 million people,” ProPublica reported. The company “saves” millions of dollars a year through these automatic denials.
My hospital and health bills have already amounted to hundreds of thousands of dollars—it’s difficult to get a correct estimate since the bills are incomprehensible. I benefited from Medicare, which was enacted through hard-fought political battles against the insurance companies, the American Medical Association, and other corporate elites and their political allies. I also benefited from a supplemental policy through my union, the Communications Workers of America. My total out-of-pocket expenses are just a fraction of the total charges. According to the National Center for Health Statistics, 30 million Americans have no health insurance at all. And according to a Commonwealth Fund survey, 43% of working age adults are either uninsured or underinsured. The survey also found that the main reason people are not covered or underinsured is due to the high cost of insurance.
The result of such costs is not just the lack or inadequacy of coverage but also medical debt. 100 million Americans have medical debt including 10 million who have medical debt greater than $10,000. A recent guest essay in The New York Times by two economics professors revealed that in mid-2020 (before Covid-19) collection agencies held $140 billion in unpaid medical bills—more than the amount collection agencies held for all other consumer debt from non-medical sources combined. Surprisingly, three-fifths of this debt was incurred by households with health insurance. The entire issue of medical debt is so bad that the voters of Arizona recently passed a proposition that limited interest rates on medical debt to 3%. Imagine that—even the conservative voters in Arizona recognize that medical expenses are an inordinate burden and voted by 72% in favor of the proposition.
Medicare for All has broad popular support. A 2020 Hill-HarrisX poll found that 69% of registered voters support Medicare for All. A Kaiser Family Foundation tracking poll found that 53% of Americans support Medicare for All. The issue—as with all these reforms—is the opposition of the entrenched corporate and Wall Street elite and the politicians they fund in both parties. But even if Medicare for All is instituted—it is limited. While Medicare for All will help address problems with insurance access and cost, it will not really address the failures of the current system in terms of the delivery of healthcare services by providers.
2. Stop the Corporate and Wall Street Take Over of Our Healthcare System
The sliding doors of emergency room open in a hospital.
(Photo: iStock/via Getty Images)
Dr. Thomas Cooney, the chair of the board of regents of the American College of Physicians (a group representing 160,000 medical professionals involved with internal medicine), wrote a very insightful article about the direction of the American healthcare system. The article is entitled “Corporatization, Consolidation, and Commodification.” His conclusion: “corporatization of healthcare, with the emphasis on profitability, market share, return on investment (ROI), and the imposition of business practices [is] often at odds with equitable, high-quality, patient-centered care.”
The corporatization of healthcare is driven by hospitals and private equity. In relation to hospitals, a report from the University of Pennsylvania summed up this process in its title “Hospital Consolidation Continues to Boost Costs, Narrow Access and Impact Care Quality.” The report found that from 1998-2021, “the number of hospitals was reduced by 25% as a result of 1,887 hospital mergers. By 2021, just 10 hospital systems controlled 25% of the market.”
The image of the independent physician toiling away in a small practice solely looking out for the interests of the patient is not the reality for most doctors. A Forbes article reported that “nearly three in four doctors now work for a hospital, health system, or corporate entity… Roughly 83,000 physicians have become employees of hospitals or other corporate entities since the start of the pandemic.” And the result is higher prices and worse quality of care. “When a hospital acquires a physician practice, prices for healthcare services increase by more than 14%, according to research published in the Journal of Health Economics.”
Even with Medicare for All, the money for care would still be funneled to the corporations and private equity firms that increasingly employ the doctors, nurses, and others who provide care. These firms will still be run based on the principles of maximizing profit while minimizing costs and thus the quality of care.
The article continues: “there’s no evidence that higher prices lead to better care for patients. In fact, practices owned by a hospital report higher preventable hospital admission and readmission rates among their patients than small, independent practices, according to a report published by the Annals of Family Medicine. And what happens to the money: Health systems are keeping much of those higher prices from consolidation for themselves. Studies indicate that a hospital’s revenue jumps nearly 20% after it acquires a physician practice.” The article concludes, “Patients and providers should lament the increasing corporatization of medicine. All too often, it’s a recipe for lower-quality, higher-priced healthcare.”
Even nonprofit hospitals are being driven by the principles of revenue maximization and cost minimization. Nonprofit hospitals must provide charity care to qualify for tax-exempt status. For-profit chains do not have such charity requirements. Yet a 2021 study published in the journal Health Affairs found that nonprofits provided less charity care per dollar of expenses compared to for-profit and government-run hospitals. The study concludes, “these results suggest that many government and nonprofit hospitals’ charity care provision was not aligned with their charity care obligations arising from their favorable tax treatment.”
