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Introduction

by Clarissa O’Conor

I had just started my first clerkship of third year at a nearby hospital when the news broke. Hahnemann Hospital, the main teaching hospital of my medical school, was closing. More accurately, the hedge fund manager who purchased the hospital a year earlier was filing for bankruptcy. He separated the valuable Center City real estate from the hospital itself to ensure a tidy profit for investors at the expense of patients and staff.

Hahnemann Hospital opened in 1885 and became the de facto city hospital for the city of Philadelphia, serving mainly people on Medicaid and Medicare. Since closing, over 2,500 people lost their jobs, including 570 residents and interns. The owner of Hahnemann is currently trying to sell these residency slots to the highest bidder, a move that the federal government is working to block in court.

By the time Hahnemann closed, I had been a member of Put People First! PA (PPF-PA) for four years. PPF-PA is a grassroots organization fighting for universal health care in Pennsylvania I became a member of PPF-PA because I knew that we cannot guarantee the human right to health care that is provided in most other industrialized nations by politely asking insurance companies and politicians. We have to get involved in the political process.

For a long time, the responsibility of advocating for the basic right to health care in America has fallen largely on patients. Patients tirelessly engage both providers and politicians to demand access to quality care and treatment as well as concrete policy reform. Certain subsets of health workers, particularly nurses, technical and support staff, have also historically organized through unions for fair compensation, safe staffing and dignity at work to ensure proper provision of care.

In this piece we analyze the closure of Hahnemann Hospital to argue that all workers in the health system — med students, residents, home health aids, doctors, technicians, nurses, and all others — are impacted by the inequities of this industry. We health workers should see ourselves as part of the same struggle: one that time and again pits the interests of CEOs, private equity firms and investors against the interests of patients and health workers. The displacement of residents by hospital closures and the abusive work environment of the brave University of Washington residents are among the most recent opportunities for us to acknowledge this reality.

The closing of Hahnemann Hospital to make a real-estate deal, therefore, came as no surprise to us in PPF-PA. This is business as usual in our current system of health care for profit. Most recently in December of 2018, in my hometown of Lancaster, Pennsylvania, the UPMC conglomerate closed St. Joe’s Hospital. PPF-PA leaders in Lancaster organized protests, wrote op-eds, brought in new members, and pushed the Lancaster City Council to unanimously endorse a key part of our platform.

As a medical student just two years away from being a resident myself, I try to imagine the horror of being an intern at Hahnemann Hospital, learning of its closing less than a month after graduating from medical school. You would be hard pressed to find quotes from interns and residents in news articles about Hahnemann, even as nurses, techs, environmental services staff and other employees of Hahnemann led rallies and gave interviews. The rumors were that residents were instructed by their program directors not to speak out, at risk of jeopardizing future job placements.

I organized and spoke at protests to save Hahnemann wearing my white coat, but I spoke as a member of PPF-PA as well as a medical student. I was part of something much larger than hastily organized protests, impassioned editorials, and uncertain clerkship placements. Our work is grounded in tight-knit statewide networks and leaders dedicated to building a system that serves patients and health workers, not profit. Our work will continue long after Hahnemann Hospital closed its doors.

Indeed, with the protests dying down, Hahnemann seems fated to become luxury apartment buildings, but I continue to organize with PPF-PA as before. We brought in new members through our rallies to save Hahnemann, including a medical school classmate of mine and a cardiology fellow. Our actions connected to the fight to save St. Joe’s Hospital in Lancaster, building a united front across the state against those profiting from the closures of life-saving hospitals, particularly in rural areas. We also deepened our partnership with the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP), a powerful health workers’ union and leader in fighting the closure of Hahnemann Hospital. We’re currently working on our plan for 2020, which includes activism around impending hospital closures, passing legislation to establish a statewide Public Healthcare Advocate, and restoring the adult dental benefit to Medicaid.

My membership in PPF-PA has allowed me to see the closing of Hahnemann Hospital for what it is. It’s a symptom of the ongoing crisis of for-profit medicine that disproportionately impacts the poor and an opportunity to organize fellow health workers into a shared vision of health care that unites all those hurt by the current system.

The lessons we drew from the closing of Hahnemann Hospital are part of a larger analysis embraced by health workers associated with PPF-PA This analysis guides our efforts as health workers to understand our potential to make change, collaborate with all those hurt by our health care system, and connect our work to other issues where regular people are struggling against for-profit systems to meet their basic needs.

