“[Management] told me I was an ‘essential worker’… but in making decisions about staffing levels and access to PPE, they increased the chances that I would get COVID and potentially die.” —Jessy (pseudonym), registered nurse (RN)
The COVID-19 pandemic placed a tremendous amount of stress on a number of phenomena, including the functioning of American governance, democracy, and capitalism. Yet not least of which was the day-to-day working conditions of tens of millions of workers, particularly those in the healthcare industry. While the country rallied such workers as “essential” at the height of the outbreak, their working conditions suggested they were, in fact, not. As Jessy (pseudonym), a registered nurse (RN) relayed to me: “It was madness… We all felt abused by the way management treated us.”
These problems, unfortunately, were not new. As several front-line healthcare workers have relayed to me in my on-going research, the pandemic exacerbated and highlighted pre-existing, sub-par working conditions—such as years and, in some instances, decades of short-staffing and stagnant pay. As Figure 1 shows, as the United States has deindustrialized, healthcare has grown to be the single largest source of employment in the country. Why does a workforce so large and central to the American economy not wield more political and economic power?
In this blog, I briefly survey the healthcare industry not as it is traditionally viewed by students of American politics—as a provider of services—but instead as a source of employment. Drawing on key concepts and research in the American Political Economy (APE) tradition, I argue that understanding the politics of the healthcare workforce requires paying attention to the particular arrangements of what is broadly known as the public-private welfare state. The APE approach’s attentiveness to the processes of institution shaping, venue shopping, and the embeddedness of race and ethnicity in American capitalism are particularly useful for gaining empirical and theoretical leverage over the distinctive politics of healthcare work and labor.
The Meta-Politics of the Health Industry as a Public-Private Employer
As scholars in the APE tradition have argued, the American welfare state, in comparative perspective, is not so distinct for its small size, as previous characterizations had it, but more so for its design and reliance on private actors to fulfill core functions. While scholars have pointed to many instances in which public goods are “hidden in the shadows,” “delegated,” or “submerged,” the healthcare industry is often held up as the epitome of what is commonly referred to as the public-private welfare state. As I show in my on-going research, the blend of public and private actors in the healthcare industry makes for a distinctive type of labor politics. The APE framework’s focus on the process of institution formation and shaping—or the ways that long-standing political and economic institutions are formed, reshaped, and ultimately influence the terrain on which political-economic action takes place—helps us begin to shed light on this.
Consider the fiscal underpinnings of healthcare provision. As several union researchers, workers, and employer representatives have relayed to me, understanding the politics of healthcare work requires examining who ultimately “pays the bills.” Most people in the United States receive their health insurance through a private source, but since they were implemented, Medicaid and Medicare have grown to become the single largest purchasers of healthcare services in the country. Their pure size matters because it influences how private insurers act and, crucially, how providers behave as employers. Even though most health care workers are considered private in legal terms, they also, in one way or another, rely on public funding for their employment. Of the roughly 10 million front-line care workers, the majority work in “traditional” health care institutions—such as hospitals, nursing homes, and physicians’ offices—but a growing share work in more dispersed sites, such as ambulatory services and outpatient services like in-home care, the latter discussed in more detail below.
As my research shows, workers, employers, and lawmakers are in constant, repeated struggle to shape the contours of a public funding structure that pays for ostensibly private services. At its best, the state’s heavy involvement in the healthcare market offers workers some leverage to improve their wages, benefits, and working conditions. Particularly in blue states featuring more friendly Democratic lawmakers, for example, workers have built coalitions with providers and provider associations—including hospitals, nursing homes, and even consumer advocates—to successfully raise reimbursement rates for services, offering them more resources to bargain over. At their worst, these arrangements leave workers subject to the limited fiscal capacity of the federal and state governments broadly, and attempts to control growing healthcare costs in particular. Such pressures can be particularly strong at the state level, where most governments operate under balanced budget requirements and where Medicaid is, on average, their single largest line item. In California, for example, workers recently helped push for a historic statewide piece of legislation that would institute a $25 per hour minimum wage for most hospital workers. Yet because of the state's budget deficit, that wage increase could be put on hold.
Venue Shopping for (and Against) Collective Bargaining Rights
The pressures imposed by America’s uniquely decentralized form of fiscal federalism have been particularly acute for home and personal care workers, among the largest and fastest growing set of workers in the country. Indeed, on the eve of the pandemic, just over three million formal home and personal care workers helped senior citizens and people with disabilities perform day-to-day activities, such as bathing, cleaning, and shopping; they also, in some cases, help provide medical care. In the 1980s and 1990s, state governments increasingly began to use federal monies to offer in-home care to senior citizens and people with disabilities, as a way to increase the independence of beneficiaries and to save money on nursing home spending. These efforts were delivered through decentralized Medicaid programs that allowed states to waive federal law, and crucially, had to be cost-neutral. In part as a result, despite underwriting their employment, state governments mostly refused to take on home care workers as fully public-sector employees, a move that likely would have improved their working conditions, wages, and access to fringe benefits. Instead, care workers were either left to a lightly regulated private sector market dominated by for-profit agencies, or they were employed as independent contractors by beneficiaries.
