Unions: A response to profit-driven medicine

1. Unions: A response to profit-driven medicine Roona Ray MD MPH AAHIVS Physicians for National Health Plan Annual Conference, Washington DC 19 November 2016

2. As Americans, we tend to know little about unions. As doctors, we are less informed about and less sympathetic to unions than the average American worker. Unions What do we know about them? What are our subjective impressions? What is our objective knowledge?

3. How many of us have personally been a union member? As a doctor or healthcare worker? How many of us have immediate family members who are or have been union members? unions What are our personal experiences with them?

4. Unions can give the average physician the ability to influence institutional health policies in a political environment that often feels hopeless and disempowering, e.g. in hospital mergers and closures, ballooning of the management class, executive pay, and of course, working/patient care conditions. Unions can be vehicles to promote fair and equitable primary care and public health systems, both in the workplace and in society. Unions are for doctors. Especially in the setting of profit-based medicine, though not only, e.g. the BMA JDC. Especially in the epidemic of so-called “physician burnout.”

5. -In 1974, the peak of the physician-union movement, ~55,000 physicians belonged to labor unions. -In 2012, ~40,000 physicians were union members; many were state or federal employees. (http://www.aafp.org/practice-management/payment/collective-bargaining.html) Doctors do unionize. And have since the 1970s.

6. The National Labor Relations Act of 1935 says: -All hospital workers CANNOT unionize together, i.e. hospital doctors can only unionize among themselves, not with nurses, etc. -Self-employed doctors cannot unionize. A union can include all clinic workers. A case study of my experience unionizing a community health center in New York City.

7. HPI: This was my first job after FM residency, 100% clinical. I was learning HIV and transgender medicine with little support. I wanted to work in a mission-driven health center for the underserved. SH: I had been a feminist, labor, & health activist as a student. I had educational debt. I did not have a mortgage or children. I was unmarried. FH: My parents were neutral to anti-union, center/liberal but not politically active, and immigrants from India who grew up poor. My personal/political history Each organizing conversation and relationship is unique, much like each patient interaction, but with common structural elements.

8. 6 floors, ~20 MD/NP/PAs, many part-time, ~230 total employees, ~170 union-eligible Departments: Dental, Medical, Mental Health, Clerical, Nursing, Care Coordination, Teen Program. Security and janitorial services outsourced. Racially diverse workers, disproportionately LGBT, younger (due to existing benefits package and patient population) Very high turnover in all departments; pay and benefits lower than similar positions in the city 2013: Top 5 earners 140-198K, Assets $27 mil, liabilities $8 mil, Net profit $19 mil The clinic An FQHC serving an LGBT population in New York City

9. Low relative pay Very expensive health insurance for non-single workers, poor coverage of transgender health needs High turnover and loss of talented dedicated staff, concern over effects on patient care and working conditions Increasing workload, focus on quantity and not quality of care Unfair disciplinary processes and firings/opaque promotion process that seemed to favor white gay men Increasing workload, focus on quantity and not quality of care No pension of 403b match Little support for education/professional development No control over decision-making The campaign pt. 1 Was initiated by therapists, mostly social workers, in the mental health department. A variety of issues drew workers to the idea of a union.

10. The timeline and legal framework: Jul 2014--I start attending informal secret meetings with co workers and a union organizer. We talk with trusted colleagues, debate the risks and benefits of unionizing. We decide to go forward with a campaign and start collecting signed cards, which are votes. Goal: 70% of eligible workers, though only 50% are needed to win. Nov 2014--We exhaust our trusted acquaintances and “go public,” notifying all workers and management of our campaign. Management rejects our cards as a vote and hires Jackson-Lewis, an infamous union busting law firm, to manage the anti-union campaign. The law states 60 days* to our vote. They also require a “Sonotone election,” dividing the “professional” and “non-professional” workers. The campaign pt. 2 SEIU 1199, the largest and most progressive healthcare union, agreed to work with us. The organizers were inclusive, good listeners, encouraged democratic participation, educated us about the process.

11. Nov 2014-Jan 2015: Management spends 2 months during the holidays intimidating us, lying about unions, spreading misinformation, creating new positions, promoting people out of union eligible positions, creating new management position. They follow textbook anti-union campaign tactics. These are illegal actions. Morale struggles The campaign pt. 3 Some senior members of the medical department lead the anti-union campaign. Medical hierarchy & fear silence many.

12. HR, some of the senior managers and I will present information and answer questions at next Tuesday’s department meetings and at alternative meetings if required. The management team here works hard to create a positive work environment and promote a collaborative culture of mutual respect. I believe that we done a good job in taking care of the needs of our employees. We have prioritized providing quality health care and disability coverage for staff that has been tailored to meet our needs, and as resources have allowed, we have made every effort to increase salaries based on community health center averages and provide COLAs whenever possible. We are committed to our staff’s development and providing competitive pay and benefits. Also I really value the ability to interact directly with staff about issues of concern to you without using the union as an intermediary. All that being said, after you have given careful consideration, I encourage to make the choice that will benefit you and your loved ones the most. We will work collaboratively with 1199 if our staff makes that choice. Thanks, Jay Dear Staff: It is my understanding that 1199 SEIU United Healthcare Workers East is currently conducting a membership drive at Callen-Lorde Community Health Center. I was a former 1199 union member and know firsthand both the benefits and the challenges of being part of a union. The union has distributed a notice with information about a meeting this Friday evening for eligible employees. (Please note that no one with a supervisory title should attend this meeting.) I have attached this notice in case you haven’t seen it. If you are considering joining the union, I would suggest attending the meeting or otherwise gathering as much information as you can about what it means to be a union member before signing a card or making any decision about joining the union. Joining a union is a serious decision. I encourage you to try to get as much specific information as you can to help you in making a choice about whether to join the union including salaries, benefits, and promotions. Please bear in mind that, while everyone wants to get pay increases and better benefits, the specifics of any union contract cannot be determined in advance of negotiations between the union and the employer. No union can guarantee what pay rates or benefits changes will be agreed upon.

13. Jan 2015: We vote and win by a landslide! 99-48, professionals 29-22. The win!

14. Major wins: Free, no cost health insurance Increased pay across the board, ensured COLA raises for each of the 3 years of the contract, biggest wins for lowest paid workers, clerical staff Steps wage increases rewarding seniority Pay differentials for previous experience, specialization, call in licensed positions, DEA coverage The SEIU 1199 Training and Education fund Grievance and arbitration procedure, seniority rights, checks on arbitrary management behavior. This is language drawn from the SEIU 199 contract that covers 400,000 workers The contract Between May 15 and Sep 16, we negotiate our first contract.

15. We didn’t win a 403b match, but there is language that leaves it open to negotiation if there is profit. Issues of workload, quality of patient care, which are most important to providers, are not addressed in a contract. These issues can be addressed in an ongoing labor management committee process, depending on internal organization. What’s left?

16. Questions: As doctors for the poor and underserved, are we justifying a highly unequal system, i.e. are we tools for an industry that makes profit off the disease of the poor? How do we create institutional power to oppose corporate power in medicine that threatens the health and interests of both doctors and patients? How do we organize to advocate to end income and other social inequalities? As the workforce in medicine diversifies to include more women and minorities, what vehicles do we have to change the work culture of medicine for all? Unions in medicine pose some questions and ideas... Charity-based vs. Interest-based politics? Greed vs. Self interest? Power from ideas/prestige vs. Power from organizing people and doctors as economic engines of the healthcare system