‘A Wakeup Call from Hell’

“When I first started I knew it was going to be bad,” said William Barak Indik, an emergency room nurse who has been working at Montefiore Medical Center in Norwood, in the northwest Bronx, since 2019. “This place has a reputation for being a really difficult place to work.” Norwood is a dense, working-class community, and the Bronx has been ranked the least healthy county in New York State for over ten years, with high rates of asthma, diabetes, and hypertension. A staffing ratio of four patients for every nurse is considered a safe standard in emergency rooms, but at Montefiore emergency room nurses may monitor as many as fifteen or twenty at a time. It can get so crowded that Indik has to climb over stretchers.

Because there is no limit on the number of people who can be admitted to the ER, patients pack the hallways, some waiting as long as forty-eight hours to be transferred to a bed up on a floor. “When it gets like that there’s no privacy, there’s no infection control,” Indik told me. “People are coughing, sneezing, screaming all over the place, and they’re so jam-packed in there that if you didn’t come in with something, you’re going to leave with it.” Overflow psychiatric patients are placed in a section of the emergency department, which sometimes leads to violent incidents. “You have people with suicidal ideation, people with homicidal ideation, people with delusions of grandeur, people with paranoia,” Indik continued. Fights can break out. “Imagine being next to that while trying to do something delicate like put in an IV.”

“I’ve used the word humanitarian crisis a lot, and it feels a little bit clichéd since I’ve said it so many times to so many people, but I’m glad I’m saying it now,” said Indik. “It just got to be too much.” We were standing on a picket line outside the hospital in January, in a sea of nurses in red hats. It was the second day that more than seven thousand members of the New York State Nurses Association (NYSNA) were on strike, at three Montefiore campuses in the Bronx and at Mount Sinai Hospital on the Upper East Side. Energetic speakers took the mic: nurses, a nurse’s fourteen-year-old son, and the wife of a patient who was taking time away from her husband’s bedside to support the strike. “He’s very sick, and I’m out here,” she said.

Montefiore had released a statement the previous day expressing disappointment that “NYSNA’s leadership has decided to walk away from the bedsides of their patients.” But the nurses received an overwhelmingly positive response from the public. It was hard to argue that they weren’t acting on behalf of patients: they had already been offered 19 percent wage increases but were holding out for safe staffing ratios, enforced with financial penalties to the hospital. A few paces away from the group, I overheard a man explain to an onlooker, “They already got their chicken. This is about something else.”

The three-day strike, the largest organized by New York City nurses in decades, was part of a wave of labor unrest that has swept the health care industry in response to Covid-19. In 2021 eight hundred nurses at Saint Vincent Hospital in Worcester, Massachusetts, went on strike for ten months, mostly over staffing issues. A strike of 21,000 California nurses was narrowly avoided last November, and in December 15,000 nurses in Minnesota threatened to strike before they won concessions at the eleventh hour. Thousands of nurses in the UK have been striking periodically for the past three months.

Nurses made up nearly a third—the largest share—of the 3,607 health care workers who died of Covid in the first year of the pandemic in the US. In the first year and a half, one in five nurses resigned. Understaffing had already been a major issue. At a time when nurses needed respite, these losses dramatically worsened working conditions for those who remained. 

The crisis was caused not only by the sheer number of patients being admitted but also by the severity of their condition, Indik told me. “We had EMSs bringing us people with respiratory failure, respiratory failure, over and over again, and we were running out of the medications we needed to intubate people. That’s how bad it was. I don’t even want to talk about the decisions we had to make when it came to helping one person versus another.” But when the storm calmed, it felt like nothing changed. “There was no lesson learned from that. None whatsoever. There should have been some sort of restructuring done, it should have been a wakeup call from hell.”

“I think I’ve blocked it out,” said Carol McGowan, a veteran nurse who has worked in a neuroscience intensive care unit at Mount Sinai for thirty years. “Everyone thought things would get better. It was extreme circumstances, but hey, that’s what we do.” But the hospital didn’t prepare for the effects of burnout on staff and the wave of retirements and resignations that followed.

For many nurses the last straw was being publicly valorized during the worst of the pandemic but still forced to work under untenable conditions. “Covid exacerbated staffing issues, but it also gave us the spotlight,” said Matt Allen, a labor and delivery nurse who has worked at Mount Sinai for seven years. “For the first time in a very long time nurses were in the headlines.” On the picket line at Mount Sinai, nurses marched back and forth in front of an entrance to the hospital emblazoned with the words TO THE HEALTH CARE WORKERS FIGHTING FOR OUR LIVES, THANK YOU. “Without Covid, I don’t think we would be in this place right now,” Allen told me. “We would probably be a little more complacent still, a little more willing to take whatever they give us in a contract.” 

