On Monday, roughly 4,000 mental health professionals employed by Kaiser Permanente in California began a planned five-day strike. The therapists (and nurses, who also walked out in solidarity) say they are protesting the massive and continued failure on Kaiser’s part to provide adequate mental health care to its own patients.
This strike is, in some ways, like other strikes you’ve heard about. While the therapists are highlighting client care issues, Kaiser itself notes that those therapists also are demanding better pay and working conditions — common demands to strike over. But this strike is also deeply unusual in the mental health world. Even when therapists are in a union, strikes are very rare. For that reason, this strike is uniquely important.
Kaiser’s troubled history on mental health care
This problem is not new to Kaiser Permanente. The insurance giant was fined $4 million by California regulators in 2013 for its failure to meet with mental health patients on a timely basis, a systematic failure that the National Union of Healthcare Workers argued led several patients to commit suicide. (The union even developed a web site, nomorekaisersuicides.org, to highlight the problem. That site was taken down after that battle ended, but it’s referenced here. This time around their URL is a bit more benign: kaiserdontdeny.org.)
At the time the fine was issued, Kaiser said they planned to fight it. But they ultimately backed off, paid the fine, and agreed to independent monitoring of their mental health system. A subsequent state report found several ongoing violations.
Slow and inadequate solutions
According to Kaiser, they have been working to hire more mental health professionals into their system. They say they have hired more than 500 therapists since 2015, increasing their mental health staffing by more than 30 percent. The union says that pace of growth isn’t even close to adequate, with clients sometimes still waiting six weeks between therapy appointments. According to the union, increases in mental health staffing have left Kaiser’s ratio of full-time therapists to Kaiser members basically unchanged: 1 therapist for every 3,000 members.
As part of the public messaging surrounding the strike, the union has shared several stories of patients harmed by their apparent lack of access to care through Kaiser.
Kaiser’s response to the strike
So far, Kaiser’s response to the strike has only served to make clear why California needs healthcare regulators.
On the PR front, they’ve been intentionally misleading. Their official statement reads in part, “It’s particularly disheartening that the union leadership would call this strike during the holiday season, when many of our patients with mental health needs may be at their most vulnerable.” On a purely factual basis, any season at all is a season where “many” patients with mental health needs “may” be at their most vulnerable. They’re correct! But this is also a blatant attempt to play into a public misconception that suicides spike around the holidays, to make the therapists look like they’re choosing to actively endanger patients. So we’re clear: The suicide rate is lower in December than any other month of the year.
Kaiser goes on in their statement to suggest that the union is being disingenuous in putting patient needs front and center during the strike. They argue that the union is actually fighting for higher wages when Kaiser already pays well, and that the union is seeking changes in performance metrics that would make therapists less available to their clients. So the therapists must be hypocrites, Kaiser appears to be implying, when they say they want more client care available.
Client care during the strike
Before addressing that implication, a quick aside on danger to patients. I know some therapists who are generally supportive of the strike, but still have concerns about client care. It is, of course, possible to support the union’s ideals while still acknowledging that this fight comes at a cost.
Thankfully, if there’s one place where both sides agree, it’s that clients in crisis will still be served this week. Emergency psychiatric services remain available 24/7 to Kaiser members.
NUHW is doing its job — and showing why more therapists should unionize
Let’s accept for a moment that Kaiser’s factual statements about the negotiations are true: That the union is asking for higher wages and those performance metric changes, and that Kaiser already pays pretty well. The union still wins the argument.
Kaiser has to pay well because Kaiser is well-known, at least among my circle of associates, as an exceedingly terrible place for clinicians to work. Precisely because there aren’t enough therapists there, the existing therapists have ridiculous caseloads. Part of Kaiser’s response to the $4m fine and subsequent violations has been to pile on to their existing staff. Kaiser told the Department of Managed Health Care that it had been improving mental health care access by (emphasis mine) “increasing the hours for contract clinicians, canceling or reducing vacations of staff and increasing the productivity of staff.” In other words, increasing caseloads and making it harder to take time off.
The union should be fighting to make working at Kaiser suck less. That’s part of why unions exist! Those changes in metrics the union is demanding make perfect sense if your group is trying to make Kaiser a better place to work.
One piece that the union loves to highlight, while Kaiser doesn’t respond to in this context: Kaiser as a whole has a cash reserve of more than $20 billion. That’s enough that some have questioned whether Kaiser, which is officially a consortium of for-profit and non-profit entities, should be stripped of any non-profit status.
When Kaiser decries the “union leadership’s tactics,” let’s be clear about what those tactics are: Highlighting Kaiser’s grossly inadequate mental health care, noting how much money Kaiser has available to solve the problem if they actually wanted to, and demanding a less burdensome work environment.
Why it matters
As we’ve discussed here previously, most therapists cannot unionize. So it’s uncommon for mental health professionals to take collective actions like this. It’s also rare for therapists, as a group, to push back so strongly against any perceived injustice. (Here’s at least some speculation as to why that is.) There are lots of workplaces for therapists that are troubled to the point of being potentially exploitive. We tend to pursue dialogue with those workplaces, even when they show no desire to change. That isn’t always a wise choice.
This strike is calling national attention to the inadequacies of Kaiser’s system, including the specific harms done to patients. The union is using the powerful leverage at its disposal — not just attempting to impact public perception of Kaiser, but also risking Kaiser’s ability to meet its legal mandates. Big picture: If Kaiser can’t convince enough therapists to be part of its system of care, Kaiser shouldn’t be allowed to sell health insurance. (That link relates to federal plans sold under the Affordable Care Act, but most states — like California — require all insurance plans to cover mental health care, which includes having an adequate provider network to make such care available.)
The strike serves as a powerful expression of an important systemic principle: Sometimes to get positive change, you can’t work collaboratively with those in power. You have to let the car crash. The union here knows they have leverage, and they know that it isn’t difficult to make the case that Kaiser’s existing practices around mental health care are grossly inadequate. California’s $4 million fine does not appear to mean much to a corporation with more than $20 billion in reserves.
You create systemic change in the ways you can. This is how a union does it. Without a union, there’s no reason to believe that Kaiser would speed up improvements to their mental health care system. California’s health care regulators and their associated fines appear to be more of an annoyance to Kaiser than a meaningful problem. So one other possible solution to end with here, if lawmakers are game: Frame the penalties for violations of state law in terms of a company’s reserves. $4 million isn’t much to Kaiser. They can eat that as part of the cost of doing business. But 4 percent of its reserve? That would be a fine of $800 million. That might more effectively move them into compliance.
For therapists: Seriously, if you can, unionize your workplace. Pay and benefits are likely to improve. It’s true that most therapists cannot unionize. But your boss is not your friend, and they don’t owe you a better place to work. For therapists, far too many work environments are toxic. Fighting that, through a union, may be the only way to make it better.
[Edited December 15, 2018 to fix my math error. -bc]