For Workers and Patients, not Greed and Profits: Vote Yes on Question 1

by Socialist Nurse

For 4 months now, we’ve been waiting for management to fill an open nursing position in our department. The word from the nursing manager is that there are “very few applicants” none of whom appear to be a “good fit.” Insert your bromides about the nursing shortage here, if you’d like, but be prepared to put your foot in your mouth: It is no big secret that the biggest chunk of any hospital’s budget is labor and, therefore, payrolls which are the first to see cuts when CFOs go looking for ways to trim costs. (For some reason, building a new half billion dollar campus is not a cost, but an investment. Pity they don’t value their workers in the same way as buildings or profit margins.) Just over two years ago, our hospital management decided that the best way to cut costs would be to get rid of the most experienced and, therefore, most well compensated workers via a buyout offer. The offer was extended to 9% of the total workforce. Two nurses on our unit decided to take the package: both were nearing retirement and, in part, were made to fear for their benefits if they did not accept. I had been hired to replace one of them: a nurse with almost a decade of experience replacing a nurse with nearly four decades under her belt. It took several months for the department to fill the other position. That person has since left the position as has another recently hired nurse. Both referenced the heavy workload and stressful conditions caused by chronic short-staffing as reasons for leaving. That’s four nurses–all well-qualified–any of whom could have filled the current position.

There is no lack of studies pointing to how more adequate staffing leads to both better patient outcomes and worker satisfaction (for example, see this study looking at effects of the nursing ratios implemented in California; for more, see here). What does short-staffing look like? Well, for me, it is mostly stress-filled days punctuated by an unending chorus of ringing phones with anxious patients on the line and a full waiting room of patients waiting to be seen. However, the stress and burnout that result from short-staffing also  negatively affects the quality of care my colleagues and I can provide our patients. If you speak to any nurse, they could recount numerous situations where either their safety or that of their patients have been put in jeopardy because of short-staffing. The mandate put in place by Question 1 would allow nurses to provide the safe, timely and compassionate care that we want and have been trained to provide our patients. As it is now, we are often forced to choose between our well-being and that of our patients–skipping lunch, working past our shifts or rushing through safety protocols to make sure that we can meet their needs. This, as you can imagine, negatively affects our ability to continue providing the kind of care we want resulting in a vicious circle of overwork and diminishing outcomes across the board.

In short, what hospital executives mean when they say there is a nursing shortage and that it is too costly for them to hire more nurses is that they value profits over both workers and patients. Full stop. They’ve even put a number on it: $19 million–that’s how much hospital executives have been willing to spend to defeat Question 1 through misleading and deceptive ads designed with the singular purpose of stoking doubts and uncertainties among voters about “rigid government mandates” or “closure of small community hospitals.” Neither of these are based in facts. For example, at present, nurses have no say in the type of care they provide nor do they get assignments based on their knowledge and experience. Rather than a rigid government mandate, Question 1 would require healthcare facilities to develop, in partnership with their nurses, tools for measuring acuity to help determine appropriate staffing per unit based on the needs and condition of patients. I think many people would be surprised to find out that such things didn’t already exist. At present, nurses have little to no say in what appropriate staffing levels should be or how much time and care our patients need. These decisions are decided by executives and administrators; in other words, by something even more rigid than any government regulation (hint: it’s profits).

Safe patient limits are both a public health and a labor issue. If Question 1 passes, it would result in dramatically improved patient outcomes and working conditions for nurses in Massachusetts. It won’t solve all the problems facing healthcare today but it will improve healthcare access and health equity in a largely problematic system driven by profit margins and corporate greed.

MA Nurses Say “Yes on 1” and You Should Too. Here’s Why.

by Nafis H.

On Wednesday, August 15th, the Boston DSA Healthcare working group organized a panel on an ongoing crisis in the healthcare industry – chronic understaffing and overworking of nurses leading to poorer patient care. The discussion centered around Safe Patient Limits, a proposal that is appearing as Question 1 on the ballot of the Massachusetts primaries on Nov. 6 and would push for a new patient safety act. The proposed law would limit how many patients can be assigned to each registered nurse (RN) in MA hospitals and certain other healthcare facilities; the max number of patients per RN would vary by type of unit and level of care. More details of the proposed law can be found on the Safe Patient Limits website.

The panelists consisted of a few Boston DSA members, including co-chair Beth Huang, and Jared Hicks, a campaign organizer with the Massachusetts Nurses Association (MNA); MNA is leading the charge on the “Yes on 1” campaign that is pushing for the patient safety law reforms through the ballot question. MNA also put the issue on the ballot after collecting the 150,000 signatures needed to do so over the past year. The goal of the panel was to host a discussion on how the safe patient limits ballot initiative related to Marx’s labor theory of value, the opposition to the campaign by the bourgeois class and how helping the campaign can fit in with Boston DSA’s goal of establishing socialism and liberation of all people.