After twenty years of advocacy by nurses’ unions, in June 2021 the state passed a law that charged hospitals with establishing staffing ratios, but it was a watered-down version of the bill that NYSNA had originally sought. Instead of mandating ratios, it tasked hospitals with forming a “staffing committee” made up of equal parts nurses and hospital administrators. Administrators had the power to override the recommendations of the nurses in the frequent event that the two sides couldn’t reach a consensus. “The original bill was the right answer,” Richard Gottfried, then a State Assembly member, told New York Focus. But “there were many in the legislature who were reluctant to do something that their local hospital was so strongly objecting to.”

In the ICU where McGowan works, nurses who have too many patients can fill out a Protest of Assignment form to report unsafe conditions to management, a measure she tells me was once a last resort before the pandemic. “We have binders and binders and binders of them filled out in the last year,” she told me. “To be short-staffed was the norm, doing extra work was the norm.”

Hospital management has countered that the hundreds of open nursing positions at both systems result from a national nursing shortage and that they can’t find more workers to hire. Meanwhile a retirement wave looms: as the baby boomers age, more and more nurses will be needed to care for them, but currently half of all nurses are over the age of fifty themselves. There’s a crunch in the labor market at the other end as well: a shortage of professors at nursing schools—as a result of low salaries, among other factors—limits the number of spots available to students. Thousands of qualified applicants are turned away.

But NYSNA and the nurses I spoke to argue that the root of the problem is that work conditions drive already licensed nurses away from the profession. McGowan said that when many new nurses began at Mount Sinai and “realized how bad it was, they just left. So we weren’t getting anywhere, especially in the ED, cardiology, medical floors.” Gabriel Winant, a historian at the University of Chicago who recently published a book about labor and health care, concurs.¹ “There is a nursing shortage at some level,” he told me. “We need more nurses. But the better way of thinking about it is to ask, are labor relations helping or hurting with that problem?”

The crisis in hospital staffing became acute in the 1990s, as hospitals grew increasingly concerned with their bottom lines. As Elisabeth Rosenthal explains in An American Sickness (2017), in the first half of the twentieth century health care was fairly rudimentary, and the primary insurers, Blue Cross and Blue Shield, were nonprofits intended to help people afford emergency hospitalizations and costs of serious illnesses. As health care became more sophisticated, more people sought insurance, and in the 1950s for-profit insurers entered the picture. Through the 1970s and 1980s they gradually took control of the market, and in 1994 “the Blues” began to switch to for-profit status.

Health care spending skyrocketed in the 1980s, as a result of economic fallout from the turbulent 1970s, expensive technological inventions, price deregulation under Reagan, and, some researchers speculate, cuts to social services. For decades insurers had acted as fairly straightforward middlemen, facilitating the free flow of health care spending to providers from employers, but in the late 1980s and early 1990s insurers sought to control these rising costs. They organized health care providers into networks and negotiated price discounts with hospitals in exchange for including them—a system called managed care. Some of the new health plans—the most common were HMOs, or health maintenance organizations—were structured to discourage expensive care like in-patient hospital stays. In 1996 Dr. Linda Peeno, a physician and claims reviewer for the insurer Humana, testified before Congress that HMOs were overly focused on denying claims, often to the detriment of patients.

In theory—Bill Clinton’s failed 1993 health care reform bill counted on this—a system populated by these managed care organizations would function like a ruddy-cheeked free market: competition between providers would increase efficiency and decrease spending. And indeed, as the power to set prices shifted from providers to insurers, in the 1990s health care spending relative to GDP leveled off after years of increase. But the age of HMOs was ultimately brief because they were so unpopular with patients, and costs soon rose again. Meanwhile, figuring out how providers could boost earnings in the face of shrinking insurance payouts had become a veritable industry, and financial consultants flocked to hospitals. “By the turn of the century,” writes Rosenthal, “many HMOs had died out, but hospitals and doctors had become far more adept at the business of medicine.”

“The important thing about health care economically,” Winant told me, is “that it hasn’t proven that possible for providers to increase the productivity of labor, which is to say to provide more services for cheaper without degrading the quality of the product.” The result is that health care comes to involve “zero sum choices,” he said. “If you think about the different stakeholders—the administration, the patient, the worker—there’s a relatively fixed pie they’re going to be fighting for shares of.” The financial pressures exerted by insurers in the 1990s resulted in nurse layoffs, hospital closures, and widespread mergers, which help hospitals bargain for more favorable rates with insurers, among other cost-saving benefits. If there had been no mergers in the past quarter century, we would have about eight thousand hospitals in this country, rather than the six thousand currently operating.