The shift in focus by nonprofit hospitals to profit maximization (called surplus by nonprofits) is illustrated by a comprehensive New York Times exposé. Nonprofit hospitals obtain significant tax breaks by providing required services such as free care for the poor that benefit the communities in which they operate. However, the NY Times article found that “some hospital systems have not only reduced their emphasis on providing free care to the poor but also developed elaborate systems to convert needy patients into sources of revenue.”
The article focuses on the practices of Providence, one of the largest nonprofit hospitals in the country with 51 hospitals and more than 900 clinics. Providence avoids more than $1 billion in taxes each year. It is supposed to provide free care to the poor to obtain these tax benefits. Instead, the exposé found that “thousands of poor patients were saddled with debts that they never should have owed.” Providence even hired debt collectors to pursue those patients who did not pay.
Providence acts just like a for-profit firm while reaping the benefits of its nonprofit status. It maximizes revenue which exceeded $27 billion in 2021. It is sitting on $10 billion that it invests, Wall Street-style, alongside top private equity firms. It even runs its own venture capital fund. But Providence is not alone. The NY Times article concluded, “…in recent decades, many of the [nonprofit] hospitals have become virtually indistinguishable from for-profit companies, adopting an unrelenting focus on the bottom line and straying from their traditional charitable missions.”
Private equity is also playing an increasing role in the corporatization of healthcare in the U.S. Private equity firms generally raise pools of capital known as funds, from a variety of investors, commonly high-net-worth individuals or families, pensions (corporate, public, and union), endowments, and foundations. The operating principle of private equity is to maximize revenue, cut costs, earn profits immediately, and then make significantly more money by selling the business.
There are significant incentives for physicians to join hospitals or be absorbed by private equity firms. The Forbes article describes such pressures: “As an employee of a larger system, doctors don’t have to deal with the administrative headaches of billing and paperwork that accompany private practice. They’re also guaranteed a set salary and working hours—unlike an independent physician, whose income and hours often depend on the volume of care he or she delivers and the overhead expenses the practice accrues.” The promise is that private equity firms will take over such time-consuming services that will allow doctors to have more time for patients. But the promise is often contradicted by reality. The healthcare provider often loses control of scheduling and has increased pressure to see more and spend less time with patients and order more expensive tests.
Public Citizen published an exposé of the impact of private equity on healthcare. Its conclusion: “The risks posed by private equity investments in healthcare are particularly acute. After all, the services healthcare providers offer can spell the difference between life and death. Private equity has targeted segments of the healthcare industry since at least the 1990s, with many predictable outcomes. Among them, shocking lapses in safety have occurred, prices have risen faster than at non-private equity acquired entities, and patients have been subjected to price gouging schemes.” The report goes into detail about private equity’s impact on purchasing hospital systems and acquiring healthcare practices specializing in urology, dermatology, orthopedics, ophthalmology, reproductive health, behavioral health, home health, and hospice care.
Other studies corroborate the higher prices charged by private equity owned healthcare providers. For example, a 2022 study published in JAMA Internal Medicine based on six years of data found that when private equity investors purchased anesthesia companies, they raised prices by an average of 26% more than non-private equity firms. A JAMA Health Forum study found that private equity firms in dermatology, gastroenterology, and ophthalmology were associated with price hikes of up to 20% more than non-private equity firms.
These research conclusions are supported by my own experience. One of my doctors is part of a group that was recently taken over by a private equity firm. The communications system—both through phone messages made to call center representatives and through internet message portals—often goes unanswered because of various failures in the system. I often had to physically go to the clinic to personally demand a meeting with the doctor or available medical and physician assistants to address several issues. Fortunately, I was able to do this—but what about the hundreds or thousands of patients served by this practice who are unable to follow through?
In addition, providers have lost the ability to schedule patients, which has placed additional pressure on them because it is in the interest of revenue maximization that they see greater numbers of patients. I have had instances that by the end of each day—and each week—many providers are burnt out and offer less than optimal service or attention. Several physician assistants and others have left the practice because of the lack of control over scheduling and communications with patients. The loss of staff has, in turn, increased the workloads of the remaining providers, which will lead to more burnout and staffing problems.