Recognizing they would be unable to effectively use the National Labor Relations Board (NLRB) to promote collective action, home care workers and their advocates ran a series of creative political campaigns to pressure state lawmakers to produce institutions that would help facilitate collective bargaining between state governments, workers, and beneficiaries. In APE terms, they looked for a friendlier venue. These campaigns have tended to draw less on economic action (e.g., strikes or walkouts) and more so on political activities, such as targeted protests, policy lobbying, and electoral campaigning—all tactics and processes similar to those highlighted by Daniel Galvin’s research on the burgeoning “alt-labor” movement and organized labor’s broader shift to promoting workers’ rights through employment law.
Several of the early home care organizing “breakthrough” campaigns were lauded as labor’s biggest victories since the sit-down strikes of the late 1930s. Over the next decade and a half, unions and workers rode this momentum to implement schemes granting hundreds of thousands of home care workers collective bargaining rights across more than one dozen states. In California, for instance, more than 300,000 home care workers are now union members, while the organizing efforts in Illinois served as pivotal to the growth of the state’s now relatively powerful SEIU healthcare unit.
But as workers piled up victories through legislation, executive orders, and even ballot initiatives, as part of broader efforts to retrench collective bargaining rights for public and private sector workers, anti-union advocacy organizations sought to strategically shift the venue of political contestation again—this time to the judiciary. As scholars in the APE field have argued, the judiciary has become quite conservative in recent decades. In 2010, home care worker Pamela J. Harris sued the State of Illinois, arguing that the dues deducted from her paycheck violated her First Amendment rights. After a series of appeals, the case reached the Supreme Court. In a precursor to Janus vs. AFSCME, a slim conservative majority ruled in favor of Harris, and significantly undercut the ability of unions to collect fair-share fees from workers, a crucial way that unions overcome collective action “free rider” problems.
Racism, Sexism, and Care Work
Any attempt to study healthcare work must be attentive to the way that racism and sexism structure working conditions and political action. More so than others, the healthcare industry is highly segregated occupationally, and such occupational divisions—referred to by practitioners as the “medical hierarchy”—have been shaped by and help reinforce inequalities along racialized, gendered, and class lines. Roughly 8 in ten workers in the health care sector identify as women, but significant variation exists across jobs. In APE terms, these inequalities tend to be invisible or “taken-for-granted,” but as my on-going research shows, they have been cemented by public policies and political contestation.
Consider three of the largest, most powerful, and/or most consequential occupations in the industry. Physicians, who disproportionately identify as men, are among the highest paid and powerful workers, a position they secured, in part, through organized political combat and medical licensing laws. Registered nurses, meanwhile, overwhelmingly identify as women—and their working conditions and mobilization have been shaped by decades of institutional and interpersonal sexism. RNs tend to make well above the median national salary, but, as Jessy’s anecdote above illustrates, they also face increasingly difficult working conditions marked by short-staffing, forced overtime, and even workplace violence. Finally, the large and quickly growing in-home care workforce is overwhelmingly women and disproportionately Black, Latino, and immigrant. In addition to many of the challenges faced by other front-line care workers, providers of in-home care have had to combat gendered and racialized ideas that work done in the home is either “low-skilled” or not “real work.”
The Healthcare Workforce and the American Political Economy
What can we expect moving forward? Even despite some of the setbacks described above, organizers and workers will continue to try to make the public-private welfare state a better employer. In no small part because of the state’s heavy involvement in underwriting and structuring the healthcare market, organizers and workers will attempt to use not only economic action, like recent large-scale strikes, but also political and policy leverage to exact change. Nurses, for example, have drawn on previous victories to push several states for staff-to-patient ratios policies—laws that promise to address the negative working conditions imposed by chronic under-staffing, as mentioned earlier by Jesse. Home care workers, meanwhile, are pressing for stronger collective bargaining protections through state laws—in states ranging from California to Michigan. As implied above, such efforts will hinge on, among other things, states’ fiscal capacity; the durability of cross-class and -occupational alliances; the partisan makeup of state legislatures; and the ability of workers to withstand and even “work around” challenges in the court.
As the United States continues to shift from an economy rooted in the production of goods to one in the provision of services, healthcare will continue to grow as not only a pillar of the economy broadly. It will also serve as a key source of employment for tens of millions of people and a key pillar of the labor movement. Scholars would do well to continue tracking how workers, employers, and lawmakers navigate the peculiar arrangements of the public-private healthcare system. As argued here, the APE framework is especially well-equipped to meet that charge.
