In April 2020, when I would walk home after a long day treating patients in a New York City emergency room, an orchestra of pots and pans would erupt from seemingly every window to honor frontline workers. Nothing could make those early pandemic days easier for me and my colleagues, but those haphazard symphonies of appreciation helped keep us going. At that time, health care workers had every reason to hope that once the Covid-19 pandemic waned, long-overdue and much needed changes to our health care system would finally materialize.
But after Covid vaccines rolled out and the country largely moved on from the pandemic, those promises were seemingly forgotten. We drifted back to our old normal in which health care workers felt unsafe, unappreciated and unsupported.
This helps explain why more than 75,000 workers at the Kaiser Permanente health care system have walked off the job, in what union leaders say could be the largest health care strike in U.S. history. Similar to Hollywood writers and actors and the United Automobile Workers, the striking Kaiser workers are demanding better pay and benefits. But many of their greatest demands can’t be met with money alone. The changes they want require a major overhaul of how health care is delivered.
The seeds of the Kaiser strike were sown before the pandemic, which certainly aggravated the issues afflicting workers. No matter how this strike ends, the problems at the Kaiser network, which operates in eight states and the District of Columbia, are not unique. Health care workers have already taken to the picket line at hospitals and clinics across the country this year — six of the 19 work stoppages involving 1,000 or more workers recorded by the Bureau of Labor Statistics in 2023 were in health care. Providers commit to serving others. That so many are walking off the job in protest means the conditions are so unsustainable, there’s no option left but to take this action of last resort.
Health care providers have long experienced burnout, a product of working in a system with grueling hours and byzantine approval processes for routine patient care. But in the first year of the pandemic, levels of reported burnout among providers soared into their own epidemic. According to a study by the American Medical Association, over 60 percent of physicians reported feeling burned out in 2021. And now large numbers of health care workers have joined other Americans in the Great Resignation over the past two years.
I work in emergency medicine, where the rate of physician burnout is the highest. Hundreds of residency training positions were initially unfilled in 2022 and 2023 — an unimaginable scenario for one of the most competitive medical specialties before Covid.
As health care has become more corporate in recent decades, physicians have also increasingly felt caught in the liminal space between their Hippocratic oath and the demands of health insurance companies. Providers routinely speak about “moral injury”: the feeling of guilt about being unable to care properly for patients in the face of hurdles like preauthorizations, diminishing reimbursements or unmanageable patient loads.
Workplace safety is also acutely on workers’ minds these days. Early in the pandemic, images of nurses wearing garbage bags in lieu of personal protective equipment resonated on social media. Thousands of doctors and nurses on the front lines died in the first pandemic year. Even as caring for patients with Covid has become safer, our jobs have not. Health care workers represented 73 percent of the victims of nonfatal workplace violence in 2018. Similarly, hospitals and health care workers have been targeted in recent shootings in Dallas, Atlanta and Portland, Ore. In July, an orthopedic surgeon was gunned down by a patient in an exam room in Tennessee.
And lastly, health care workers often feel they don’t have the resources needed to provide the best care to patients. Eighty-three percent of health care workers in California surveyed in 2022 reported that “their departments are either severely understaffed or somewhat understaffed.” An open letter published this year by the union representing Kaiser workers stated, “There simply aren’t enough health care workers to safely and properly care for patients,” a sentiment felt by health care workers in clinics and hospitals across the country.
This isn’t just a pandemic problem. California recognized that in 1999 when it became the first state to pass legislation mandating nurse-to-patient ratios in hospitals (such as one nurse for every five patients). Now, New York, Oregon, Washington and other states have recently passed or have legislation on the table to do the same. But staffing standards are meaningless if you can’t find the people to work.
The Kaiser strike aims to address the factors that fuel these systemic problems. But resolving them outright is a bigger task. As a society, we should ask what we owe health care workers who shepherded us through the pandemic, workers we promised to protect back in the days we banged pots and pans at our windows. What we most owe them is the ability to do their job.
One place to start is by providing mental health resources to workers experiencing burnout, not just “wellness” programs. Many providers are concerned that seeking mental health care could threaten their own medical licensing and disability coverage. One medical resident I worked with during the pandemic sought out a mental health provider, given everything she’d witnessed in Covid’s darkest days, only to have it emerge as a barrier when she applied for a disability insurance policy. She was ultimately denied.
In addition to mental health resources, providers need alternatives to quitting the industry when they experience burnout. The federal government should create a program for workers who feel compelled to leave their specialty but not health care itself that could support their transition to another specialty like primary care (which needs more practitioners).
Similarly the federal government, which provides only vague guidance, can take action to support stronger staffing ratios. Both patients and health care workers would benefit from stronger enforcement: Research suggests better staffing ratios improve patient outcomes and lower costs while reducing worker burnout.
In March, Representative Jan Schakowsky of Illinois, and Senator Sherrod Brown of Ohio, both Democrats, reintroduced legislation that would “establish new minimum federal safety standards — including nurse-to-patient ratios.” But we should look at this bill as only a first step to easing staff shortages.
As it stands, it may not be possible to pull enough providers to the bedside to provide the best possible patient care. A shortage of as many as 450,000 nurses by 2025 is predicted. This is in addition to estimated shortage of up to 124,000 physicians in the next decade.
We desperately need broader federal support to increase the number of providers, especially in BIPOC communities and underserved areas, where a more diverse health care work force can lead to better care for patients as well as save the country hundreds of billions in health care costs annually. The Supreme Court’s rejection of affirmative action in higher education will make increasing diversity in health care only more difficult.
Many of these necessary reforms are captured in the bill for the Bipartisan Primary Care and Health Work Force Act introduced by Senator Bernie Sanders of Vermont and Senator Roger Marshall, a Kansas Republican. But many of its proposals will undoubtedly face strong opposition. Even if this bill fails, many of the solutions they’re calling for — such as greater support for community health centers and a big increase in the health care work force — are necessary if we hope to solve the problems brought up by the strikes at Kaiser and other health care institutions.
In most places, the Kaiser strike is expected to last only three days. But the issues that pushed health care workers to the picket line will remain. And although the strike at Kaiser may be the largest of a U.S. health care institution in history, without overhauling the conditions under which health care workers do our jobs, it undoubtedly won’t be the last.
Craig Spencer (@Craig_A_Spencer) is an emergency medicine physician and an associate professor of the practice of health services, policy and practice at Brown University School of Public Health.
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