The Public Citizen article provides a list and explanation for several bills that would regulate private equity and corporate ownership of healthcare providers to improve transparency, reduce costs, and ensure the delivery of quality care. The Stop Wall Street Looting Act was introduced in the 2021-22 session of Congress. This legislation would significantly increase accountability for private equity companies across industries and would reduce their ability to profiteer without consequences and better protect workers and consumers in the event of an acquisition or declaration of bankruptcy. In March 2023, Rep. Jayapal introduced the Healthcare Ownership Transparency Act. This act would require private equity firms and other investors to better disclose ownership of health facilities, including nursing homes. Corporations would have to disclose their assets, debts, and financial transactions for the previous 10 years to take part in the Medicare program. It also requires the Department of Health and Human Services to create a taskforce on private equity and healthcare consolidation. In 2022, Sen. Elizabeth Warren and others introduced the Health and Location Data Protection Act, which would ban the sale of health and location data, especially important for Americans seeking access to reproductive health, to better protect patients from a crucial gap in current privacy statutes and prevent unscrupulous companies, including private equity-backed firms, from profiting and placing personal information at risk.
These bills seem very unlikely to pass Congress. However, there is hope based on experience with surprise billing. As explained by the Consumer Financial Protection Bureau, surprise billing is “…an unexpected bill, often for services received from a healthcare provider or facility that you did not know was out-of-network until you were billed. Your health insurance may not cover the entire out-of-network cost which leaves you owing the difference between the billed cost and the amount your health insurance paid. This is known as ‘balance billing.’ This bill could be for a service like anesthesiology or laboratory tests. You may not know that the provider or facility is out-of-network until you are billed.”
Public outcry over surprise billing grew so intense that Congress was forced to take action and passed the No Surprises Act in December 2020, which banned providers from billing patients out-of-network rates under most circumstances and forced insurers and providers to deal with each other, instead of patients, to determine payment levels for out-of-network care. The act was passed despite significant opposition by private equity companies.
However, such piecemeal reforms will not be enough to counter the corporate takeover of our healthcare system. A very provocative article was published recently in The Nation, entitled “Medicare for All is Not Enough.” The authors point out that while Medicare for All would change the way we pay for our medical care, it would not change the providers who receive those payments. Even with Medicare for All, the money for care would still be funneled to the corporations and private equity firms that increasingly employ the doctors, nurses, and others who provide care. These firms will still be run based on the principles of maximizing profit while minimizing costs and thus the quality of care.
The combination of a national health insurance program and a national health service would comprehensively eliminate the “profits before people” principle that guides our current healthcare system.
The Nation article proposes that a more direct and comprehensive approach to stop corporatization would be the creation of a National Health Service which would employ all healthcare providers. Obviously, this would exclude for-profit entities from controlling or providing healthcare services. Such a program seems far-fetched at first glance. However, the U.S. already operates a type of National Health Service program. It is administered by the Veterans Health Administration (VHA), which operates the nation’s largest integrated health system, offering comprehensive health services to eligible U.S. military veterans who enroll. The VHA has an annual budget of around $64 billion and provides care at 1,298 healthcare facilities, including 171 VA Medical Centers and 1,113 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million veterans enrolled in the VA healthcare program. The VHA employs 371,000 healthcare professionals. In a 2018 study, the Rand Corporation concluded that “Consistent with previous studies, our analysis found that the VA healthcare system generally provides care that is higher in quality than what is offered elsewhere in communities across the nation.”
As expected, the Veterans Health Administration is under attack by corporate interests and their political allies. These groups want to—and are in the process of—privatizing the VHA. This entire process—and the efforts by VHA staff and veterans’ groups opposing this effort—is well documented by former colleague Steve Early and Suzanne Gordon in a number of articles and a book. “These powerful private interests which gained this new $33 billion a year federal revenue stream [part of the VHA revenue stream] want to preserve and expand it… [they have] siphoned billions of dollars away from the agency’s direct care budget and steered that money toward private doctors and for-profit hospitals often less well prepared to treat veterans…” As already indicated, the VHA provides specialized treatment that is far better coordinated and more cost effective than care in the private healthcare industry.
Yet, despite bitter opposition by the corporate elites, the combination of a national health insurance program and a national health service would comprehensively eliminate the “profits before people” principle that guides our current healthcare system. A national health insurance program like Medical for All would remove corporate control of the cost of and access to insurance. And a National Health Service program (along the lines of an adequately funded Veterans Health Administration) would remove corporate control of healthcare providers.
3. Institute Appropriate Nurse Staffing Levels
A nurse attends an elderly male patient.
