This article appears in the August 2023 issue of The American Prospect magazine. Subscribe here.
The bourgeoisie has stripped of its halo every occupation hitherto honored and looked up to with reverent awe. It has converted the physician, the lawyer, the priest, the poet, the man of science, into its paid wage laborers.
—Karl Marx and Friedrich Engels, The Communist Manifesto, 1848
While Marx and Engels’s prophecies about the proletarian revolution haven’t exactly panned out, their analyses of how capitalism would change the world still look pretty good. In some cases, they look newly good. It may have taken nearly 175 years for a clear majority of American physicians to become the “paid wage laborers” that Marx and Engels saw as their future, but as an article published last year in The Journal of the American Medical Association documented, that has now come to pass. Indeed, it’s really only in the last decade—with an almost mind-boggling speed—that the medical profession has lost its autonomy to corporate control.
As the JAMA article noted, “in 2012, 60 percent of practices in the U.S. were physician-owned.” At that point, only 5.6 percent were direct hospital employees. By 2022, physicians who are direct hospital employees climbed nearly tenfold, to 52.1 percent, with another 21.8 percent employed by other corporate entities. “Many physicians now are employed by consolidated corporate health care systems that span many different communities and increasingly are spread across multiple states,” the JAMA article points out.
Health care in the United States has long been notorious, of course, for rationing access to medical care by the calculus of ability to pay. Once that ability had been established, however, there was a presumption that a patient could get to see a doctor in a reasonable time period, and that the doctor or the clinic or the hospital would have the time and resources to adequately examine and treat the patient. Today, that’s become an iffy proposition. The consolidation of medical care into top-down institutions, many of them for-profit companies and even private equity firms, has altered, often radically, what physicians can do.
Private equity has managed to purchase large swaths of medical care. In more than a quarter of U.S. metropolitan statistical areas (MSAs), 30 percent or more of the physicians are owned by a single private equity firm, according to a report from the American Antitrust Institute. In 13 percent of those markets, that number is more than 50 percent. Private equity acquisitions of physician practices hit 75 deals in 2012; by 2021, they rose to 484.
One Kaiser Family Foundation article last December estimated that private equity firms controlled between 25 percent and 40 percent of the staffing in the nation’s emergency rooms, where lifesaving had traditionally eclipsed profitability as the standard to be met. Four of the top six emergency medicine employers are private equity firms; one of the others, US Acute Care Solutions, was private equity–owned until physicians bought it out two years ago—with a $711 million loan from a private equity firm.
Interns and residents today are members of what polling reveals to be the most pro-union generation in nearly 60 years.
Added to that are the consolidations of hospital networks, where mega-mergers continue to be announced. As of 2016, 90 percent of all MSAs had what would be termed “highly concentrated” hospital markets. In Pittsburgh, 71 percent of all licensed hospital beds can be attributed to one company, the University of Pittsburgh Medical Center (UPMC).
Hospital consolidation and private equity influence have led to higher prices, reduced access, and worsening health outcomes, economic and government studies show. But in addition, the new criteria that the new owners have imposed on the practice of medicine have affected the basics of physicians’ work.
“We’re called upon to deal with traumatic events on a daily basis, but we’re told we can’t care for patients as much as we want to,” says Katie Esse, a neurologist who works for the Allina chain of hospitals in Minnesota. Allina, ostensibly a nonprofit health system, was recently cited in The New York Times for denying treatment to patients with unpaid medical bills, including children and the chronically ill. The chain suspended this policy for the pandemic before restarting it in April 2021.
Allina has 12 hospitals and 15 urgent care facilities in the state, and Esse’s duties include dealing with patients at all 27, through telemedicine. “Often, while I’m on a video with one patient, I’m getting paged constantly to get on calls with other patients. Patients can’t get in to see their primary care physicians, who are booked up, and are told instead to go to clinics or the ER, or, more recently, to send messages to their doctors. I have primary care colleagues who get up to 100 in-box messages a day. You can never get caught up.”
