Health Care Professionals and Technicians

In 1999, health care services comprised the largest industry in the United States, employing 11.3 million individuals in more than 460,000 establishments. It is also one of the fastest growing: between 1988 and 1998 employment in health care grew at an annual rate of 3.3%, compared with less than 1.8% in all other sectors of the economy. This growth is expected to continue. Indeed, the Bureau of Labor Statistics estimates that about 14% of all new wage and salary jobs created between 1998 and 2008 will be in health care (Career Guide to Industries, 2000-01 Edition).

Employment

The health care industry employs a large number of professional and technical workers. In 1998, more than 54% (614,200) of all industry employees were working in professional and technical occupations.

These professionals and technicians work in several sectors of the industry, with a large number employed in public and private hospitals. The BLS estimates that although hospitals comprise a small percentage of total health care establishments, they employed almost half of all health care workers in 1998.

Earnings and Working Conditions

The health care industry is characterized by large wage disparities. Working conditions also vary greatly among job categories. While some health care professionals enjoy a high level of autonomy and respect, others suffer from understaffing, a high rate of occupational injury and significant occupational stress. In 1997, for example, the incidence rate for occupational injury and illness in hospitals was 10 cases per 100 full-time workers compared to an average of 7.1 cases in the private sector as a whole. The rate in nursing homes and personal care facilities was much higher: 16.2 cases per 100 full-time workers (Career Guide to Industries, 2000-01 Edition). Most at risk were health care workers directly responsible for patient care, who must often lift patients and heavy equipment, are exposed to radiation and caustic chemicals, and face possible infection from numerous diseases, including AIDS, tuberculosis and hepatitis (Ibid.).

A common concern for all health care workers, however, is the transition to managed health care systems and the resulting changes at the workplace that affect the quality of care. Prior to the early 1980s, health care was delivered largely on a "fee-for-service" basis, allowing health care professionals to make case-by-case medical decisions on behalf of patients they had treated for many years. The fee-for-service system was criticized, however, for not encouraging preventive health care and for allowing abuses in the form of unnecessary tests and hospital stays. In some well-publicized cases, doctors were found to have "routinely ordered unnecessary tests and overnight hospital stays in order to receive higher reimbursements" (Oberfield and Tolbert, 1989).

Concerns with excessive billing and overcharges led to a call for prepaid health insurance, where subscribers would pay a flat fee in return for a full range of health care services. Organized labor was among the first institutions to promote the concept of "managed care." In the 1940s, some unions experimented with having their members use doctors and other health practitioners hired by their unions for a fixed monthly fee. Originally the focus was on promoting preventive medicine. By the 1970s, however, the mission of managed care underwent a transformation as government and employers sought new ways to reduce health care costs, and new firms began competing to provide health care for a profit. Today the system is widely criticized as placing patient health and the appropriate delivery of quality medical services second to profits amassed from the unspent portion of capitation payments.

The managed care system has had widespread and serious effects on those it employs as well as those who rely on it for care.

The Nursing Occupations

The number of registered nurses in the United States has grown significantly in the past twenty years, with the number doubling between 1977 and 1999. In 1998, a majority (59.6%) were employed in hospitals. Although much smaller percentages were employed in offices of physicians (8.3%), nursing and personal care facilities (7.2%), and home health services (6.2%), the Bureau of Labor Statistics anticipates rapid growth in these areas through the year 2008. The number of nurses in home health care services, for example, is expected to explode by an astounding 82.2%. Some of this change can be attributed to managed care policies that encourage less hospital care and more outpatient treatment. Note that employment among registered nurses in hospitals is projected to expand by only 7.9%.

Overall, the number of RNs is expected to grow by more than 450,864 by 2008, a 21.7% increase over the number employed in 1998. As for salaries, in 1998 the mean annual wage for registered nurses was $43,070, and the median annual wage was $40,684. However, there are significant regional and occupational differences. While the mean weekly wage for a registered nurse in the U.S. was $782 in 1998-99, RNs in the New York area earned $1,065 a week, compared to $706 in Oklahoma City. The difference between RN and LPN earnings is greatest in the New York metropolitan area, where LPNs made 41% less than RNs; the difference is least in Boston, where LPNs made 25% less than RNs.

