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An Ounce of Dissension

Texas nurses are getting organized, with help from a veteran California labor activist
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On a gray March day, 250 rambunctious nurses wearing rose-colored smocks and waving blue picket signs marched up Congress Avenue. They ascended the Capitol steps in sneakers, clogs, and high heels, determined to cajole legislators into supporting a bill that would cut the number of patients a nurse can be required to care for at one time. Recounting gruesome tales of how skeleton staffs cause misery and pain for patients, the nurses argued that Texas hospitals force them to oversee more sick and dying people than they can handle.

“Safe ratios save as many as 72,000 lives a year,” said Beverly Leonard, a critical-care nurse from Austin. Registered nurse Nancy Davis agreed “I’ve worked all around the country. But the problems here in Texas are horrendous.”

Though its fervor was contagious, the ragtag crew apparently didn’t sway many lawmakers to support the Texas Hospital Protection Act of 2007. Sponsored by Houston Democratic Rep. Garnet Coleman, House Bill 1707 was referred to the Public Health Committee on the last day of February and has stalled there without so much as a public hearing.

Still, it may prove downright foolish for lawmakers-and the state’s hospitals and health care providers-to dismiss the fledgling movement.

The reason is Rose Ann DeMoro, a veteran labor organizer from California, a savvy political player who has already brought California Gov. Arnold Schwarzenegger to heel, turned California nurses into folk heroes, and sparked a nascent movement of nurse activists.

Rose Ann DeMoro

The dark-haired 58-year-old is executive director of the California Nurses Association and its subsidiary, the National Nurses Organizing Committee. In the past year, DeMoro has turned her attention to Texas, bringing along her colorful, anti-corporate show.

If history is instructive, the marching nurses are merely the advance guard for organizing efforts that could dramatically change health care in Texas.

DeMoro has been called Wonder Woman by admirers and Nurse Ratchet by enemies, of which she has plenty. Born in St. Louis, Missouri, to an Irish beautician and Italian pizza maker, the working-class girl attended Catholic school and wound up marrying her junior high crush. They moved to California for graduate school, Rose Ann in women’s studies, and husband Don in economics. When her two children were old enough, DeMoro left school to organize supermarket checkers. In 1984, she became the first female organizer for the Western Conference of Teamsters, where she persuaded independent film producers to join the trucker union. But she chafed inside the “good old boys club,” says Joe Kaplon, a former Teamsters attorney. So when the CNA-the state’s largest nurses’ union-offered her a job in 1986, she jumped.

At the time, California had fewer registered nurses per patient than any other state. Night-shift nurses in some hospitals cared for as many as 12 patients at a time, and hospital staffs turned over regularly. Care became so bad that patients dialed 911 for help, according to published accounts. Starting in the early 1990s, CNA began pushing for a state law that would limit nurses to five patients. Yet every year, California’s wealthy hospital industry killed the bill.

Finally, in October 1999, then-Gov. Gray Davis signed the nation’s first safe patient-ratio law. Phased in over several years, it meant that nurses would eventually care for five patients, and sometimes fewer, depending on the patients’ conditions. It also gave nurses whistleblower protection, which should have been the end of the story. In 2003, Davis became ensnared in a recall election and lost his job to a celebrity who weakened the staffing bill after taking office in 2004. “That’s the irony of it all,” DeMoro says. “The nurses weren’t a ‘problem’ until Arnold started picking on them.”

Schwarzenegger delayed a key portion of the law at the behest of his hospital donors. Infuriated nurses sued to overturn his decision and began picketing the then-popular governor. The RN’s were ignored until Schwarzenegger made a grave mistake one day in December 2004. While he was addressing a crowd of 11,000 at the state’s 18th annual women’s conference, a few nurses unfurled a banner they’d been hiding. “Hands Off Patient Ratios,” it read, a reference to his reputation for groping women. Schwarzenegger grinned and told the audience to “pay no attention … to the special interests. I am always kicking their butts.”