Marx’s Labor Theory of Value

As a Boston DSA member described, the origin of Marx’s labor theory of value can be traced to Adam Smith’s description of how a free market is supposed to work:

“The real price of every thing, what every thing really costs to the man who wants to acquire it, is the toil and trouble of acquiring it. What every thing is really worth to the man who has acquired it, and who wants to dispose of it or exchange it for something else, is the toil and trouble which it can save to himself, and which it can impose upon other people.”

In simpler terms, this basically says that the price (exchange value) of something is derived from the amount of labor (human effort) put into it; the labor includes both the immediate labor of manufacturing, transporting, marketing and selling the thing, and also the indirect labor associated with the equipment required for such activities. This idea is also applicable for non-physical goods, and thus can be extended to services as well, such as caring for patients.

Marx took this idea all the way to the end, assuming a perfectly functioning capitalist free market, and showed that at the core of this idea is exploitation. He asked that if labor creates all the value, then where does profit come from? Profit, in a nutshell, is the surplus value, i.e. the difference between the value of what a worker produces in a given time and what the worker is paid in wages for the same time period. From the capitalist perspective, it wouldn’t make sense to hire someone if no surplus value can be obtained from that action, and therefore, exploitation is inherently built into the capitalist system. Historically, the surplus value that workers have produced, generations after generations, across societies, has all gone into the pockets of a certain class of people, the rulers and the bourgeoisie, who have maintained this vicious cycle through a combination of law, tradition, and force.

Capitalism further exacerbates the exploitation of workers in the modern era by 1) alienating the workers from immediate means of subsistence (we buy everything we need from the market, a concept Marx termed “generalized commodity production”), and 2) fostering competition between companies in the global market that forces them to reinvest that surplus value constantly. The latter also contributes to a cyclical capitalist economic crisis and environmental destruction. The exploitation of the workers can take many forms in the modern era, but the most profitable ones seem to involve speedup of work (shorter deadlines), increased workload, extensions to the workday (longer working hours), and the blurring of the work-life balance (checking work emails at home or over weekends). Therefore, to paraphrase Marx, what determines a working day is essentially the result of the struggle between the capitalist and the working classes. The class struggle is the fight over control of the surplus value created by workers – we can fight back by demanding higher wages, shorter working hours, better working conditions and less intense working pace. And these tenets are all in accordance with the logic behind the Safe Patient Limits ballot initiative.

Safe Patients Limit Ballot Initiative

The next segment of the discussion was led by Jared Hicks, a fellow Boston DSA member and a campaign organizer with MNA. Jared described the chronic understaffing at hospitals across MA, a problem that has been continuing at least for a decade now. The MNA has been leading the charge in fighting for both nurses’ and patients’ rights, not only in Boston (eg. the Tufts strike last year) but also across the state in western Mass. Nurses are the caregivers that spend most time with patients and therefore, are also liable for their patients. The profiteering nature of the hospitals lead the administration to force more workload on the nurses, thus subjecting nurses to cut interaction time with individual patients and reduce the quality of care that they can provide for such patients. This, in turn, leads to poorer patient care quality, increased number of preventable readmissions, and overall higher cost of healthcare. A fellow DSA member present at the event, Gemma, described how a nurse had caught certain irregularities in her father’s health condition which the doctor hadn’t picked up on, and how that helped her father get earlier treatment and prevent future medical expenses for her family.

The Safe Patients Limit initiative proposes a revision of the Patient Safety Act, and has been written by nurses for patients. Under the new law, which will go into effect Jan 1, 2019, if passed, different limits on nurse-to-patient ratio will be set according to the needs of the units. For example, in units with anesthesia, a 1:1 ratio will be mandated for patients under anesthesia and a 1:2 ratio will be mandated for patients recovering from anesthesia. Also, if this initiative passes, MA will be the second state in the US to have implemented a limit on nurse-to-patient ratio; CA passed a similar law in 1999, which went into effect in 2004.

Of course, the healthcare industry’s “ruling class” is not sitting idly by as MNA gears up their campaign. The MA Health & Hospital Association PAC, under the name “Coalition to Protect Patient Safety”, have funneled money into their opposition campaign against MNA’s “Yes on 1” campaign. The top contributors to this PAC are mostly made up of CEOs and top executives of healthcare companies such as Gene Green (President and CEO, South Shore Health System, Inc.), Mark A Keroack (President and CEO, Baystate Health, Inc.), Bruce Auerbach (President and CEO, Sturdy Memorial Hospital) and Joseph White (President and CEO and Trustee, Lowell General Hospital) (info obtained through MA Office of Campaign and Political Finance). While the publicly available donation amount may seem meager, it is an open secret that ballot initiatives cost millions of dollars and there is a lot of dark money in play, as exemplified by the charter school ballot question from 2016. The PAC is also supported by the American Nurses Association (ANA), the Emergency Nurses Association (ENA), and a long list of Chamber of Commerce boards with a few other industry organizations.