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Social Justice Understandings and Practices for Health Workers

by Karim Sariahmed, Clarissa O’Conor, Jacob Hope, Noha Eshera, and Zach Hershman

In economics, a “class” is a group defined by their relationship to the economy, usually by their relationship to production. A minority of people, represented in our industry by CEOs, investors and private equity firms, have legally purchased the tools (capital) required for the provision of health care in our current system: hospitals, insurance companies, clinic buildings, pharmaceutical manufacturers, residency programs, etc. As the “owning class” they collect hundreds of millions of dollars in passive income from the profit generated by these investments.

The rest of us are not so lucky. The vast majority of people in the US are instead required to sell their labor in exchange for an hourly or salaried wage, as workers. Health workers provide care, treatment and upkeep of all the things required for the provision of services (labor), and we receive back a portion of the profit our labor produces in the form of a paycheck. This second group is traditionally referred to as “the working class” — the class who must work to survive.

This framework, which has long been utilized by economists in various forms, does not claim to explain every phenomenon in the labor market, but it can help clarify what we, as health workers, have in common. Therefore, our definition of the working class necessarily includes all nurses, doctors, scientists, environmental services staff, social workers, hospital food services workers, therapists and other kinds of health workers. Despite differences in wages, benefits and education level, we all have to sell our labor to survive. We all encounter exploitation by the executives who run hospital systems, we all are subject to the whims of bosses and private equity firms without recourse, and we all must deal with difficult working conditions and unhealthy and unrealistic performance expectations.

When thinking about all health workers, it can be tempting to focus on the differences between us in terms of  income, education level, and job title. These differences, however, obscure the foundational conflict of interest between the health care CEOs’ and investors’ drive to make a profit and our interest in providing quality care while having our basic needs met. The story of Hahnemann Hospital shows us how the long-term interests of Hahnemann doctors, nurses, techs, environmental services staff, social workers, therapists and other health workers were not only aligned with one another, despite differences in pay and title, but also how those interests conflicted with the interests of Hahnemann CEOs, investors, and private equity. At Hahnemann, for private equity to make a profit, workers paid the price.

Who does a Hahnemann cardiology fellow have more in common with: an ICU nurse or Joel Freedman, the owner of Hahnemann who stands to profit handsomely from its closing? A food services worker in the hospital cafeteria or Paladin International, the private equity firm that purchased Hahnemann before closing it a year later? Was it food services workers who wanted to turn the hospital into condos or ICU nurses pushing to convert it into a hotel? Of course not. What separates health workers from one another are only our wages and level of job security. What separates health workers from Joel Freedman and Paladin Health care is a fundamental conflict of interest rooted in the structure of the health care economy. If we are only paying attention to the perceived gap between a cardiology fellow and a food services worker — in terms of annual salary, years of education and social status — it’s harder to be clear about how the for-profit health care system hurts everyone who has to sell their labor. More importantly, it’s harder to be clear about what can be done to address the problem.

We know that when workers try to unionize, bosses divide and conquer by pitting different workers in the same institution against one another. For example, one of the most common claims made by hospital CEOs and management consultants is that nurses unions will hurt doctors and patients. But we know that safe staffing and better working conditions for nurses leads to better outcomes for all health workers and patients. Instead of playing into these divisions, we should look towards the interests we share as a class of health workers that can help us more effectively collaborate and push for both necessary reforms and more fundamental systemic changes.

The dysfunction, inequality, suffering, and exploitation that is rampant in our health care system is not a glitch or a mistake. It is the intended outcome of the way the industry is structured. As a simple matter of economics, the source of profit in health care is the difference between the actual costs of the services we provide and the money charged to patients for these services. In other words, a surplus is collected by the systems we work for and the people who own them. Like any competitive business, both “for-profit” and “non-profit” hospitals seek to maximize this surplus by pressuring health workers to see more patients and work longer hours. We often do measure certain metrics related to health outcomes for patients. But the measures of effectiveness related to how much money we make for the hospital system have far more influence over our day to day lives. Charting and documentation, for example, has little to do with health outcomes or a person’s lived experience of illness. However, they are the tools we use to minimize liability for the hospital and maximize insurance reimbursement, and so they are front and center in our working lives. The “review of systems” is another mark that our medical billing structure has left on medical care. The way we talk about billing often blurs the distinction between academia and industry. The profit motive is so pervasive in health care that it’s hard for us to imagine any other way. A system that provides all the health care people need would simply not be profitable for the Joel Freedmans and Paladin Healthcares of the world.