The disparity in wages for RNs can be attributed at least partially to two factors: the rate of unionization and a shortage of nurses in certain regions and specialties. Although the shortage has increased job stress and workplace demands, it also increased nurses’ leverage at the bargaining table and, as the 20th century ended, brought about unparalleled wage and benefit gains. While the union "premium" stood at 10.2% in 1986, by 1996 it had increased to 16.5% (Malone and Marullo, 1997). With the advent of managed care, nurses and their unions have become increasingly concerned about maintaining their hard-won gains of the 1990s. Many find the content of their jobs changing to keep pace with new technology and with the "bureaucratization of medicine." A 1997 survey by RN magazine, for example, found that while 80% of respondents reported doing paperwork and charting and 59% reported supervising other personnel, only 38% said their primary responsibility was to comfort and talk to patients. The same survey also found that RNs increasingly are given responsibilities once carried by physicians:

While many nurses — 7 of 10 in the survey conducted by RN magazine — are satisfied with their jobs, it is clear that many also are concerned about changes in the health care industry and their effect on the quality of patient care and on their own working lives. Their most frequent complaints are about workloads, uncaring administrators, and poor salaries and benefits (Lenkman, 1988).

Nurses are reporting serious concerns about the quality of patient care in many health care facilities. In the RN survey, for example, 75% of respondents reported that the severity of illness and the number of patients per RN had increased during their tenure on the job, leading to fears that many patients are not receiving the best care. Additionally, many nurses reported that the shift to managed care and health maintenance organizations (HMOs) has created a situation in which patients are hospitalized for shorter periods of time and released too early, all in the interest of cutting costs.

Mounting concerns for the quality of patient care have led organized nurses to the legislative arena, as well as the bargaining table. They are in the forefront of efforts to promote passage of the so-called Patients’ Bill of Rights and patient protection laws at both the national and local level.

Physicians, Interns and Residents

Of course, nurses have not been the only group of health care professionals affected by managed care. Physicians, once the model of the "free professions", are increasingly being forced to accept the status of an employed professional. Some estimates have placed the number of physicians who are salaried employees at 42% (approximately 240,000) (Adelson, 1997; Slaughter, 1997).

A growing number of doctors, deploring the changes wrought by managed care, have started speaking out against restrictions placed on their professional autonomy and cost-cutting measures implemented by managed care and insurance companies, and they are forming or joining unions in increasing numbers. In 1999, the American Medical Association reversed its historic position and endorsed unions for doctors at the same time as it undertook to form a union under its own aegis.

It is estimated that about 50,000 physicians belong to unions. Many can be found in the Union of American Physicians and Dentists (which affiliated with the American Federation of State, County and Municipal Employees (AFSCME in 1997); it represents approximately 6,000 physicians. Another AFSCME affiliate, the Federation of Physicians and Dentists, also claims approximately 6,000 doctors among its members. In addition, smaller groups of physicians belong to other AFSCME affiliates. Both the Committee of Interns and Residents and the Doctors’ Council of New York are affiliated with the Service Employees International Union (SEIU), which counts about 15,000 doctors among its membership. The Office and Professional Employees International Union (OPEIU), which represents 7,500 podiatrists (50% of all podiatrists) also represents several thousand MDs. The American Federation of Teachers (AFT) has 13,000 physician members. These and other unions of salaried physicians probably represent about 35% of salaried physicians and 8% of all physicians (including those who are self-employed and therefore not eligible to join a union).

The number of unionized doctors would undoubtedly be much higher in the U.S. were it not for labor laws and court decisions that have frustrated unionization in this, as in other professions. Although most physicians are still self-employed practitioners, managed care is rapidly undermining their autonomy and changing their status. Though their new status, in most instances, resembles that of an employee, the courts and the National Labor Relations Board (NLRB) have been slow to acknowledge the change.

However, on another legal front, interns and residents have, after many years and many unsuccessful efforts, achieved recognition by the NLRB that they are employees entitled to the protection of the National Labor Relations Act (NLRA) as they organize and seek to bargain. In a reversal of its position, in 1999 the Board determined that the interns, residents and fellows at Boston Medical Center were not only students, as previously held, but employees as well, and therefore entitled to union representation. This decision ensures that a new generation of physicians will "begin their careers in the union camp . . . primed to join other physician unions once they enter private practice" (Lowes, 1998).

Health Care Technicians, Technologists and Other Health Care Professionals

Health technicians and technologists numbered more than 2.4 million in 1998. They operate technical equipment, assist health practitioners in administering patient care, help make medical diagnoses, and maintain patient records. Growth among these occupations is expected to be robust.

Approximately 616,000 new jobs will be created in health technician occupations by 2008, with particularly rapid expansion expected among medical record technicians and dental hygienists — occupations with some of the lowest wages in the industry. In part, this rapid job growth can be attributed to changes in the industry which shift work from higher to lower paying jobs.

Several other fields are also expected to grow significantly in the coming years. Physical therapy is projected to grow at a rate of 34%, with 41,000 new jobs created through 2008. Occupational therapists also will increase in numbers and percentage, as will respiratory therapists and recreational therapists. The mean annual wage for these jobs ranges from a low of $29,080 for recreational therapists, to a high of $57,190 for physical therapists.