(Photo: iStock/via Getty Images)
The relationship between the number of nurses on a hospital’s staff and the quality of patient care has been established by many studies. Appropriate staffing levels result in reduced mortality rates, reduced length of patient stays, and the reduced number of preventable events such as falls and infections. Conversely, when RNs are forced to care for too many patients at one time, patients are at higher risk of preventable medical errors, avoidable complications, falls and injuries, pressure sores, increased length of stay, and readmissions. (Examples of such studies can be found here, here, and here).
The ratios of nurses to patients that I experienced on my trips through the hospital system were at least six patients to each nurse in the post-surgery unit, which could flex up to 12 patients depending on the number of patients and available staff. The nurse-staffing ratios in the Emergency Department were even higher. The nurses were working long hours and under constant pressure to service too many patients.
And it wasn’t just nurses. There were only three transport workers (those who move patients within the hospital) on staff at any one time. These three transport workers could not keep up with the demand. For example, I was transported from my hospital bed to the radiology department (I couldn’t walk very far following surgery). The radiologist (who had been retired but was induced back to work by a lot of money) finished quickly. And there I was, stuck on a gurney in the hall waiting for the transport folks to bring me back to my room. After waiting for more than an hour, a nurse I knew happened by and generously wheeled my gurney back to my room. Wait times for transport were averaging 1-1.5 hours each way. This is just one example: All the nurses and support staff I talked to were stretched to the breaking point.
“The hardest thing I have had to do in the past few years is communicate to families and patients that I won’t be able to provide good service.”
The lack of staffing issue is profound. One nurse I talked with stated, “the hardest thing I have had to do in the past few years is communicate to families and patients that I won’t be able to provide good service. I have been told by management again and again—you never tell patients that we are short staffed but tell them ‘they are the most important person in that moment.’ However, again and again I can’t lie. I have had to tell people sorry grandpa can’t get washed up because I’m too busy with more urgent medical things—and that SUCKS. I am heavily burnt out and compassion fatigued.”
Requiring appropriate and sustainable nurse-to-patient ratios is one way to address the problem of inadequate nursing levels. Such requirements can be reached in at least two ways. As will be discussed below, such ratios can be imposed by union contracts. Another way is through legislation. We should all support legislation that mandates safe staffing to patient ratios. California remains the only state with a legally defined minimum nurse-to-patient ratio for all nurses. Per the regulation, there is always a mandatory 1:4 ratio in the Emergency Department (ED). For critically ill patients in the ED and those admitted to the ICU, the maximum ratio is 1:2. In the hospital where I stayed, the ED had at least a 1:6 ratio at the time of my admittance.
One major study comparing California’s mandated staffing ratios with the experience in New Jersey and Pennsylvania hospitals found that “When we use the predicted probabilities of dying from our adjusted models to estimate how many fewer deaths would have occurred in New Jersey and Pennsylvania hospitals if the average patient-to-nurse ratios in those hospitals had been equivalent to the average ratio across the California hospitals, we get 13.9% (222/1,598) fewer surgical deaths in New Jersey and 10.6% (264/2,479) fewer surgical deaths in Pennsylvania.” The study concluded:
“Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur. Thus, the minimum nurse-to-patient staffing ratios mandated in California have great potential to improve patient outcomes and nurse retention.”
4. Move from Fee-For-Service to Value-Based Reimbursement Payments
A senior patient leaves a clinic with his arms raised.
(Photo: iStock/via Getty Images)
There is a systemic problem that provides incentives to hospitals to actually cut the level of nurses and other staff. The underlying issue is that nurses (and techs and aides) are a cost center for hospitals. They provide the essential human infrastructure for treatment but do not create revenue. Conversely, doctors create revenue by ordering tests, prescribing medications, and conducting exams and surgeries. The hospitals charge for each of these services, which are paid by insurance companies, Medicare, or by patients. However, hospitals do not charge for nursing services even though they are essential for doctors to do their jobs and for patient care. Instead, nursing services are part of the charge for the hospital room—they are purely “cost centers” that hospitals seek to minimize while maximizing revenue sources like tests and surgeries.
According to credit rating agency Fitch Ratings, labor expenses (salaries and benefits) are the largest expense category for hospitals, making up more than 50% of a hospital’s total expenses. Another study found that registered nursing alone accounts for 30% of the hospital’s total expenses. As a large cost center, hospitals have made nurses an easy target for reduced hours and other cutbacks. But those cuts come at the expense of patient well-being and nurses’ safety.