The main arguments against the ballot initiative include increased cost of healthcare that might lead to closure of hospitals, a shortage of nurses, federally mandated nurse-to-patient ratios and not enough money to hire nurses. Some of these arguments have been already proved false by the situation in CA. A 2010 study looking at patient outcomes across different medical units showed that since enactment of the staffing law in 2004, unfavorable outcomes in CA hospitals have decreased compared to hospitals in states without such policies. Additionally, nurses in CA hospitals were less likely to receive verbal abuse and complaints from patients families, experience job dissatisfaction and burnout, and in fact, suffered 30% less occupational injuries. The CA hospitals also showed increased retention of the nurse staff, and the staffing increased at a rate higher than compared to other states. Contrary to fears that overall skill level of nurses would fall because of the law, CA hospitals actually saw an overall increase in skill level of nurses.

The argument that hospitals don’t have enough money to employ more nurses is an age-old boogeyman pulled out by hospital administration everytime the workers have demanded higher wages and better working conditions. Given that hospitals have been found to stow away money in offshore accounts in the Cayman Islands, and that hospital CEOs have been making more and more money every year, this is a laughable argument. The most egregious display of such lies is probably the allegations that Tufts Hospital administration ended up paying a similar amount of money to the temporary nurses they hired during the nurses’ strike which they would have paid to the retirement fund of a certain portion of nurses on strike. An attendee at the panel discussion, Sheridan, herself a RN, attested that temporary nurses can get paid up to $3200 per week plus accommodations, which can pay the salaries of two or even three full time nurses.

“Yes on 1” — A Socialist Campaign?

Following Jared’s talk on the ballot initiative, a discussion led by Steve Stone explored the connection between MNA’s “Yes on 1” campaign and larger socialist ideals. Attendees argued that nurses, belonging to the working class, are easily exploited by the profit-driven healthcare industry where nurses’ wages are the low-hanging fruit when it comes to cutting costs. The workers below the RNs in the hospital hierarchy, such as nursing assistants, are similarly affected, while nurse managers and hospital administrations are not affected as much, thus creating an inequality among the waged laborers within the same industry. On the question of where the surplus value goes besides the pockets of the CEOs, Beth described the intricate relationship between the healthcare industry and finance/banking sector where hospitals will often take out mortgages to construct state-of-the-art buildings to attract consumers and end up with huge amounts of debt. This is directly in line with how a free market operates – capitalism forces constant reinvestment of the surplus value into the market to retain a competitive edge.

Often times, the workplace hierarchy in a hospital runs along racial lines. For example, Gemma described that in Philadelphia, nurses were mostly white working class women, whereas the nurse assistants were mostly women of color. Historically, the ruling class has often incited hatred among the different races in the working class, and therefore a socialist campaign to uphold the interest of working class must also take into account such racial, and in cases, gendered issues.

On the question of whether this campaign is a non-reformist reform or a reformist one, Beth articulated that a non-reformist reform is one where one campaign lays the foundation for a future,more progressive campaign. She described while the issue itself is not the most transformative reform for everyone, it certainly is for healthcare workers, which would set us up for a bigger campaign such as Medicare For All (M4A). Additionally, given that MNA is a critical ally of Boston DSA (the local had supported the nurses strike in Tufts in 2017), the presence of DSA members at the picket line, as well as canvassing with MNA, will strengthen the partnership. Other attendees agreed that this would help set up for the M4A campaign that DSA National has been leading across the country and will also better the conditions of one segment of the working class.

Next Steps

The MNA will bring this campaign to the General Meeting on August 25 and will ask for a chapter endorsement. In the meantime, they are holding weekly phonebanking events at Jobs with Justice (375 Center St.) on Wednesdays, 5-8 pm. There are also canvassing events coming up in the next few weeks, so if anyone is interested to help canvass for this campaign as an individual, please contact the Boston DSA Healthcare working group at boston-dsa-healthcare@googlegroups.com.

 

A Case for Safe Staffing Limits

Baystate Franklin nurses mount second strike at Greenfield hospital in 2017

Katie J. & Brad B.

The fight for health justice in the United States is gaining momentum, including rapid take-up of single-payer healthcare as a basic premise of left political platforms and as a rallying point for resistance to the gratuitous inequality of our economic system. Alongside wealth redistribution, health redistribution has become increasingly central to leftist visions for a just world.

However, the fight will not be easy, nor will it be won be overnight. While a majority of Americans support such demands and a Medicare For All Caucus is emerging in Congress, our corporate- and Republican-controlled government has stymied the most egalitarian proposals.