The sheer volume of work that residents and many attending physicians now confront, and the ticking-clock (and ticking cash register) pressures that their employers impose on them, have consequences that go well beyond exhaustion and burnout, though those consequences are surely apparent. The loss of control, the inability to change their conditions of work and, with that, some of the scope and efficacy of treatment, has prodded an increasing number of doctors to do something new under the American medical sun: join a union.
TO BE SURE, ONLY A SMALL SLICE OF PHYSICIANS are currently unionized: 5.9 percent. Even at that level, they’re not far from the overall rate of unionization among the nation’s private-sector workforce, which is just 6.1 percent. But by all previous standards, doctors are now positively flocking to unions.
The Committee of Interns and Residents, for instance, has seen its membership grow by 58 percent in just the past two years, its ranks swelling from 19,000 doctors to 30,000. During this time, CIR, which is an affiliate of the Service Employees International Union, won union recognition elections—by substantial margins—at such storied hospitals as Massachusetts General Brigham, Montefiore, George Washington, Stanford, and USC Keck. To handle the hundreds of requests from doctors during this time, CIR staff has grown from 60 employees to 100.
This wave of unionization began in the wake of the COVID pandemic, which not only posed obvious dangers to health care workers, but also led to roughly one-quarter of those workers opting to leave the industry. Those who stayed on the job, as the overwhelming majority of doctors did, had to take up that slack by working longer hours.
The confluence of the pandemic’s more grueling working conditions and the growing control of those working conditions by investors, corporations, and insurance companies that viewed patients as consumers, provided the spur to unionization. One poll of physicians conducted in November of last year found that 51 percent of clinicians were willing to join a union, but believed they wouldn’t be able to do so—a belief that reveals, among other things, the still very limited efforts of unions to make contact with physicians. The conventional wisdom among doctors, says Esse, used to be that they “thought it was illegal for us to unionize. Every time I brought the issue up, colleagues told me that we were essential, that there was something unethical in our joining a union.”
Clearly, that’s not what younger doctors believe today, as the poll revealed that the desire to unionize was strongest among the young. While three-fourths of doctors in their thirties said they were willing to join a union, the share of older doctors who shared that sentiment declined with successive decennial age groups.
The increased willingness of the young to form unions reflects both the long-standing structure of the medical profession, and the more recent hurdles that young doctors must surmount. Much like universities’ non-medical graduate students, who’ve been unionizing at a torrid rate over the past two years, interns and residents have long been viewed and treated by hospitals more as exploitable students than valued workers. The industry standard calls for them to work up to 80 hours a week, and with the dislocations and resignations that accompanied and now have followed the pandemic, they’ve been frequently required to work longer, often reducing their hourly wages to under $20. Hannah Abrams, who completed her residency at Mass General in June, notes that intern and residents’ pay scales aren’t really adequate to meet the cost of living in cities like Boston.
RINGO CHIU/AP PHOTO
The Committee of Interns and Residents, seen here protesting in Los Angeles, has seen its membership grow 58 percent in the past two years.
At the same time, today’s interns and residents “start their careers with more debt than any professionals in history,” says CIR’s Sunyata Altenor. Several decades ago, that debt averaged roughly $50,000; today, it has soared to $250,000 or even $300,000.
The changing demographics of doctors has been another factor in the push toward representation and unionization. Once a profession that was overwhelmingly white and male, the field now contains a substantial percentage of immigrants, and 51 percent of medical students today are women. Medical residencies almost always encompass the years between doctors’ mid-twenties and early thirties, when families often form and children are born. Even a topline residents program like that at Mass General, Abrams notes, doesn’t provide child care benefits—a program that Mass General doctors will negotiate for when contract talks with management commence.
