When the Kaiser Family Foundation health research organization this spring asked people to rate their greatest personal concern, the rising cost of health care topped the list at nearly 40 percent, exceeding worries about jobs, stock market losses and terrorism. Working families have reason to worry: Some 41.2 million Americans lacked health care coverage in 2001, according to the U.S. Census Bureau, and nearly 75 million went without it some time during 2001 and 2002, reports the Families USA advocacy group.

Machine operator Daniel Lozano Jr., a member of Machinists Local Lodge 774, lost his family health coverage when Cessna ­Aircraft in Wichita, Kan., laid him off in March. A single father who returned to college while looking for work, Lozano enrolled daughter Raquel, 5, in a state ­children’s health plan. But now paying $290 monthly for his own respiratory medications, Lozano knows he won’t have coverage again until he’s re-employed. “And it’s almost impossible to find a job now, much less one with health insurance,” he says.

Skyrocketing health care costs have driven an 11.9 percent increase in per capita private health spending in 2002 compared with a 4.3 percent rise in 2001, according to Kaiser researchers. In turn, employers are demanding higher premium contributions, deductibles and co-payments—and as a result, workers with job-based care experienced a 15 percent increase in total health care costs in 2002. The percentage of workers in health maintenance organizations (HMOs) facing $20 co-payments for doctor visits—an often-insurmountable barrier for low-income workers—rose sharply from 2 percent to 11 percent last year, according to Kaiser.

Then, when workers become sick and enter the health system, they’re all too likely to find that their pricey coverage hasn’t purchased quality care. Hospital personnel cutbacks are a big cause of diminishing quality care—studies consistently find low nurse staffing levels in hospitals lead to thousands of preventable deaths and injuries.

Meanwhile, public safety nets that supplement job-based coverage are under attack. State Medicaid cuts could leave up to 1.7 million of the nation’s most vulnerable poor persons without coverage this year, according to the Center on Budget and Policy Priorities. The lack of a Medicare prescription drug benefit for seniors and people with disabilities continues to force many to choose between food and necessary medicines.

Clearly, the American health care system is in crisis. But the nation also faces a moment of opportunity—major health reforms historically have followed times of great spending on health care.

While Republicans and Big Business propose Americans fend for themselves in the private insurance market, union activists and Democratic presidential candidates are making meaningful proposals ranging from legislation to expand children’s coverage to comprehensive health care coverage.

At the same time, union leaders continue fighting at the bargaining table to preserve affordable health benefits. Grassroots activists are joining community partners and educating union members on health care issues to prepare for mobilization around legislation and upcoming elections. Distribute the following information to members, lawmakers and the public as fliers, leaflets and talking points.

Bush Policies Cut Health Coverage for the Unemployed and Low-Income Workers

Olga Williams, an AFSCME Philadelphia Retiree Chapter 47 member and city of Philadelphia youth counselor supervisor and social worker for 25 years, had to give up her retiree health coverage five years ago when it got too expensive. With Medicare providing no drug coverage, she pays $180 monthly for cholesterol, high blood pressure and glaucoma prescriptions. “I don’t have money to buy anything or go anywhere, but I do give a little something at church,” she says. “Sometimes I wonder what has happened to me. It’s bad to be a grown lady walking around with no money in your pocket.”

As a result of lobbying efforts by union activists, these planned cuts will be softened by the $20 billion in state assistance, including a temporary $10 billion increase for Medicaid, that was part of Congress’s final tax bill approved in May. This money will provide some relief and economic stimulus for the states: According to the nonprofit Families USA, states on average gain $3.4 million in new business activity—including job creation and increased production and sales of goods and services— for every $1 million invested in the Medicaid program.

Taking advantage of the ongoing Medicaid underfunding crises in the states, the Bush administration is proposing to lend extra Medicaid money in coming years only to states that agree to combine Medicaid and SCHIP into one block-grant program for the next 10 years. With a block-grant, states would receive fixed dollar amounts rather than federal dollars that match their expenditures. In effect, these states would be accepting caps on federal Medicaid and SCHIP assistance that would be fixed even if their needs grow.

And the Bush proposal further squeezes states that desperately need extra Medicaid money in the near future by requiring they pay it back by receiving fewer dollars in the last three years of the block grant ­program.