The hall of working women fell silent, but DeMoro pounced. Standing on a CNA picket line outside, she told reporters: “For the governor to denigrate nurses while speaking to an audience of women is an affront to women everywhere.” That night, the governor’s crude joke-and DeMoro’s smooth rebuke-made national news. She grabbed the spotlight and began educating Californians about the nurses’ battle. Citing a study published in the October 22, 2002, Journal of the American Medical Association, she explained that when a nurse cares for more than four patients, the chance that one of them will die increases 7 percent for every extra patient. “People really do die when staffing is inadequate,” she said. A few weeks later, when the governor gave yacht owners a sales tax break-and cut public education and safety funds-DeMoro called on teachers, police, and firefighters to join her protest. They balked at following the small, then-50,000 member union. “We were told … that if we attacked the popular governor, the public would turn against nurses,” DeMoro recalls.

Unbowed, DeMoro stepped up the guerrilla theater. In early 2005, the union threw a New Orleans-style funeral march on the steps of California’s Capitol with a jazz band, weeping widows, and pallbearers carrying coffins marked “Patient Care.” On Super Bowl Sunday, CNA rented a plane to buzz the governor’s bash, flying a banner over his mansion that read: “It’s no party for nurses and patients.” When Schwarzenegger pulled up to the 21 Club in New York to attend an $11,000-a-plate fundraiser, he bumped into a picket line of nurses and ducked into an alley. The celluloid figure was accustomed to well choreographed media events. Now he was facing telegenic nurses, and he didn’t seem to know how to handle it.

The skirmishes didn’t amount to much until one spring day in 2005, when 1,000 nurses descended on Sacramento. Teachers, firefighters, PTA dads, and policemen converged on the Capitol that day to protest state budget cuts. When DeMoro’s forces arrived, the crowd parted for them, and cheers erupted. “That was a truly inspiring moment,” says registered nurse Kay McVay. A few days later, state Judge Judy Hersher ordered Schwarzenegger to lift his “arbitrary, capricious” delay of the ratio law, handing nurses a victory. Only then did other unions join the nurses’ anti-Arnold demonstrations.

Firefighters began hosting tailgate parties, serving protesters burgers and baked beans. At one rally, nurses passed out a dozen cartoon masks of the governor, which teachers wore atop faux business suits. “But my favorite was the time we put Arnold on eBay,” DeMoro says. In the fall of 2005, CNA and its national subsidiary listed Schwarzenegger for sale on the Internet auction site: “Genuine, corrupt Governor … not an imitation,” read the ad. Bidding started in the morning at $12 and zoomed to $3.6 million by afternoon, when eBay Inc. yanked it from its Web site.

A frustrated Schwarzenegger had already appealed the court’s decision on the patient-ratio law. He was also asking voters to approve a bundle of his pet policies in a special, $70 million election. His ballot initiatives targeted public employee unions and their allies while giving pharmaceutical companies more power. The nurses recommended rejecting all the propositions. On November 8, they gathered nervously inside a tiki restaurant to await the results. When it became clear that voters had crushed Schwarzenegger’s entire slate, the nurses danced a conga line around the room while a teary eyed DeMoro watched. CNN and other news outlets reported the jubilee. Two days (and some 107 nurse protests) later, a chastised Schwarzenegger dropped his appeal.

By then, DeMoro was already expanding her movement beyond California’s borders. With the fledgling National Nurses Organizing Committee, she began looking around for her next wrangle, and saw that Texas was ripe for her roughneck brand of organizing.

Texas nurses in 2005 were in roughly the same place as California nurses had been 15 years earlier. The Texans found themselves responsible for eight, 10, in some cases as many as 16 patients at a time, performing not just traditional nursing duties, but janitorial and clerical chores, too. Postsurgical patients moaned in their beds because nurses were too busy to administer pain medicine or change bedpans, says Leonard, the Austin nurse. Recently, articles report that some patients have dialed 911 from their beds, while others have simply given up. “We found a patient dead after we got four admits in a short time,” says one San Antonio nurse who asked to remain unidentified.

Not even family members of registered nurses are immune from such horrors. Susan McElreath, an intensive care nurse in San Antonio, says her grandmother was recently convalescing at the Baptist Hospital System (owned by Tennessee-based Vanguard Health Systems Inc.) with a broken hip and broken wrist. The elderly woman needed help getting to a restroom and pushed the call button for half an hour. Eventually, she pulled herself out of bed and crawled to the bathroom, where she was found later at 2 a.m. “She was so humiliated,” McElreath says. “It’s amazing to me that this hospital has no money for staff, yet somehow manages to be a Fortune 500 company.” She later spoke to the hospital’s chief executive about the incident. “But he didn’t make me feel any better,” she says.