For these reasons, the Healthcare Working Group of the Boston Democratic Socialists of America agreed unanimously in June to endorse the Patient Safety Act, which establishes nurse-to-patient limits across different fields of care. In emergency rooms, for instance, one nurse could be assigned no more than five patients. It will be Question 1 on the Massachusetts ballot in 2018. We understood our endorsement as one component of a broader strategy for achieving health justice, bookended on one side by our mutual aid project to relieve the ravages of medical debt in local communities, and on the other by our continued support for a national single-payer healthcare program.

The Patient Safety Act could be brushed aside as a reformist reform. Its success would not directly call into question the entire system of for-profit medicine in the United States. But to disregard the fight for staffing limitations on these grounds would do a disservice to the workers, particularly organized nurses, struggling to make better care a reality. It would also understate the implications of a possible triumph.

Nurses in the United States face some of the most difficult, often brutal, working conditions in the country. A spate of recent articles have laid out the basic dilemma: salaries have risen marginally, but nurses in the United States are more and more overworked, which has resulted in immense burnout and lower quality of care. Cost-cutting at hospitals and an emphasis on maximizing the extraction of surplus value wherever possible have led to reductions in staffing, which has in turn shifted the psychic burden of care onto fewer and fewer individuals. This occurs alongside the violence and disrespect that nurses experience daily. Public health scholar Jason Silverstein put it bluntly: “We’re working nurses to death.”

This situation must change. America’s nurses have, for many decades, represented one of the most powerful voices of the working class. They have been at the forefront of left politics, particularly the fight for an egalitarian healthcare system. Recently, nurses in Vermont went on strike to demand a model of care that emphasizes patients rather than executive compensation. [https://jacobinmag.com/2018/07/vermont-nurses-strike-safe-staffing-ratios] One of their demands was reasonable patient limitations. The Patient Safety Act would represent an important victory for organized labor against the corporate care industry, particularly at a time when labor more broadly is threatened by right-wing politics and union-busting.

Tellingly, opposition to the Patient Safety Act has been led by wealthy hospitals, executives, and a powerful medical lobby. A campaign of disinformation — both in Massachusetts and in other states where staffing limits have come up for debate — has spread apocalyptic claims about the dangers to patient safety and about exorbitant costs. These groups emphasize fear over phrases like “government mandates” and “top-down control,” claims that have long served as bogeymen against left interventions. In some situations, they have resorted to rhetorical blackmail, threatening that hospitals will leave rather than hire additional staff.

It is not simply that these sorts of arguments have been repeatedly disputed, nor that nurses have made their perspective clear (77% of MA nurses believe they are assigned too many patients, with as many as 36% reporting deaths directly attributable to the problem). It is also the case, as Suzanne Gordon recently argued, that the “cost control” model, with its underlying assumption that profits should determine care, has entrenched our unwieldy and exorbitantly expensive healthcare system. The commodification of health has grown steadily alongside its devaluation. However, a consciously planned system with a more egalitarian distribution of health is possible.

Better care from nurses means better hospital experiences for patients, particularly poor and minority residents who cannot afford expensive hospitals and clinics. Throughout history, it has been a common tactic of the dominant to keep workers just healthy enough to work, but not enough to resist or live comfortably. Nurse staffing limitations would increase personalized care where and when it is needed most, shortening stays, lowering readmissions, and decreasing medical errors. Staffing limitations would ensure rested and supported nurses who respond within minutes, rather than hours, to the blinking of patient call lights. In the most difficult times for many families, this kind of care is critical for healing and well-being.

The campaign by Massachusetts nurses has received support and endorsements from groups across the country (only California currently has a staffing law). One important reason is that victories in the Commonwealth have historically spilled over to successes elsewhere. Success for organized nurses here could galvanize the national movement for safe patient limits.

At the same time, it is important to recognize that health provision in Massachusetts will remain unequal. We live in the shadows of Romneycare, the ultimately conservative reforms that led to the Affordable Care Act. The dream of just healthcare in Massachusetts remains unrealized, medical debt continues to afflict residents, and hospitals place the needs of managers over nurses and patients. That dream will require energy and determination beyond present the battles.

Victory against the forces of corporate care would bolster efforts by working class organizations to transform the structure of American healthcare. It would allow nursing unions, occasionally bogged down in staffing battles, to direct their energy fully toward other struggles. Success in support of the Patient Safety Act would send a strong signal that justice and dignity should determine our health, not the needs of for-profit hospitals and the health insurance industry. And it would strengthen the coalition of left political organizations and unions that is fighting for the most significant transformation of them all: free health care, for all, no matter what.

 

Bios: Katie is a registered nurse and member of Boston DSA. Brad is co-chair of Boston DSA’s Healthcare Working Group and a PhD candidate in History of Science at Harvard.

The Healthcare Working Group usually meets on the third Monday of the month at 7pm, and any changes will be indicated on our Facebook page