“It’s a bargain with the devil,” says Sally Tyler, an AFSCME health policy analyst. “This proposal is part of the overall Bush administration strategy to abdicate federal responsibility for low-income people. It says the program would be voluntary, but it is hoping that states are so desperate that they’ll accept this small increase in up-front funds in exchange for selling out the future health care needs of their citizens.” @

U.S. Health Care Vital Statistics

74.7 million Americans younger than 65 without health coverage at some point during 2001–2002 (Families USA) 41.2 million Americans without health coverage in 2001 (U.S. Census Bureau) 80 percent Portion of the uninsured who live in households with working members (Urban Institute and the Kaiser Commission on Medicaid and the Uninsured) 1.2 million Increase in number of individuals who lose health coverage with each 1 percent increase in unemployment (Kaiser Commission on Medicaid and the Uninsured) 15 percent 2002 increase in health care costs for workers with­ ­job-based coverage (“Tracking Health Care Costs: Growth Accelerates Again in 2001,” Bradley Strunk, Paul Ginsburg and Jon Gabel, Health Affairs, Sept. 25, 2002) 15-20 percent The portion of every premium dollar that reflects cost of caring for the uninsured (The nonprofit insurer Blue Shield of California) 11.9 percent 2002 increase in private health spending per capita (“The Sad History of Health Care Cost Containment as Told in One Chart,” Drew Altman and Larry Levitt, Health Affairs, Jan. 23, 2002) 9.8 million Medicare recipients who lacked drug coverage throughout 1999 (Kaiser Family Foundation) 30 percent Percentage of health care cost increases attributable to the rising cost of prescription drugs between 1995 and 2000 (Alliance for Health Reform) $6.8 billion How much a Medicare drug benefit would save states annually, helping them avoid cutting Medicaid (The Commonwealth Fund) 20 percent Percentage of employers who say they are very or somewhat likely to terminate retiree coverage for future retirees (From a December 2002 Kaiser Family Foundation survey of 435 employers with 1,000 or more workers) Two-thirds Portion of states that implemented or planned a second round of Medicaid cuts halfway through fiscal year 2003, which began in the summer of 2002 (Kaiser Commission on Medicaid and the Uninsured) 1.7 million Individuals who may lose Medicaid coverage this year because of states’ 2003 fiscal year cuts (Center on Budget and Policy Priorities) 0 Number of industrialized nations besides the U.S. lacking a plan for universal health coverage (The Commonwealth Fund)

In Oregon, Health Care’s a Heartbeat Away

The Oregon AFL-CIO is at the forefront of state federations fighting for affordable health care. In partnership with SEIU’s national health care campaign and a state legislator who also is a union member, Oregon activists have created a foundation of community and political support they’ll be building on for years.

“Other than job loss, there is probably no greater threat to the well-being of working families than the rising cost of health care,” says federation President Tim Nesbitt.

Driving health care coverage

	Health care coalition: Oregon AFL-CIO President Tim Nesbitt (center) joins union activists in a rally for affordable health care.

During the ongoing 2003 Oregon legislative session, the federation is promoting three health care bills. One would allow all employer health plans and the uninsured to join with state and local governments and school districts to buy prescription drugs at bulk prices. The second would create an employer payroll assessment ensuring health care for the state’s 900,000 children, either through parents’ job-based coverage or the Oregon Health Plan (OHP), an expanded Medicaid program. The third would function like the children’s bill, but cover all adults.

Given the weak economy, plus strong opposition by pharmaceutical industry lobbyists, a Republican majority in Oregon’s House and an even Democrat–Republican split in the Senate, Oregon activists aren’t surprised that only a limited drug bill may pass or that House committee chairs never allowed hearings on the other bills.

In fact, activists are upbeat. “Because we have a very active ballot initiative process, we often regard the legislature as the place to work out the bugs in ideas that have a lot of public support but face political obstacles,” Rosenbaum says.