Finally, interns and residents today are members of what polling reveals to be the most pro-union generation in nearly 60 years, with union approval ratings that in some polls exceed 75 percent. The agonizingly slow recovery from the 2008 financial crash and ensuing Great Recession was particularly arduous for millennials, many of whom responded by backing the presidential campaigns of democratic socialist Sen. Bernie Sanders (I-VT). Confronted with the traditionally exploitative demands of medical residencies, the added burdens of working through a pandemic, reduced levels of staffing, and the transformation of their profession into that of employees—in many cases, of profit-seeking companies—it shouldn’t be that surprising that so many young doctors are turning to unions.
LIKE THEIR CONTEMPORARIES WHO WORK as teaching and research assistants at universities, the residents who’ve been seeking to unionize over the past two years almost invariably succeed. The reason for their high win rate is simple: Unlike assembly-line workers or retail salespersons or restaurant waitstaffs, they can’t be easily replaced. The main weapon that American businesses customarily deploy to keep their workers from unionizing is to threaten and even carry out the firing of pro-union workers during their campaigns (which is illegal, but for which the penalties are negligible). That threat simply doesn’t work when the workers can’t be readily replaced; there is no reserve army of unemployed residents lurking about. This dynamic is why teaching assistants and docents and think-tankers and now doctors are winning union recognition elections, while blue-collar and service-sector workers hardly ever even come close.
That said, most hospitals and medical groups still wage campaigns opposing their doctors’ efforts to unionize. Not to do so, apparently, could invite investor dismay or scorn from peer institutions or violate some unwritten code of American business. Allina, the nonprofit hospital chain in Minnesota, brought in the nation’s premier union-busting law firm, Littler Mendelson, to deter its doctors’ efforts. Physicians were barraged with text messages and emails that urged them to vote no on unionization. Management held multiple meetings telling workers that going union would only make things worse. Doctors were “strongly encouraged to come to these meetings,” Esse says. In workplaces where employees are more readily replaced, however, the workers wouldn’t be merely “encouraged”; they’d be required to attend.
The unionization of physicians is about trying to create a more humane and patient-centered health care system.
At Mass General, Abrams says, doctors experienced the same kind of anti-union messaging from the hospital, and workers were also invited to meetings where program directors said that bringing in a union might diminish departments’ flexibility to provide certain kinds of benefits. “The invitations to the meetings meant your attendance was expected,” she says.
But penalizing doctors for nonattendance goes beyond what hospitals can do to professionals who know they can’t really be sacked without disrupting the hospital’s business. That’s especially true when the profit margins of the hospital depend on doctors being perpetually productive, to maximize the moving of patients through the system.
Where Littler Mendelson and its union-busting counterparts can have their greatest effect in that kind of workplace probably comes in the post-election period, where votes can be challenged if the election was close, and in delaying the bargaining that is supposed to lead to a contract.
TO DATE, THE SURGE IN DOCTOR UNIONIZATIONS is largely confined to interns and residents, many of whom work at university hospitals affiliated with the same universities that have seen their teaching and research assistants go union as well. As I’ve noted, a common generational and sectoral sensibility is at play here, as is the fact that interns and residents spend more of their time sharing the same workplace and working conditions than older attending physicians do.
Nationally, there are two unions that focus almost entirely on representing attending physicians, but their combined membership barely exceeds 10,000. One of those unions is the Doctors Council, an affiliate of the Service Employees International Union (SEIU), which recently won recognition at two of Allina’s 12 Minnesota hospitals. The Doctors Council began in 1959 as a city employee union for doctors employed by the Departments of Health and Welfare in New York City; at the time, doctors who worked by the session were paid $5.00 an hour, and those who worked full-time, about $7,000 per year (about $73,000 today, well below what doctors command).
Unlike the hospitals that CIR has been able to organize, the Allina hospitals organized by the Doctors Council are preponderantly not teaching hospitals but community hospitals. There, much of the work that residents perform at the Mass Generals is performed by older attending physicians.