Dylen Scott in a series of articles for Vox addresses not only the problem posed by fee-for-service but also describes an alternative reimbursement system. Fee-for-service severs the link between appropriate nurse staffing levels and patient care. For example, a study by Yang Wang cited by Scott found that “when hospitals have excess revenue because of higher prices paid by private insurers, they don’t end up spending that money on improving patient care, such as by hiring more nurses. Instead, most of the extra dollars went toward administrative spending and the hospital’s own surplus…The majority of the additional income was allocated primarily to services and programs that promoted hospital’s self-interest instead of patient benefit.”
One alternative cited by Scott is to change the current fee-for-service reimbursement structure to “value-based” payments based on the results patients experienced instead of only the services they received. This would provide economic incentives to invest in nursing that have proven to result in better outcomes. Scott explained:
“The idea is that if a hospital’s patients are less likely to have complications or to be readmitted later for a related health problem, then the hospital deserves to be paid better. To make those benchmarks, hospitals would have good reason to invest in nurses, given what we know about the relationship between higher staffing levels and outcomes such as readmissions.
Of course, the hospital-industrial complex is adamantly opposed to both mandated nursing ratios and value-based payments. As the Yang Wang study showed, hospital management is more interested in expanding “surplus and administrative costs” (which include their salaries and perks and advertising) than in “spending on services that will directly benefit patients.”
5. Unionization
There were two examples of the need for healthcare unions that I experienced during my journey through the healthcare system. First, I talked with a phlebotomist (the person who takes blood). He was overworked and underpaid by the hospital and had spotty health benefits. But he was leaving his job to take the same position at a unionized healthcare clinic. He would be getting a significant pay raise, much better health insurance, and have a say in his own working conditions (and thus the care given to patients). He described these changes to me in glowing terms—it would make a major difference in the financial condition for his growing family but also in his working conditions so that he could improve the services given to his clients.
Second, hospitals had undertaken the strategy of increasing profits by cutting staff to the bone before the pandemic. Then the pandemic hit and exacerbated the crisis of a nursing shortage. Many hospitals responded by hiring what are called traveling nurses—nurses who sign temporary contracts to work at hospitals, clinics, etc. Historically, travel nurses were used to temporarily fill in for full-time staff who were on leave or other short-term gaps in service. However, travel nurses now form the core of many hospital nursing staffs. In the hospital I stayed, approximately 85% of all nurses were travel nurses. This has led to a number of problems and inequities.
Travel nurses are paid significantly more than full-time “staff” nurses. On average, travel nurses earned $33,300 more a year than staff nurses. Travel nurses also get sign-on or referral bonuses; travel reimbursements; stipends for housing; and food, mileage, or job-related expenses. These extra stipends can amount to thousands of dollars a month and are not taxable because they are classified as reimbursements and not income. Staff nurses not only are paid less but all their income is taxable. In addition, the hospitals also pay the staffing agency through which they contract for the traveling nurses. One analysis states that an agency will usually take around 30% of the full bill rate and of that, profits might be around 20-25%. Agencies usually make profits somewhere around the ballpark of $5,000-$6,000 per 13-week contract depending on the specialty. Obviously, the hospitals—who often plead poverty when addressing staff nurses’ wages and benefits—have enough money and surplus to afford the much higher costs associated with travel nurses.
The very process of corporatization that is undermining the quality of our healthcare services is driving healthcare workers to unionize.
The staff nurses I talked to were really upset at the inequity of the situation: They all did the same job but traveling nurses had higher salaries, free housing, better health coverage, and reimbursed expenses. Moreover, staff nurses—unlike travel nurses—are constantly being pressured into working more or being coerced into doing things beyond a typical workweek. These disparities in wages, benefits, and treatment provide strong incentives for all nurses to consider becoming traveling nurses. However, many nurses cannot become traveling nurses due to family obligations and other considerations militating against their moving from contract to contract, place to place.
The traveling nurses I met were all skilled and competent. However, I witnessed problems integrating the traveling nurses into the hospital’s procedures and culture. In one of the units in which I stayed, all the nurses were travel nurses and there was chaos during shift changes because the nurses did not know one another, and their patient assignments were not clear. It took quite a while for these problems to be ironed out—which took valuable attention away from the patients.
A vicious cycle has thus emerged. Hospital policies have reduced the number of staff nurses and nurse retirements are increasing due to burnout, pay disparities, and a general the lack of respect. These reductions in staff nurses, in turn, increase the reliance by hospitals on travel nurses which increases disparities with staff nurses and, thereby, increases the incentives for staff nurses to retire, burn out, etc. It is a vicious cycle created by hospital policies.