Meanwhile, we experience unprecedented levels of exhaustion and dissatisfaction with the jobs we chose to serve and care for others. Health workers know intuitively that most of us are not faring well in this system — patients and providers alike — despite how hard we work. When we say that providers and patients share the same interests, we’re also talking about the ways in which our collective suffering results from the drive for profit central to our current health care system. It’s not selfish to acknowledge our suffering, and it isn’t harmful or distracting from the suffering of our patients. On the contrary, not only will it make us better at our jobs, but also we have to be honest about this shared experience in order to effectively confront the health care crisis in its totality.

“Burnout” has become a popular way to describe the way we feel in this situation. Our institutions have responded with various superficial psychological supports. But we know that there is a fundamental contradiction between accumulating profits and treating health workers fairly that no amount of yoga, therapy dogs, self-care trainings or free lunches can address. It is bad enough that these are often superficial efforts to circumvent the actual demands workers make for better wages, benefits, and working conditions. Even more insidious, however, is the psychology of individual responsibility these efforts perpetuate. They send the message that if you are a health worker and you are “burned out,” maybe you need to practice better self-care. As health workers, we are also fighting attempts by hospital CEOs and investors to blame us for the ways their system hurts us.

Because of the technical skills and social authority health workers have, we are in a position to meaningful participate in the struggle to guarantee health care as a human right. We are also well-positioned to unite with other health workers to secure the wages and benefits necessary to fairly sustain a health care workforce. We experience the conflict between owners and workers as a choice: we can prioritize the conditions we share with our colleagues and patients or we can align with the hospital owners and investors who want to hoard the wealth moving through our health care system. Although we, as individual health workers, are often unsure about where we stand on these issues, the owners and investors of the health care industry are not. The mounting defense against Medicare for All, for example, is funded by the insurance industry because they are clear about this conflict. Even though they compete with one another for customers, health insurance companies are united as a class in protecting their ability to make a profit. The company that purchased Hahnemann Hospital was clear that they could close the hospital and no one would be able to stop them. The investors, private equity, and real-estate firms were united in pursuing their class interests, but the workers, staff, and patients of Hahnemann were not united in an organized opposition.  When the class interests of hospital owners and investors come into conflict with the interests of patients and workers, we have an opportunity to pick a side. If we choose to stay neutral, we are abandoning our colleagues and patients — some of whom are the most vulnerable of our society — when our support is most needed. But instead if we get as clear about this conflict as the owning class of hospital CEOs, investors and private equity firms are, we can choose to prioritize our own needs and the needs of our patients over the agendas of the millionaires who extract profit from our honest work.

Health workers must ask ourselves, why do we put up with such terrible working conditions? At every level of hierarchy in the health care system, we are offered privileges which influence our perception of our conditions: higher pay, prestige, better hours, publications, grant money, administrative positions, sometimes even public office. It is much easier to accept unfair working conditions when our career paths promise these rewards. We might be able to justify seeing 20 clinic patients in a day if we’re promised a prestigious job title in a few years. We might be able to push down the burnout we feel from endless charting requirements when we consider the salary we’ll be able to make in a few years. Calling insurance companies to convince them to pay for medication might feel acceptable if we plan to leverage our clinical experience to win a cushy industry position. It’s easy to feel like we’re already doing enough good just by being doctors.

Despite all the ways that health workers, especially doctors, may be able to gain some measure of economic security on their own, we know that in the long term the most fundamental interests of all working people are the same. Even today, many doctors might think that they can keep their heads down and carve out their own small patch of economic security in their own private practice or physician’s group. 30 or 50 years ago, they might have been right. The past 10 years of our health care economy should dissuade anyone of this notion today. Doctors will never return to their status as small business owners. This was a deal with the devil doctors made with dire long-term consequences for the larger sector of health workers. On the one hand, doctors were able to maintain status, stability, wealth, and control over their medical practice. As a consequence, however, they became more and more isolated from other health workers, keeping their professional organizations and personal practices separate from the labor struggles being fought by other sectors of the industry.  And as owners, investors, and Wall St. firms pillaged our health care system by closing public hospitals, patenting life-sustaining medication, proliferating HMOs and massively expanding corporate hospitals, doctors stayed silent. Now Capital, through industry pressures, hospital mega mergers, and corporate buyouts, is remaking the doctor into an employee like the rest of us. The lessons should be clear. Health workers cannot abandon one another for short term gains. Doctors must reject these deals with the devil, and health workers must organize together with doctors, residents, and medical students. Our enemies are united. So too must we.

