Critically Ill-equipped

Philip was on the phone. He had fallen down the stairs, a cup of coffee in his hand at the top, the cup broken and empty at the bottom. His limbs had tumbled and banged on their flight downward, the top of his right foot gouged so deeply that skin and flesh were simply missing, disappeared. He waited three days to dial my number because it was the weekend, because he was stubborn, because I’m a friend in a city three hours away and he didn’t want to be a burden.

But the primary reason Philip waited was that he didn’t want to go to the hospital emergency room in the middle of a pandemic. The ER, even from the bottom of the stairs, looked more dangerous than his pulverized right foot. “I knew that if I could stay out of the hospital, I should,” Philip told me, “everyone with Covid was in there.” Philip, like the rest of us, had read stories about overcrowding, about combative patients, nurses stretched to their breaking point, and about the chance of catching Covid, or something else, in the hospital.

He finally called when the oozing wound on the top of his foot failed to heal. Hospital stranger danger gave way to his welling fears of amputation, blood poisoning, or untimely death. I made the drive to Philip, who lives in my hometown in Pennsylvania, while he had gotten himself to Lancaster General Hospital. All the way I imagined the scene inside the ER, but I still wasn’t prepared for it.

I found Philip sitting upright in a wheelchair, his brown overnight bag on the floor next to him, while a sea of bodies slumped and shifted throughout the packed room. His hair and clothes were neat, but he looked exhausted, stiff, as if he were holding his breath. The air was too warm, too thick with the smell of sick people—more than 125 in the L-shaped room, by our count. Philip was unable to keep his swollen foot propped up, to get comfortable. When the flashing red lights on the buzzer in Philip’s lap finally went off, like a pager at Olive Garden when your table is ready, he had been waiting nearly eight hours.

Since Covid-19 first struck the United States more than two years ago, arguably the most vulnerable link in our health care infrastructure has been hospitals, ill-equipped (in innumerable ways) for the influx of Covid patients. The waves of infection have depleted hospital staff, filling up ER waiting rooms like the one Philip sat in at Lancaster General. Yet some have asserted the problem is entirely one of vaccine hesitancy. Public discourse even veered off-kilter to advance the argument that hospitals should stop treating the unvaccinated. That way, routine surgeries could take place and emergency injuries like Philip’s could be treated. Supposedly, those who are vaccinated but experiencing breakthrough Covid would be entitled to treatment.

Playing lifeboat with the glut of sick people slumped in ER waiting rooms is an unfortunate recent pastime among journalists, policy makers, wonks, medical professionals, and academics. But scapegoating sick people misses the problem our hospital system—indeed, our entire health care system—faces. The pandemic is not the cause of hospital collapse, but it has confirmed how unprepared this nation is for national health emergencies. 

“Your chances of dying go up by 7 percent for every additional patient your nurse has to care for,” a recent New York Times opinion-section video stated, noting a Lancet study from 2014. The video, “We Know the Real Cause of the Crisis in Our Hospitals. It’s Greed,” begins with a series of nurse close-ups. At first, the nurses describe the abuse they’ve received from anti-vaxxers and other patients, but they quickly move on to diagnose the problem at hand: hospitals that refuse to provide the staffing necessary to make nurses’ lives easier and to prevent unnecessary patient deaths. “Focusing on pandemic burnout lets hospitals off the hook,” the documentary states. Indeed, hospital understaffing has been a problem for decades.

Yet, according to University of Chicago history professor Gabriel Winant, greed is only part of the reason why labor costs are always the first to be cut in health care. In The Next Shift: The Fall of Industry and the Rise of Health Care in Rust Belt America, Winant traces the development of our contemporary model of health care in regions where industry was once the dominant labor market. His research focuses on Pittsburgh, a steel town where strong unions were able to negotiate social benefits, including health care, through repeated strikes and collective bargaining, beginning in the 1930s. After the Second World War, as steel slowly declined—due to postwar competition and other factors like automation, decentralization, and innovation—hospitals in the region began to expand, meeting the increasing health demands that former steel workers experienced. This privately insured group exhibited a predictable set of health challenges that hospitals could reliably cater to. The first year that U.S. imports exceeded exports was 1959, Winant noted in an interview on the podcast The Dig with Daniel Denvir. For industry, the heyday was nearly over. Health care was ascending, specializing, expanding.

The Wagner Act of 1935 established the right of most employees to form unions (though domestic and agriculture workers were left out). In 1947, the Taft-Hartley Act cut Wagner’s reach, removing workers at private nonprofit hospitals from federal protection and leaving regulation of collective bargaining up to each state. “It was a legal decision,” Winant said, “that claimed these people are not employees.” The decline of domestic service in the era of big industry coincided with the rise of health care work, thus associating care work with the domestic, maternal, and religious. (Many hospitals were religiously affiliated—and still are today.) From the beginning, care work was not valued as work.

It took another twenty-seven years for health care employees to regain labor rights, with the passage of the 1974 Health Care Amendments to the National Labor Relations Act. “It was recognized that labor relations in the healthcare industry required special considerations,” the NLRB website reads. No one wanted strikes to interfere with the provision of health care services to the public—but the dampening of collective bargaining meant workers were on their own in a high-intensity-labor, low-pay industry.