Building support

Strategies: Health Care at the State Level Union activists in dozens of states are supporting legislation and proposals to expand health coverage for working families. In California, activists are fighting for passage of the state Senate’s S. 2, which would allow employers to choose to provide coverage to workers or pay into a state pool that would purchase insurance for workers and their families. Wisconsin activists advocate a budget plan that would tax all public and private payrolls, with the money going into a common comprehensive health plan that would cover all working families in the state. Strategies for moving health care legislation at the state level will be a key topic at the AFL-CIO’s annual Workers’ Voice State Legislative Issues Conference in July in San Francisco. A resource for state federation and affiliate leaders and staff working on state legislation, the conference highlights existing and upcoming state issues that affect working families and allows activists to hear from experts and share strategies. For more information on health care and other issues at the state level, read the AFL-CIO state-by-state report, “The State of America’s Economy.”

As state federation leaders contemplate bringing the children’s health coverage measure directly to voters as a ballot initiative in the 2004 elections, they know activists already have raised awareness about health care issues during the past 18 months.

With the goal of creating a “health care legislature,” as Healey puts it, activists with Oregonians for Health Security—a coalition of Oregon senior, consumer and health professionals and SEIU locals 503 and 49, all working closely with the Oregon AFL-CIO—began in early 2002 to knock on more than 100,000 doors of voters from all parties. Looking to identify and educate those who said they would vote for health care candidates, activists found nearly 43,000 households.

Coalition members held one-on-one meetings with candidates and asked them about their positions on issues, including reducing drug costs. Then, in October, activists sent more than 324,000 direct-mail pieces to voters, including union members in target districts.

The result: Activists won eight of the 14 races they focused on and were instrumental in splitting the Senate, which Republicans previously controlled by a 16–14 margin. Candidate education yielded big benefits. “When we got to the session, they already understood health care policy,” Healey says.

In April, when the drug bill was scheduled for a Senate hearing, the state federation swung into high gear. Over three days, the federation’s automated phone dialing system left some 7,800 recorded messages asking union members to call their state senators—and more than 1,500 listeners pushed a button that gave them their senator’s phone number.

“All our coalition building and member education is going to pay off, whether it’s with a ballot initiative or bills in the legislature in 2005,” says federation research director Lynn-Marie Crider. “So many people are worried about losing their access to health coverage and waiting for somebody to offer concrete solutions—and we’ve got them.” @

Health Care Regional Conferences Set

“Working families are tired of candidates just talking about the health care crisis—they’re ready for them to do something about it. Oregon should serve as a wake-up call to people running for office all across the country. Health care had better be their priority.” —SEIU President Andrew Stern Health care tops the agenda in union bargaining today as double-digit health care premium increases threaten current coverage and disadvantage unionized employers competing with nonunion and overseas companies. This summer, the AFL-CIO is sponsoring regional health care conferences enabling union activists to discuss bargaining strategies and policy reform advocacy to make affordable health care a reality. Following a June 12 conference in New York City, additional conferences are slated for June 30 in Chicago and July 18 in San Francisco. Among the topics: best practices in bargaining; strategies to control costs while protecting benefits and quality of care; and state and federal health care financing reform initiatives. The cost is $35 per participant, and a limited number of scholarships are available. For more information, call Lisa Robbins at 202-637-5219.

Bargaining for Health Care

National problem, national solution: UAW President Ron Gettelfinger calls for a “universal, comprehensive, single-payer health care program.”

Several unions have been successful in retaining health care coverage in recent negotiations. SEIU’s Justice for Janitors made health care the key issue in contract talks between janitors and building owners in cities across the country. In Washington, D.C., janitors, members of Local 82, gained support from unions and the community and won employer-paid health benefits for the first time. Previously, the 750 part-time janitors were forced to rely on emergency rooms, government-run clinics and charity care for their health needs. In Washington, D.C., and nearly a dozen other cities, including Boston, Chicago, Los Angeles and San Diego, janitors maintained health care coverage or gained new coverage.

Larry Allen has chronic liver disease and high blood pressure. A full-time Wal-Mart produce department employee in Las Vegas, he opted for coverage under the health insurance plan of his wife Jacque, a United Food and Commercial Workers Local 711 member. At 40 percent coverage, her plan was a better bet than Wal-Mart’s pricey insurance, which would not cover any medical expenses for pre-existing conditions during the first year. After five days in the hospital this year, Allen received a $13,200 bill. “I’ll pay it off if I have to hand it down to my grandchildren,” he says.

