If you get a check-up at any health clinic in America today, you may have no idea how much it will cost, but two things are virtually certain: The bill will be too high, and the nurse who saw you will be paid too little. The sickening paradox at the root of the American health-care system is that, despite skyrocketing costs for patients, front-line workers like medical assistants and home-care aides are shockingly underpaid—while insurers and health-care corporations pocket the difference. The health-care-reform debate in Washington is finally starting to grapple with the equity gap in the health system for consumers, and momentum is gaining for a fairer government-run single-payer system. Yet, for all the promise of the “Medicare for All” proposal, there’s surprisingly little discussion on how an overhaul of our health-care system would affect the people delivering our care.
The new single-payer legislation in Congress, alongside parallel state-level proposals, promise free care for all. But according to Center for Economic Policy Research (CEPR), however services are financed, hospital-based institutions are set to consolidate and downsize, and workers will be left with more work for less pay.
With or without an overhaul of Obamacare in Congress, the system is changing, for better or worse: For years the health-care industry has been shifting from a hospital-centered model of care to a more community-based infrastructure. If current trends in health-care restructuring continue, public and private facilities will undergo major cost-cutting measures, such as merging large corporate hospitals and moving basic services into simpler local facilities for outpatient care—emphasizing streamlined care, such as medication management or in-home nursing programs. That could mean leaner, more efficient services for patients. But the downsizing may also shift jobs to more precarious sectors, where, since 2005, according to CEPR, “wages are declining or stagnating, and inequality is increasing.”
As the employment structure devolves to outpatient facilities, workers tend to slip into lower-paying positions and, as a result of job disruption, perhaps lose union representation. Over time, researchers conclude, “the unraveling of hospital-based employment systems is associated with greater wage inequality.” While the health-care workforce has grown generally, real median earnings slipped from 2005 to 2015, falling on average 2.4 percent, and outpatient facility workers were especially hard-hit, with median wages declining 6 percent. (Insurers’ profits and health-care costs grew steadily during the same period.)
Could health-care reform fix the imbalance? By centralizing health-care finance and eliminating private insurance, single payer would protect consumers from corporate profit motives, since all providers would by definition be publicly funded and managed. However, the single-payer proposals currently before Congress include scant detail on labor standards. So, beyond the cost of care for patients, could a better-regulated system also provide a living wage and a union? Would home-care workers get a $15 minimum wage or paid parental leave under Medicare for All? Whether your clinic is funded through an insurance company or a Medicare-for-All-type government-run plan, many workers might end up with a painful pay cut without additional protections for health-care labor.
Under current workforce trends, there has been an increase in black workers in outpatient facilities, a doubling of Latino workers, and a more than 80 percent increase in Asian and other workers, with women driving the job growth across sectors. From 2005 to 2015, black men’s earnings sank by more than 12 percent, driven by declining wages for medical technicians and assistants. Female technicians and professional staff in outpatient facilities, while continuing to earn less than male coworkers across the board—with wage gaps of about 8 to 24 percent—earn substantially less than their in-hospital female peers. Even mostly college-educated social- service workers in outpatient centers earn less than $38,000 a year, less than what a unionized nurse might earn in a hospital.
The pattern of inequity is exacerbated under our corporation-controlled system, since the monopolization of health care through corporate consolidation tends to drive up the cost. But for labor single payer is no panacea. According to CEPR analyst Eileen Appelbaum, whether the clinic staff’s paychecks come from Washington or a private insurer, financial pressures and regulation will persist, and employers risk focusing excessively on meeting cost-efficiency goals at workers’ expense. As long as providers, in any care setting, “are judged on how they hold down costs and punished if costs rise, they will have an incentive to cut wages, not spend on training, and intensify work in order to reduce costs.”
To make universal care universally fair for labor, Appelbaum argues, “If we look at making health-care jobs good paying for workers and don’t focus exclusively on consumers…single payer will have to do more than just alter the financing mechanism if it also has a goal of making these good jobs.” For example, she notes, currently, many nursing-home staff are compensated under Medicaid’s centralized public-subsidy programs, but because of paltry reimbursement rates, “even the best-run and best-intentioned nursing homes are unable to pay nurse aides anything close to a decent wage.”
However, given the relative strength of public-sector unions—which, as state-based entities, would presumably be free of union-busting corporate monopolies—a single-payer system could help expand union representation, so that outpatient staff could keep up with the incomes of their counterparts at large medical institutions.
This is where organized labor could play a critical role in health-care restructuring: Collective bargaining could ensure fair, stable pay scales and working conditions. There have been strong unionization drives in health care in recent years; for instance, the SEIU has campaigned in several states to provide representation to home health aides who are employed through state-level Medicaid programs—providing a potential model for boosting wages and defending labor rights in non-hospital, community-based care. Still, despite some expanded federal labor protections under Obama, home-care workers overall remain irrationally underpaid, working under high-stress conditions for only about $10 an hour, often without adequate health benefits themselves. These workers, under any management system, will need stronger labor standards combined with a culture shift in the health-care industry that fairly values a labor force that is fueled by women of color and immigrants.
In the coming years, the health-care system is poised to restructure to respond to our communities’ diversifying needs. If this system is going to be sustainable for the whole community, the workforce will need an upgrade too. Moving toward an integrated, universalized model of care for all should also integrate labor, so the state, unions, and communities ensure that every worker is taken care of.