Part of the solution to these problems is unionization. Unions attempt to equalize salary structures (same job, same pay) and provide better benefits for all the healthcare workers. There are many benefits to unionizing hospitals including job security, better working conditions, guaranteed wages and pay increases, seniority advantages, better benefits, a guaranteed process for grievances, and legal representation. There are also benefits to patients. One of the few comprehensive
studies relating unionization to patient outcomes found that “hospitals with a successful unionization attempt experience a decline in the incidence of hospital-acquired illnesses compared to hospitals that experience a failed unionization attempt and compared to hospitals more broadly conditional on hospital-specific time trends. This holds true across a broad range of potentially nurse-sensitive medical outcomes, ranging from less serious illnesses such as urinary tract infections to critical ones such as in-hospital death.”
About 9.7 million individuals currently work in critical, albeit lower-wage, healthcare occupations (e.g., medical assistants, home health aides, and nursing assistants). Just over 3 million individuals work as registered nurses in the Unites States. Over the next five years there will be an estimated shortfall of 3.2 million lower wage healthcare workers and 200,000 registered nurses.
Currently, just 11.7% of healthcare practitioners and related technical workers are union members. Among physician residents, about 15% of house staff across more than 60 hospitals belong to unions. Overall, about 7% of practicing physicians belong to a union. And 20% of registered nurses and 10% of licensed practical or licensed vocational nurses belong to unions.
Unionization not only helps workers but also patients. Nursing and healthcare unions in general fight for better working conditions, which include better quality of care for patients. This is illustrated by nurses’ union strikes across the U.S. Tens of thousands of nurses have gone on strike over the last two years in New York, California, Minnesota, Michigan, and Wisconsin. As reported in Common Dreams, in June, 2,000 registered nurses in Texas and Kansas went forward with a historic one-day strike against Ascension (the second largest Catholic nonprofit hospital chain in the U.S.) to demand safe staffing levels in their contracts—a matter, “they said, of putting patients over profits.” The strike is reportedly the largest ever held by National Nurses United—the largest nurses’ union in the U.S.—in Texas and the first in Kansas. Each of these strikes had a common theme: forcing management to address the understaffing issue by requiring appropriate nurse-to-patient ratios.
Of course, the corporate elite in the healthcare sector vehemently oppose unionization. After all, more money going to workers—and to quality of care for patients—represents costs that eat into corporate profits. Healthcare companies engage in the same anti-union activities as many private sector corporations. Five common union busting activities include the following: The employer hires union busting consultants; the employer hires anti-union workers who reinforce the actions and arguments provided by the consultants; the employer forces workers to attend meetings where they are required to listen to anti-union propaganda; the employer promises to make changes without ceding any power to the workers; and the employer will delay, delay, delay to try to erode union support. There are many examples of these anti-union tactics in the healthcare industry—Mercy Health in Michigan; HCA Healthcare (the largest hospital corporation in the U.S.; Ascension Seton Hospital in Austin, Texas; Rochester Regional Health in New York; and McLean Hospital in Belmont, Massachusetts.
But there is much more. The corporate offensive against unions in the healthcare industry takes place within a general and historic corporate attack against unions in general. This offensive against unions has been instituted at the policy level by a bipartisan coalition created by the corporate elite. It began as soon as the New Deal formally institutionalized unions as the legal representatives of workers. Congress and the courts have weakened unions through anti-union laws such as Taft-Hartley, the prohibition against secondary boycotts; the banning by states of union security agreements; dramatically expanded management rights; and the curtailment of the ability of unions to bargain with their employers about contracting-out decisions and plant closings. Free trade agreements—primarily sponsored by Democrats—such as NAFTA, CAFTA, and admitting China into the World Trade Organization—led to the loss of an estimated five million manufacturing jobs—most of these jobs were union. And the right wing Supreme Court has instituted a number of anti-union decisions. These policy decisions have directly and indirectly impacted the healthcare industry by tilting power to corporations and away from workers.
Yet, despite these obstacles workers still put themselves on the line to join unions. In the healthcare industry, there are many examples of recent major victories including in North Carolina to form the largest hospital union victory in the South since 1975 and in Texas to form the largest hospital union in that state. And it is not just nurses. In Oregon, thirteen thousand home healthcare workers joined a union. Thousands of young doctors who are medical residents are joining unions. And it is not just young doctors. A report in Axiosstated, “There were more than 67,000 physician union members, or about 7% of all practicing U.S. doctors, as of 2019, according to the American Medical Association. The numbers have likely increased since then, in response to hospital consolidation and more physicians working as employees of a health system or other provider.” Thus, the very process of corporatization that is undermining the quality of our healthcare services is driving healthcare workers to unionize.