One day, Fortune showed a Wal-Mart regional personnel manager his wife’s benefit package from a Las Vegas casino.

“He said Wal-Mart couldn’t afford to give its workers such coverage,” Fortune recalls. “I asked who would take care of our associates [Wal-Mart’s term for staff]. He said, ‘Let the states do it.’”

In fact, taxpayers, other employers and all health care consumers do pick up the tab for Wal-Mart, which reported that 46 percent of its hourly workers participated in some form of its health coverage (including its cancer-only insurance plan) in 2001. In contrast, 85 percent of United Food and Commercial Workers members in retail have full employer-based ­coverage.

Plenty of large, profitable companies don’t offer workers affordable health coverage. “The Benefits Divide: Health Care Purchasing in Retail Versus Other Sectors,” a study by James Maxwell, Peter Temin and Saminaz Zaman published in the September/October 2002 issue of Health Affairs magazine, examined 1999’s Fortune 500 list of the publicly traded companies with the largest revenues. The top 10 on that list included four retail companies. Only 8 percent of employees of nonretail Fortune 500 companies lacked health coverage, the researchers found—but among the Fortune 500 retail companies a whopping 38 percent of workers lacked coverage. 

So while it is a workplace trendsetter as the nation’s largest private employer with nearly 1 million workers and the top spot on the Fortune 500 list, Wal-Mart has plenty of company among free-rider employers both small and large that activists say should participate in the U.S. system of job-based, comprehensive and affordable health care. 

“Employers currently getting around [the job-based health care system] should be held to some sort of standard to help cover workers,” says Georgetown University health care economist Ellen O’Brien. “It can’t all be shifted to others.”

In Washington state, for example, where the current budget deficit is more than $2.7 billion, Democratic state Rep. Steve ­Conway—president of the National Labor Caucus of State Legislators and a member of UFCW Local 81—last year asked state officials to identify employers with workers on Medicaid or in the Basic Health Plan (BHP), the state’s expanded Medicaid program.  

Wal-Mart topped both lists with 453 workers on Medicaid and 341 in the BHP. “It’s outrageous,” Conway says. “Workers are electing this coverage because they cannot afford the coverage of one of the most profitable companies in America.”

We all pay to support Wal-Mart

Employers like Wal-Mart that game the nation’s health care system have helped provoke the worst budget crises hitting the states since the Great Depression. With Medicaid generally their second greatest expense after education, states now are slashing enrollees and services.

And workers who don’t qualify for Medicaid but make too little to afford job-based care are costing taxpayers tens of billions of dollars annually in other ways, according to Jack Hadley, a senior researcher at the Urban Institute and the Center for Studying Health System Change, and John Holahan, director of health policy at the Urban Institute. They have found the uninsured, who often don’t get medical attention until they wind up in costly hospital emergency rooms, received about $35 billion worth of uncompensated care—that neither patients nor private or public insurance plans paid for—in 2001.

Federal, state and local governments—taxpayers, in other words—paid for $29 billion (83 percent) of that uncompensated care.

Hospitals and other health care providers push some of the remaining uncompensated costs onto bills they give insurers, who in turn shift the tab to premiums paid by working families. The nonprofit insurer Blue Shield of California estimates that between 15 to 20 percent of each premium dollar goes for the payment of uncompensated care, and some experts estimate that number may be as high as 30 or 35 percent.

Employers that don’t provide their workers affordable insurance not only pass the buck to taxpayers and those barely managing to pay for their coverage, but they do a double-whammy on fair-minded employers. If uninsured workers have spouses with job-based insurance, they’ll sign on to it if they can—and drive up that plan’s costs. And by not providing affordable insurance, these employers have an unfair competitive advantage.

As Wal-Mart increasingly offers full-service grocery departments in its stores, it is threatening hard-won health benefits and wage standards in the unionized grocery sector. Craig Cole is president and CEO of the 34-store chain of Brown & Cole grocers employing 2,070 workers including 1,334 UFCW members, 141 Teamsters and 44 Bakery, Confectionery, Tobacco Workers and Grain Millers members in Washington state.