In 2005 New York governor George Pataki convened the Berger Commission—named for Stephen Berger, the investment banker who chaired it—to restructure the state’s health care system. About twenty hospitals had closed since the turn of the millennium and others were struggling financially, “squeezed by health insurers, declining demand, decades of heavy borrowing and outright mismanagement in some cases,” The New York Times reported. The promise of federal aid gave the state an incentive to address the commission’s findings: New York State had the most expensive Medicaid program in the country, and the Bush administration, looking to reduce its contribution, offered $1.5 billion if the state would meet cost reduction goals.

The commission ultimately advised reducing inpatient capacity by 7 percent. The cuts were mostly carried out, but due to state-level policies like the deregulation of hospital reimbursement rates and caps to Medicaid spending the pace of closures accelerated far beyond the commission’s recommendations. Between 2000 and the start of the pandemic, the state lost about 28 percent of its hospital beds—a statistic that journalists cited pointedly when Governor Andrew Cuomo called in USNS Comfort, a dysfunctional Navy hospital ship, and set up a tent hospital in Central Park to help triage the crush of Covid patients. 

There has also been an ongoing move to shift patients away from overnight stays and emergency rooms by using more home care, preventative care, and outpatient facilities like ambulatory surgical centers. There is a logic to this: the benefits of preventative care are obvious, technological advances make many procedures less invasive than they once were, patients tend to prefer to be at home than in the hospital, and hospitalization carries increased risk of infection. But insurers also have a strong financial incentive to discourage expensive inpatient care, and providers have adapted by snapping up outpatient facilities to capture revenue that has moved away from the hospital proper. Additionally, patients who are uninsured or on Medicaid tend to seek care in hospitals rather than primary care clinics, which are more difficult to access. In a 2013 op-ed for the New York Post, Berger urged “New Yorkers, especially those in vulnerable, low-income neighborhoods, to overcome their reliance on hospitals and embrace the rapidly shifting health-care landscape.”

Many worry that the hospitals closed before alternatives were put in place. “Hospitals are not sustainable,” said Caitlin Henry, a geographer at the University of Manchester who has studied hospital closures in New York City, but she also believed that the industry was abdicating responsibility for maintaining its health care infrastructure. “We can have robust systems of home care, and visiting nurses, and community-based care, but we have to really invest in those.” Meanwhile, there is currently a shortage of primary care physicians, which a 2021 report from the Association of American Medical Colleges estimated would be between 16 to 22 percent more severe “if currently underserved populations were to have care-use patterns similar to those of populations facing fewer barriers to care.”

The result of the arms race between hospitals and insurers is a landscape dominated by large cost-motivated conglomerates. There are no for-profit hospitals in New York, but the nonprofits behave in some ways like corporations, with exorbitant salaries for administrators and huge investment profiles, hundreds of millions of dollars of which are held offshore. Montefiore, which serves a predominately low-income community, had over $560 million in net assets in 2020, the last year for which tax returns are available, although it has been running a deficit since the pandemic began. Mount Sinai, far wealthier, had $2.9 billion in net assets and $185 million in excess revenue on its latest tax filing. 

Hospitals have an incentive to make up for the lower reimbursement of Medicaid and Medicare patients by pursuing lucrative procedures they can bill to private insurance, like knee surgeries. “If you’re not getting closer to the premium dollar, you’re in trouble,” said the CEO of the hospital system Providence in a candid interview with an industry publication. When health care is run as a business, albeit a shambling, wildly inefficient one, it leads to grotesqueries like hospitals closing pediatric wings because children do not generate as much revenue as adult patients or forcing nurses, generally highly empathetic people, to experience the “moral injury” of providing substandard care, as one nurse speaking at the Montefiore picket line put it.

The statistics are clear: higher nurse staffing levels are associated with a lower risk of patients dying while in the hospital. But it is hard to monetize the kind of careful bedside nursing that patients find deeply meaningful in a vulnerable time. “For the same reason that you can’t increase productivity, there’s a lot of fuzziness about how much nurses are capable of, because it’s interactive human relational labor,” said Winant—so understaffing proves a reliable way to keep costs down. “The nurses,” Indik said, “bear the brunt of all of the inadequacy of the hospital.”

On the third day of the strike the hospitals made major concessions, and nurses returned to work. I asked Johnaira Dilone-Florian, a nurse practitioner at Montefiore since 2015 who was on the bargaining committee, what she was happiest with in the contract. “Everything, oh my god,” she said. There was a new program that would bring nursing students to the hospital as assistants in order to prepare them for a career there. There was a promise to reopen a general surgical unit that has been sitting vacant for years. Most importantly, there were enforceable staffing ratios, a victory without precedent in recent memory. “We definitely kicked butt.”

Three weeks after the strike, McGowan told me she was optimistic that with watchdogs in every unit, staffing changes would happen in time. “Thankfully, we’re back at work,” she said. “Let’s hope they put patients before profit. It’s all about the money, baby—we live in America, you know what it’s about.”