There should be a strong alliance between healthcare unions and healthcare consumers and advocates. Nurses’ unions have been in the forefront of attempts to get state and federal legislatures to mandate staffing requirements and other healthcare improvements. Healthcare unions are one of the few institutions fighting for such patient safety policies. Of course, the same institutions and elites that oppose better nurse-staffing ratios and Medicare for All also oppose efforts to unionize healthcare workers. Yet, another example of profits before people.
6. Patient Advocacy
A community nurse using a digital tablet to record details of senior patient.
(Photo: iStock/via Getty Images)
Every hospital patient needs an advocate—and not just someone who visits intermittently. In modern medicine, the burden of monitoring overall care often falls to the patient. Each doctor has their own specialty, but it is rarely the case that there is a doctor who is responsible for overall care, i.e., ensuring that every doctor of the “team” is on the same page of treatment. There is an “attending physician” in the hospital who is supposed to have an overview and guide overall care by the different doctors, but attending physicians are overworked and are not always present due to shift changes. So, it falls to the patient or their representative to oversee their own care.
It is not an optimal situation when the burden of coordinating care falls to the patient or their family and friends. After all, they are not trained in medicine. But there it is. Personally, I cross-checked medications with my various doctors before I would accept the drugs to make sure nothing would harm my remaining kidney or damaged heart valve. And it’s not just ensuring that all doctors refer to the big picture. From an early age, my mother taught me to be extra vigilant in the hospital: to constantly monitor the medications, the heart rate, and to make sure the drip was working for any infusions. Fortunately, I was able to accomplish many of these tasks, but I was also helped by family members who were by my side for much of my hospital stays.
There are two other examples that illustrate the need for an advocate. I was placed in a room where the ventilation system was directed toward the top of my bed. And it was really cold. I was afraid that in my weakened condition I would get a cold, which could lead to other problems. I hobbled over to the nurses’ station and told them about the problem. Their solution was to give me a heated blanket, which did nothing to alleviate the strong draft. I started to sit in the hall which I was told was not permitted. Finally, after many complaints, an aide came in, brought a ladder, and taped cardboard over the vent which provided a temporary solution to the problem. I thanked him profusely.
Optimally, Medicare and Medicaid should provide patient advocates to ensure that the patients’ needs are met.
The other example is heart wrenching. My hospital room was separated from another room by a partition. The elderly person in that room was in constant pain, repeatedly asking for help, and vocally expressing her discomfort. The patient told the nurses exactly what pain medication she usually took—but there was some bureaucratic snafu from the assisted living facility where she resided so that her previous prescriptions were not sent to the hospital. So, there she was, caught in a Kafkaesque loop. I even went to the nurses’ station to urge them to do something, but without a proper prescription their hands were tied because they cannot do anything without a doctor’s order. At some point, they wheeled her away.
Nurses traditionally acted as patient advocates. But this source of advocacy has been whittled away by the lack of nurses and other staff at hospitals and at doctors’ offices. One nurse stated:
“My least favorite part of being a nurse is being the middleman between patients and doctors who do not communicate. A good nurse (which I think I am) will act as a patient advocate and piece things together and make sure people are communicating—but often I do not have time to sit down, make phone calls, and read notes—or if I do, I am not spending time actually caring for my patients. Doctors rely 100% on nursing staff to fill in the picture that is not apparent from the three-minute visit or lab data. With such high staffing ratios, it’s impossible for me to advocate for my patients because I do not get the chance to know them.”
There are at least two ways to address the issue of patient advocacy. The first is at the level of the individual. Since the responsibility for patient advocacy falls on the individual—it is critically important for everyone to be prepared for the eventuality of a hospital stay whether scheduled or emergency. Everyone should have an updated “hospital” packet readily available if a hospital visit is required. The packet should include the names and reach numbers of all the individual’s physicians, a list of current medications, a living will, durable power of attorney, and power of attorney for healthcare. Here is a list of what you should do before, during, and after your hospitalization.
In addition, each individual should designate a relative or friend as their lead patient advocate. The duties and responsibilities of a patient advocate are explained here and here. Currently, patient advocates are not covered by Medicare. Hospitals and some private insurers do pay for their own healthcare advocates at no cost to the patient. However, these advocates work for the hospital or the insurance company and serve the interests of those institutions. And those institutions pressure their employees to maximize revenue and minimize costs—which may not always be in the best interests of the patient. For example, hospital healthcare advocates are usually employed by the hospital’s risk management department! One nurse told me that the “patient advocate” at a hospital is primarily concerned with “damage control”—to minimize the risk faced by the hospital and to let patients and families vent their frustrations rather than to find solutions to the underlying issues that caused the complaints.