Workers Without Health Care

“When the nation’s top employer provides inferior benefits and uses lower labor costs as a competitive weapon, it lowers the bar and endangers the good benefits that workers have struggled for over decades to provide some level of security,” Cole says. “As long as health care in this country is job-based, I think it’s a very serious public policy problem where employers can play games, offloading their responsibility onto other employers and the public.”

A 1999 study by University of Nevada economist Jeffrey Waddoups found Las Vegas’s major county hospital provided more than $10 million in uncompensated care in 1997 to patients who had jobs but no health coverage. (According to the Urban Institute and the Kaiser Commission on Medicaid and the Uninsured, 80 percent of uninsured live in households with working members.) Just this past April, Nevada’s state Assembly passed Democratic Rep. Chris Giunchigliani’s bill requiring large grocers to offer reasonable health insurance to employees or repay Nevada for care it provides those workers. The vote was 30–12, with all the Democratics and seven Republicans voting for it. Activists can build public support for such legislation, says John Martini, president of the United Union of Roofers and Waterproofers. When Waddoups’s report revealed constructions workers, followed closely by retail workers, had the greatest proportion of workers without insurance, roofers activists leafleted at model homes.

Activists told potential home buyers the houses were built by contractors who don’t provide insurance and, as taxpayers, they would eventually pay those costs. “We didn’t push it as a union issue but as a fairness and pocketbook issue,” Martini explains. “People respond to that.” @

Retired with No Health Care

When Steelworkers Local 2609’s Andy Plitt retired in March 2002 after 33 years as an electrician at Bethlehem Steel’s Sparrows Point plant in Baltimore, he never imagined losing his retiree health insurance. But he and 100,000 retirees nationwide lost their health coverage this year after the sale of a bankrupt Bethlehem.     Cost conscious: Ensuring all union members use prescription drugs that deliver the best value can mean more options for retiree health care, says TWU President Sonny Hall. The steel industry is a marker in the mounting breakdown of retiree health coverage. Since 1997, 38 bankrupt steel companies have left more than 200,000 retirees and their dependents without coverage. According to a September 2002 report from the federal Agency for Healthcare Research and Quality, the share of private-sector businesses offering health care to retirees younger than 65 dropped from 21.6 percent in 1997 to 12 percent in 2000; coverage for those 65 and older dropped from 19.5 percent to just 10.7 percent. Plitt, 61, divorced with a grown daughter, may be luckier than many retirees. Because Bethlehem’s troubles were trade related and the Pension Benefit Guaranty Corp. took over its pension plan, Bethlehem retirees qualify for a new federal tax credit that will pick up 65 percent of the cost of replacement coverage premiums. And thanks to Maryland legislation supported by USWA and AFSCME activists, he can afford coverage through a new state plan that, unlike most private plans taking on new customers, will cover his pre-existing illnesses including asbestosis. But like Medicare, which he’ll join at 65, the Maryland plan offers no drug coverage. “My drug costs are currently $54 monthly, and that may grow as I get older,” Plitt says. “Some of my fellow retirees are now paying $400 monthly and up for prescriptions.” To fight the retiree coverage breakdown, union activists are working for reforms that include: A meaningful Medicare prescription drug benefit that doesn’t leave seniors and others at the whims of the private market, as the Bush administration proposes. “Medicare hasn’t kept up with health care, which is increasingly delivered through drugs,” says Ruth Antoniades, a consultant to union health plans. Ensuring all union members use prescription drugs that deliver the best value. “Labor and management must together review the cost and value of all drugs and ensure that money for prescriptions is spent wisely,” says Transport Workers President Sonny Hall. “When you save money on pharmaceuticals, you keep more money available for retiree health care.” Allowing retirees under 65 to buy into Medicare or other government-sponsored group health plans. “These workers often can’t find or afford private coverage,” says Steve Sleigh, director of strategic resources for the Machinists. The $35 billion annually that government now inefficiently spends on care for the uninsured could help expand Medicare, says Urban Institute researcher Jack Hadley. @

Nurse Staffing: Situation Critical

	Understaffing unsafe: “Understaffing is compromising patient care,” says UAN President Cheryl Johnson.