It should come as no surprise, then, that the organizing campaigns at those two Allina hospitals were initiated by the facilities’ hospitalists, the admitting physicians and care managers who do much of the work that is done by residents in teaching hospitals. Allina hospitalists, says Esse, may have 20 to 25 patients a day whose care they need to coordinate, whose families they need to talk with, and whose conditions they must record in writing at the end of the day. The hospitalists are under constant pressure to move recovering patients to other facilities, though other facilities may not have available beds. Like many other attending physicians who work in community hospitals, their hours may approach those of residents in teaching hospitals.
EVAN FROST/AP PHOTO
Allina Health System has 27 hospitals in Minnesota; the Doctors Council won union elections at two of them.
Esse makes clear that the work environment at Allina is far from toxic, and that the financial strain the chain is under is real. But that strain has placed a heavy burden on hospital employees. In the past few years, management has reduced matching contributions to the doctors’ retirement benefits, and stopped funding for their continuing medical education, though the CME funding has since resumed. It was, Esse says, “a perfect storm” of problems—not just the elimination of what had been routine benefits and the overall lack of resources but also the fact that these decisions came from above with no input by or discussion with the medical professionals who did Allina’s work.
Even as the campaign to unionize those two Allina hospitals was proceeding, the company tried to ensure that the organizing didn’t spread to the other ten hospitals in the state. The union’s efforts to sway doctors at those other hospitals frequently encountered fearful responses, despite the limits of what the company could do to its professional workforce. “The only thing they didn’t do is threaten to fire doctors,” says Doctors Council Organizing Director Joe Crane, a former graveyard shift assembly-line worker at a Frito-Lay plant who became a professional labor organizer. “But the fear is still there.”
It may be that older physicians in mid-career have more at stake than younger doctors; it may be that they come from a less diverse and progressive generation of physicians than today’s interns and residents. For the time being, it seems clear that the doctors seeking to unionize, and succeeding at it, will be interns and residents.
GIVEN THE CONSTRAINTS THAT AFFLICT many medical institutions today, what is it that doctors hope their unions can realistically achieve?
The first is representation—by which doctors mean not just more demographic balance among decision-makers, but the presence of their voices in their institution’s deliberations. “Not enough of the people who see patients are involved in the decision-making process,” says one physician, who asked for anonymity because of a current union campaign. “We need people who see the problems firsthand. If the rate of doctor and nurse retention is to rise, as it needs to, if patient care is to get better, that’s what we need. A union could make doctors part of the process.”
Usually, says Abrams, it will be doctors and nurses who sound the alarm on issues of safety, as was frequently the case during the pandemic, when masks and other safety equipment wasn’t sufficiently available. That’s one reason, she says, why Mass General interns and residents voted so heavily for a union, which would open a regular channel for such concerns to promptly reach management. During the pandemic, she and her colleagues realized that “we needed an organized body to better protect us if this were to happen again.”
Ultimately, however, the unionization of physicians is less about the kind of wage and working condition issues that are the basics of labor relations than it is about trying to create a more humane and patient-centered health care system. “When you talk about doctors unionizing,” says Crane, “what’s driving it is the moral injury to physicians’ raison d’ȇtre, the sheer fact that they can no longer advocate for either patients or themselves.”
For example, Esse and other doctors have lamented the shorter time slots they have to actually meet with patients. “If we can help make physicians realize the leverage they can have with a union,” Crane says, “maybe they can win, who knows, a couple more minutes with a patient. Many doctors today have to sit on what are effectively death panels. These are the things that are driving them to unionize.”
Most doctors are cognizant of how many of the basics of American health are deteriorating, with whole segments of the population experiencing shorter life expectancies, rising rates of maternal mortality, and deaths of despair. Winning back a share of the control over what they can do for patients is clearly not a sufficient remedy to what ails American medicine. But it’s a necessary one, and one for which a growing number of doctors are prepared to fight.