The health care crisis will only worsen if we don’t act. If we, as health workers, develop a clear sense that we are part of a larger class of working people, our careers can be in the service of fundamentally changing our health care system to serve health workers and patients, not CEOs, investors, and private equity. There is certainly nothing morally wrong with wanting to pursue academics or with looking for a way to work fewer hours. But whether we’re doing these things in ways that benefit the whole class of health workers and other working people depends on our political education and our connection to movements and organizations of social change. We have the opportunity to make visible the ways that the interests of bosses and owners come into conflict with the interests of working class people, especially our colleagues and fellow health workers.

Without clarity about how the system really works, we’re vulnerable to divide and conquer tactics that keep us separated and powerless. It is a common assumption that we’ll be most able to affect change as individuals by taking on privileged positions, such as those in academic medicine, which can only be reached by playing by certain rules over many years. But even the most professional, effective, studied career advocates have limitations on their influence. We will not win universal, guaranteed rights to health care by simply persuading insurance companies with graphs, charts or studies. There is no systematic review or NEJM op-ed that will convince hospital system executives that health workers deserve humane working conditions if it means reducing profitability and breaching their legal obligation to shareholders. Only mass movements of working people fighting for our shared interests as a class can do that. Health workers belong in these movements. When we remain isolated, we tend to blame ourselves for the failures and dysfunctions of the health care system, or take out our frustrations on our colleagues and patients. By taking action together, we break the isolation and combat that despair. With a commitment to uniting all health workers, we can build a force strong enough to fight the interests of the owning class and change our industry for the better.

It was the health workers — nurses, doctors, medical students, techs, and environmental services staff — united in their fight against the closing of Hahnemann Hospital, who shifted the local, statewide, and national narrative around health care for profit. Without our struggle, the sale of Hahnemann would simply have been another story of a long-ailing and “bad” hospital finally closing its doors. It is true that the closing of Hahnemann Hospital has worsened our city’s health care crisis. But if we see its closing simply as a defeat, we ignore the many lessons and successes that have come out of this struggle. We must see this struggle as a vision of what kinds of victories are possible when health workers and patients are united. We can imagine a world where we’re strong enough to keep our hospitals open, and operate them as fully funded public hospitals. We can imagine a world where health workers and patients are treated with fairness and dignity. We can imagine a world where every person is guaranteed the human right to health care.

Below are some principles to guide us in connecting to other health workers and indeed, the whole working class.

1. Move past paralysis about whether you are “disadvantaged enough” to speak out or be a leader. Connect with the ways you are frustrated or exploited by the health care industry. Understand your own stake and interest in making things better. It’s going to take a mass movement to change the health care system, and we will need everyone. Your specific background and expertise is a valuable contribution to the fight!
2. Relationships are how we learn and grow as human beings. Cultivate relationships with social justice organizations, in particular organizations led by those most affected by the health care crisis like unions and patients’ groups, to support your own political growth and expand your understanding of the politics of health care reform. Organizations like Put People First! PA and other organizations of the Poor People’s Campaign: A National Call for Moral Revival do this work in a principled and rigorous way.
3. Other people are moved to take action because of relationships, too. Cultivate relationships with co-workers across different specializations and roles in the health industry, especially service, technical, and support staff. You will better understand their situation and can better work together to make a change when the time comes.
4. Take a long-term perspective. In our entrepreneurial culture, the instinct is to always be starting something new – a new organization, a new non-profit, a new website. Instead of re-inventing the wheel, try to learn from the people already building organizations grounded in working class communities. It’s a slow, patient process to build power by bringing people together, but this is the best way to avoid feeling isolated and demoralized.
5. Join and support unions as they are available to you- or start them. Rampant anti-union discourse in medicine, particularly the idea that unionized nurses make the lives of doctors more difficult, betrays our patients and undermine our shared interests. These dynamics are obscured by academic discourse about “quality” and “value” that dominate health care. Unions help us shift that conversation towards better conditions for health workers and patients. Unions are historically the single strongest tool to affect change in a hospital or other health care institution.
6. Everyone has an ego, and sometimes it comes out when we want to be seen, loved, acknowledged, or appreciated. It happens in our work, it happens in our personal life, and it happens when we work for social justice. As a result, it can be challenging to balance our ego and self-interest with our role in the larger movement for social justice. But the trusting relationships we build with others will nurture us, and alleviate this burden of ego that often leaves us feeling isolated or powerless. That great relief is what solidarity feels like.

Editor’s note: A version of this piece was originally published on the PPF-PA blog.

Image credit: Sanders_Rally_19 (4) by Michael Stokes is licensed under CC BY 2.0.