In the Veterans Affairs Medical Center in Salisbury, N.C., 40 miles northeast of Charlotte, each registered nurse in the long-term care unit is responsible for 60 patients, and they often are required by ­management to work double shifts. In the medical-surgery ward, where patients need nearly constant monitoring, the ratio is one nurse for every 12 patients. And with an influx of new patients from the war in Iraq, the nurses fear they will be forced to care for even more patients and work longer hours.

“America’s heroes deserve better care,” says J. David Cox, a registered nurse who described conditions at the medical center. “Exhausted nurses lack the level of concentration and emotional stamina needed to deliver high-quality care with compassion. Medications, basic care and critical medical interventions will be delayed, forgotten or mixed up because the nurse on duty has too many patients and has worked too many hours.”

Cox, president of AFGE Local 1738 and a nurse at the Veterans hospital for 17 years, was one of the more than 500 nurses who traveled to Washington, D.C., May 6—National Nurses Day—to call on Congress to pass safe staffing legislation. In an unprecedented effort, half a million nurses from AFL-CIO affiliates are joining together as AFL-CIO Nurses: A United Voice for Safe Staffing Now in a campaign to push lawmakers to establish nationwide nurse staffing ratios.

Fewer nurses, more patient risks

Studies have found that low nurse staffing levels in hospitals greatly increased the risk of preventable deaths and injuries to patients. A recent report in the Journal of the American Medical Association found that when a hospital increases a registered nurse’s patient load from four patients to eight, the risk that a surgical patient will die within 30 days is increased by nearly one-third.

“Inadequate staffing is compromising patient care,” says United American Nurses President Cheryl Johnson, a critical care nurse at the University of Michigan Health Systems in Ann Arbor. “Understaffing also has forced many nurses out of patient care—and America knows it.”

On Nurses Day, the AFL-CIO nurses released the results of a nationwide telephone survey conducted in April by Lake Snell Perry & Associates in which an overwhelming majority of the public says there are not enough registered nurses to care for the number of patients admitted to hospitals. Three-quarters say there are not enough registered nurses, while only 15
percent say there are enough or more than enough.

Slightly more than three-quarters of the public also believe the shortage of registered nurses has a large impact on the quality of care provided to patients in hospitals, according to the survey.

Linda Straubhaar-Soose, a IUE-CWA Local 715 member and General Electric worker, spent two days on the picket line in January fighting management’s proposed midcontract increases in health care premiums and co-payments. When she broke her elbow earlier this year, the injury compounded the pain from the repetitive stress injuries in her elbows and hands. With Straubhaar-Soose now out on sick pay at 70 percent of her regular wage and husband Michael making $9 hourly servicing equipment for a nonunion employer, her physical therapy “is a big bill for us,” she says. “I’m supposed to go three times weekly for therapy, but I can only afford twice because of the $25 co-payment per visit.”

Protecting patients with a strong federal staffing law

These results come as no surprise to Martha Baker, a registered nurse in the trauma intensive care unit at Jackson Memorial Hospital in Miami, the nation’s largest public hospital, which was on the frontlines of the tuberculosis crisis in the 1990s.

“The hospital staffing crisis isn’t new,” says Baker, president of SEIU Local 1991. “Hospitals have been systematically understaffing for at least a decade. Medical care has become big business—and more attention is paid to the financial bottom line than to the quality of patient care.”

Rep. Janice Schakowsky (D-Ill.) told the nurses she plans to introduce legislation that would mandate safe nurse staffing ratios. The AFL-CIO Nurses also are supporting H.R. 3238, the Safe Nursing and Patient Care Act, sponsored by Rep. Pete Stark (D-Calif.), which would eliminate mandatory overtime for nurses.

In 1999, California became the first state to enact mandatory staffing ratios, says Kathy Sackman, a registered nurse for 40 years in Pomona, Calif., and president of United Nurses Association of California/Union of Healthcare Professionals, an AFSCME affiliate. The law was enacted after a long campaign by nurses’ unions for safe staffing. But that is not enough, she says. “We need a strong federal law to protect all patients no matter where they live.”

—James B. Parks

Learn more about AFL-CIO Nurses at www.aflcio.org/nurses. @