There are also professional patient advocates. However, there are only 75,000 professional healthcare advocates in the U.S. with an average annual salary of approximately $34,000. Independent advocates are paid out of pocket by the patient and are not covered by private insurers or Medicare or Medicaid. Optimally, Medicare and Medicaid should provide patient advocates to ensure that the patients’ needs are met. Ultimately, such services could prove to be cost effective in terms of better patient outcomes.
Conclusion: People Before Profits
An Occupy Wall Street protest in Bryant Park, New York, against Pfizer's profiteering and to raise awareness about the destructive political activities of the American Legislative Council and the corporations, Pfizer among them, that run it.
(Photo: Viviane Moos/Corbis via Getty Images)
The inability to pass Medicare for All—or any viable form of comprehensive national health insurance—and to enact the other reforms outlined above is rooted in the power of those who benefit from our for-profit health system: the insurance companies, drug companies, for-profit hospital chains, and the direct providers themselves such as doctors and surgeons. The system is predicated on profits before patients, which is irrational in terms of providing the most efficient and best care for patients nationwide.
These health industry corporate elites defend and preserve their power by providing hundreds of millions of dollars to subservient politicians who then enact policies that generate hundreds of billions of dollars in profits. These politicians support policies that extend corporate profits such as monopolies granted to big pharmaceutical companies and simultaneously prevent policies such as Medicare for All that would cut profits.
The relationship between Sen. Kyrsten Sinema of Arizona and Big Pharma provides an illustrative example. Sinema campaigned on lowering drug prices in her 2018 Senate race. And in 2021, her website boasted that she “was fighting to ensure life-saving drugs” would be more affordable. Yet, from 2017-2022, Big Pharma invested $564,000 in Sinema’s campaign funds and at least $1.2 million in dark money. In the fall of 2021, Salon reported that Sinema and her allies had “effectively torpedoed their own party’s efforts to claw back more than $400 billion in prescription-drug costs for consumers and taxpayers.” That is an incredible return on investment for the big pharmaceutical corporations. Another instance of profit before people.
This corporate—especially the financial corporate elite—dominated system has undermined our healthcare system, our environment, and our economic and civil rights.
And it’s not just the healthcare system. The entire political-economic system is a testament to legalized corruption. The corporate and Wall Street elite legally fund their political agents with billions of dollars in campaign contributions and then spend billions more in lobbying these corporate politicians to pass pro-corporate legislation and prevent the passage of progressive legislation. This rotten system is at the core of our problems because it places profits before people. This corporate—especially the financial corporate elite—dominated system has undermined our healthcare system, our environment, and our economic and civil rights. Thus, the reform of healthcare depends on the reform of our corporate-dominated political economy.
Changing this system will take a broad progressive movement that will involve the concerted efforts of millions of people. And how do we launch, manage, and sustain, such a movement? I don’t know. But I do know that it has been done before.
The American Revolution sought national liberation from the strongest empire in the world—and it succeeded. The abolitionist movement sought to end a slave system that formed a major portion of the national economy and was institutionalized by the Constitution, enabled by the Supreme Court, and supported by the Democratic Party of that time—and it succeeded. The labor movement arose from the darkest days for unions in the 1920s and early 1930s and sought to create workers’ rights against the entrenched interests of capital—and it succeeded. A multi-decade movement to improve healthcare coverage created Social Security, Medicare, and Medicaid—and it succeeded against the opposition of the entire healthcare establishment. And we could go on with other movements—civil rights, environment, anti-Vietnam war, women, LGBTQ, etc.
All these movements were separate but could achieve successes because they were also intertwined with other progressive movements. For example, the civil rights movement gained important—even essential—support from unions, and the civil rights movement supported unionization. This relationship was best illustrated by Martin Luther King, Jr. who was in Memphis in support of a sanitation workers strike when he was assassinated.
The point is not that a progressive movement is guaranteed to be successful now—we face a rising fascist movement in the U.S. that is funded by right-wing corporate billionaires, institutionalized by the U.S. Supreme Court, and supported and often led by the Republican Party. The odds are against us. But we have millions of supporters and activists working daily in alliance with many progressive causes. Right now, we are less than the sum of our parts. My hope is that at some point soon, the fragmented progressive movements can develop into a unified force for change. And once this happens—the politicians will be forced to follow. That is my hope. I won’t live to see it, but I believe that many of you will.
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