Throughout these policy changes, women and people of color who were often not eligible for private insurance were mobilized by the growing health care industry to serve those insured patients within it, Winant explains. The costs of care were rising rapidly, and by the late 1950s, political pressure had increased for some solution. The creation of Medicare and Medicaid in the 1960s didn’t “displace in any way the core public-private bargain that’s driving the growth of the health care system,” Winant told Denvir. Rather than directly providing care, the U.S. government becomes the “buyer of services on behalf of people who can’t get it for themselves through their jobs.”

Winant sees little way toward improving health care workers’ jobs without a major reorganization of the entire sector. “The actual structure forbids an adequately staffed, economically secure health care work force,” he told me on the phone in January, “There are marginal improvements” that could be made, efforts that organizers and legislators could undertake, but “I don’t think you could just adjust on the margins and solve the problem,” he said.

Today, health care is the largest sector of jobs in the country, making up 14 percent of the total labor force. The expansion of the industry capitalizes on municipal bond markets, which, according to Winant, hook up patient demand with the capital market. He calls it the “virtuous circle.” Yet the industry is locked in an inflationary dynamic with few checks. The public sector could do it differently, Winant told me, because it can absorb and redistribute. But the current “semi-privatized welfare state” means the industry will always be under pressure to underpay and under-protect its work force. The pandemic has made visible just how we all are dependent on a system that runs on poverty-level wages and brutal work conditions. Our health care is subsidized by the low wages of the predominantly female workforce that does care work.

Since the pandemic began, health care workers have left their jobs in droves, about one in five, or 18 percent, according to data from last November. Others found better-paying work, the story of altruism and higher purpose they told themselves to get through bad conditions not measuring up to the challenges of Covid. Still others have become “traveling nurses,” temporarily moving to regions experiencing waves of Covid, risking infection and displacement for higher pay. Hospitals and legislators have acted accordingly, often punitively. Texas has outright banned any nurse working at a Texas hospital or EMS from applying for emergency response contract positions with FEMA in the state.

On January 24, Vermont Democrat Peter Welch and H. Morgan Griffith, a Virginia Republican, wrote a letter to the White House Covid-19 Response Team coordinator, Jeffrey Zients, effectively asking that a cap be placed on nurse’s wages. “We are writing because of our concerns that certain nurse-staffing agencies are taking advantage of these difficult circumstances to increase their profits at the expense of patients and the hospitals that treat them,” the letter reads. Welch and Griffith’s effort recalls the days when the National Labor Relations Board put service to the community above the lives of care workers.

Medical professionals weren’t having it. “Capping nurses’ pay? During a pandemic that shows no signs of stopping? When we don’t have nursing ratio caps in 49/50 states???” wrote Sheryl Recinos, MD, an author and hospitalist in California, on Twitter. “Cap admin/C suite salaries. Cap salaries of the insurance companies. Don’t come for nurses. This won’t turn out the way you expect.”

What are the ultimate costs of working in the health care industry for women? Prior to Covid-19, the risk of suicide among female nurses was twice that of the general female population. Data for suicide rates among women in health care during the pandemic is not yet available.

After Philip’s buzzer went off, we followed a nurse into the ER where he was placed on a rolling hospital bed and neatly tucked into the corner of the ward, like a Tetris block wedged into place. We were told by staff that he would get a room as soon as one opened. Eight hours later, after multiple examinations and three courses of intravenous antibiotics, Philip was still in the corner, sandwiched between two glass rooms where critical Covid patients were being treated. “Staff were stressed, and abrupt,” he told me. One nurse said that if he thought he could go home he should, that he would be safer there.

When he was released in the morning, we picked up his prescription at the local CVS and then got heaps of Chinese take-out. We were lucky, we knew; his foot was going to be fine. But that news came with another concern: watching for symptoms of Covid-19.

Meanwhile, the hope for better conditions for hospital workers is on the margins: on January 25, Pennsylvania nurses traveled to the state Capitol in Harrisburg to support HB106, the Patient Safety Act, which would establish patient-to-staff requirements in hospitals. With proper staffing, nurses unions and associations say, many of the Covid deaths in the state could have been prevented. According to Pennlive.com, a local news outlet, the Hospital and Health System Association of Pennsylvania opposes the bill.

Illinois has a similar bill under discussion; Massachusetts voters failed to pass theirs in 2018 (according to the New York Times, because of a $25 million campaign by the hospital industry). In May last year, Ohio Democrat Sherrod Brown introduced a bill that would set federal standards for hospital staffing. California (2004) and New York (2021) are the only two states that currently have laws regulating patient-staff ratios, but California waived their law temporarily during the pandemic.

There are a few short-term relief measures, too. On January 26, Pennsylvania’s governor, Tom Wolf, signed legislation that provides state hospitals with a total of $225 million, funds from the American Rescue Plan, for retention and recruitment of staff. Lancaster General Hospital will receive $3,794,542 (with nine hospitals and health care centers in Lancaster County receiving a total of $6,670,734).

While these measures may alleviate some of the intolerable pressure on staff at Lancaster General and elsewhere, none of us are safe until the model of health care delivery in the United States pays care workers what we owe them. Even as hospital caseloads receded in February, it was clear that the pandemic has taken its toll. Without a nationwide reform effort, the health care system will be hobbling along with a depleted workforce when the next national emergency arrives.