Union Density

Despite dramatic increases in union membership among doctors, nurses and others in recent years, the overall rate of unionization in the health care industry is quite low. In 1998, unionization of all hospital employees was 12.9%, while union density in other sectors of health care was substantially lower, e.g., 3.1% in offices and clinics of physicians, 2.8% in offices and clinics of dentists, 1.2% in offices and clinics of optometrists, 9.6% in nursing care facilities and 8.1% in health services that are not classified elsewhere (Union Membership and Earnings Data Book, 1999).

In the last decade, union organizing activity, as defined by NLRB elections, was greatest in nursing care services and hospitals. In both cases, there was a healthy ratio of union wins to losses, especially among small units. Large unit elections are much less common and have resulted in a lower rate of union success. There were far fewer elections in health care offices and clinics (typically fewer than ten per year), medical and dental laboratories (less than four per year), home health care, and miscellaneous and allied services, although the ratio of wins to losses in these sectors is respectable.

As the new century begins, several major unions are presenting themselves as representatives of health care employees. And with good reason: the health care industries are large and growing rapidly. Vigorous efforts are being made by nurses and doctors, in particular, to form and join unions that can protect their professional integrity, and enhance their careers in the face of radical changes in the way that health care is managed. Without doubt, their actions will stimulate others to seek union organization in this massive industry.

Strong growth is projected for all sectors of the industry. Obviously, the labor movement must step up its organizing efforts to match the predicted expansion if it is to maintain and increase the degree of union membership in this major industry. Doing so not only will improve working conditions among health care professionals, but also will enable them to protect their professional autonomy and offer the quality health care all Americans deserve.

Sources Cited

Adelson, Andrea. "Physician, Unionize Thyself: Doctors Adapt to Life as HMO Employees," New York Times, April 5, 1997, Section 1, p. 35.

American Federation of Teachers, The State of the Health Care Workforce 2000, Figure 3.7, 2000, p. 56.

American Medical Association, Report 30 of the Board of Trustees (A-99), Collective Bargaining as an AMA Advocacy Tool, 1999.

Basinger, Julianne. "An NLRB Official Rejects Unionization Bid by Medical Interns and Residents." The Chronicle of Higher Education, October 31, 1997, p. A14.

Braddock, Douglas. "Occupational Employment Projections." U.S. Department of Labor, Bureau of Labor Statistics, Monthly Labor Review, Vol. 122, No. 11, November 1999, pp. 51-77.

Bureau of National Affairs. Union Membership and Earnings Data Book: Compilations from the Current Population Survey, 1999 edition, Washington, DC.

Ginsberg, Carl and Helen Demeranville. "Nurses Stand Tall," The Nation, May 25, 1998, pp. 6-7.

Glasel, John. "New Jersey Coalition Fights Privatization Plan," Action for Universal Health Care, October/November 1997.

Health Letter. "Managed Care vs. Medical Care," September 1997, pp. 4-5.

Lenkman, Sheila. "Nursing Satisfaction and Job Design," Health Management Technology, April 1988, pp. 34-36.

Lowes, Robert L. "Strength in Numbers: Could Doctor Unions Really be the Answer?" Medical Economics, June 29, 1998, pp. 114-116.

Malone, Beverly L. and Geri Marullo. "Workforce Trends Among U.S. Registered Nurses," Washington, DC, 1997, American Nurses Association Policy Series.

Moore, Amy Slugg. "The Way It Is Today: in a Special Survey, Nurses Tell Us What They Think of the State of the Profession Today." RN, October 1997, pp. 27-31.

Multinational Monitor. "Doctors Unite," November 1997, pp. 22-24.

The New York Times. "Union Pickets Hospital to Protest Privatization," July 2, 1998, Section B, p. 4.

Oberfield, Alice A. and Pamela S. Tolbert. "Physicians’ Work," ILR Report, Vol. 26, No. 2, February 1989, pp. 8-13.

Olmos, David R. "Podiatrists Plan Unionizing Vote as Managed-Care Debate Escalates," Los Angeles Times, May 28, 1997, p. D-1.

Sherer, Jill L. "Kaiser’s Labor Pains," Hospitals & Health Networks, March 1998, Vol. 20, pp. 30-32.

Slaughter, Jane. "Fighting for Fairer Health Care," The Progressive, November 13, 1996.

Thompson, Allison. "Industry Output and Employment," U.S. Department of Labor, Bureau of Labor Statistics, Monthly Labor Review, Vol. 122, No. 11, November 1999, pp. 33-51.

U.S. Department of Labor, Bureau of Labor Statistics. 2000. Career Guide to Industries, 2000-01 Edition. Bulletin 2523. Superintendent of Documents, U.S. Government Printing Office.

U.S. Department of Labor, Bureau of Labor Statistics. National Compensation Survey, http://stats.bls.gov/comhome.htm.