A large part of the employment growth in American society over the next two decades will be in the health care sector. While much of this increase will occur in areas we typically think of as highly visible health care professions - physicians, nurses, pharmacists - the majority of the employment growth will take place in the front line workforce - nursing assistants, home health aids, long-term care assistants and others - who will provide essential care and services to an aging population. Unlike many other health professionals, these individuals are often at risk by making lower wages, having less generous benefits, and fewer opportunities for education and advancement.
As an already expensive and often under-performing health system becomes more costly and under more pressure to produce, the burden to respond is likely to be disproportionately shared by the large and growing group of workers who serve in these occupations. It is not unimaginable with the current dynamics that a majority of the workers in these and other first contact occupations will find themselves making the health system work by taking lower wages. Even with the sacrifice, however, many of them will not be offered or will not be able to afford health insurance. Should such a dynamic arise it would be a regrettable domestic policy tragedy, as it would inevitably lead us not only to a less equitable society, but a health system that discriminates against those that sacrifice to make it work.
To prevent this from occurring we need to acknowledge the problem and approach it from a variety of perspectives. From the employers perspective this workforce needs to be considered the most valuable asset available. On the one hand, if entry level workers are provided with a safe and encouraging work environment, given opportunities for education and advancement, and provided a livable wage for the area in which they work, they will return the investment by creating new value from the ways in which they do their work, including remaining loyal to the organization and therefore reducing the growing costs of high turnover and low productivity. If, on the other hand, workers are treated as commodities they will soon act accordingly by demanding unsustainable wage increases, not making a personal commitment to the quality and safety of their work setting, and creating a hostile environment that is the antithesis of what patients and their families need and want from health care. Managers and leaders must have the skills to create such a work environment, but first they must have the vision of what such a place would look like.
Much of this workforce is, or soon will be, unionized. Labor representation seems one of the best ways to ensure that voices are heard and needs are met. However, the traditional work rules of American labor, which are informed by its growth out of the industrial age with a stark separation of labor and management, cannot meet the challenges of this growing service sector. Quality was once the product of design and machine tooling. It now comes as the work of the hands, heart and head of dedicated service workers and professionals, particularly in the health care and education sectors. It is not surprising that these two sectors buck the trend of declining labor membership. But do the old work rules of first hired last fired, no assessment of quality of individual work, and no promotion except by seniority, work in service sectors? Clearly they don't, so new service sector rules that evaluate individual performance on improvement, pay for that improvement when it takes place, and create opportunity that moves workers up without necessarily moving them into management need to be created and advanced by union leadership.
These changes are needed from labor and management if the nation is to have any chance of remaking health care in the coming decade. The idea that practice models, staffing patterns, new work rules, and collaborations will come about through traditional collective bargaining over contracts belies the past experience and will not likely lead to any truly creative approaches to how this critical workforce is deployed against the nation's health care needs. Experiments such as Kaiser Permanente's Labor Management Partnership in California have started the labor management relations over from first principles guaranteeing employment, involving workers in work redesign, obligating everyone to look at overall resources, and figuring out how they can best be used to achieve the best outcomes for patients and those that produce care.
New levels of collaboration between labor and management in health care will not produce all of the changes that are needed to make the health care workplace successful. Care management technology will need to be developed and deployed, making labor more efficient and fulfilling. Even with these substitutions, more home, family, community and self care will need to be a part of the mix of services. Also, part of the answer for health care will undoubtedly be a deeper integration of global labor markets to better serve the problem, whether we import the workers or export resources to the patients. At the most fundamental level, labor and management must first learn new ways of collaborating and compromising in order to build a system that is truly sustainable.