Texas’ health care industry is the nation’s third-largest, according to the U.S. Census Bureau, with some $82 billion in 2002 expenditures. Texas also is the uninsured capital of the nation, claiming the highest percentage of children without coverage, and the third-highest of malnourished residents. It has among the fewest nurses per capita, according to a legislative report by state Senator Eliot Shapleigh, an El Paso Democrat, called “Texas on the Brink.” Texas also has among the fewest dentists, pharmacists, and doctors. No wonder health care professionals in the state feel overworked.

Bedside nurses have an intimate view of the business, says Colleen Miller, a second-generation nurse who’s worked at for-profit and nonprofit facilities. She’s watched patient care deteriorate in Texas. “I saw how everyone, the doctors, nurses, and staff, was tense and angry with each other,” she says. “I’d go to the hospital CEO and explain that the problem was understaffing.” The executive, she says, would shrug and say: “We had to cut the budget.” Miller can’t understand why executives were cutting staff positions when more-and sicker-people were streaming into acute care facilities. “At first, I had no idea what it meant,” she says.

What it meant is that health care over the past two decades has became big business. Texas is home to the nation’s second- and third-largest hospital chains: Dallas-based Tenet Healthcare Corp. ($10 billion revenue in 2006), and Plano-based Triad Hospitals Inc. ($5.5 billion). The country’s largest hospital chain, HCA Inc. ($25 billion), of Nashville, Tennessee, has 57 facilities here. Kindred Healthcare Inc. ($4 billion), US Oncology Inc. ($3 billion) and others firms profit nicely, too.

During the 1980s and 1990s, most of these companies grew aggressively by dipping into the government honeypots of Medicare and Medicaid. Medicare reimburses hospitals for care provided to patients over 65 and the disabled, while Medicaid helps the needy. Since Wall Street loves nothing more than guaranteed profits, fortunes were made on the assumption that Uncle Sam would continue to pay hospitals generously. When Congress relaxed antitrust laws in 1994, mergers and acquisitions in the multi-billion dollar health care industry began to boom.

Nurses had to become more corporate, too. They now spend approximately 15 minutes of each hour filling out documents to comply with company rules, says Carol Riley, an Austin RN. The remaining 45 minutes is for patient care, chart review, and other duties. On a shift of eight patients, that leaves about five minutes a patient. “That means we can’t do a decent job,” Riley says.

The job became tougher in 1997, when Congress slashed Medicare reimbursements by $115 billion over five years. The government-subsidized model of health care began to flounder, forcing many companies to get creative. Tenet, for one, was accused by the U.S. Justice Department of inflating the amount of Medicare and Medicaid work it performed by submitting phony bills. So was HCA, which pleaded guilty to some fraud charges and settled others by paying $1.7 billion in 2000. Tenet fought the feds until 2006, when it settled for $900 million. Between 1995 and 2003, Uncle Sam recovered some $8 billion from hospital chains, pharmaceutical companies, and other medical businesses.

Since then, many firms have retrenched. HCA has gone private in a huge, $33 billion deal that allows it to escape some public scrutiny during a most challenging time. Tenet has refocused its operations in a few growing markets, primarily in non-union states such as Florida and Texas. While many community-based hospitals get by on a roughly 2 percent profit margin, for-profit companies depend on institutional shareholders and investors who expect returns of 15 to 20 percent annually. That’s impossible to achieve every year, which is why Merrill Lynch & Co. forecasts that the average hospital will post income gains of 8 percent this year. To obtain that figure, companies still must watch expenses and increase employee productivity.

Meanwhile, money floods to the bottom lines of HMO, hospital, and pharmaceutical companies in Texas. Most comes from taxpayers, according to a national 1999 Harvard Medical School study. Medicare, Medicaid, the Veterans Administration, programs for the military, federal employees, and Congress continue to reimburse corporations for treating patients. Revenue from income, sales, and property taxes also helps buy coverage for state and local public employees. According to the Harvard study, taxpayers fund as much as 60 percent of health care costs. Given that the Texas’ population of 22 million is forecast to grow 60 percent by 2030 (according to the U.S. Census Bureau), it stands to reason that the state’s gargantuan health care business will boom, too.

All of this angers nurses, many of whom are appalled that the system privatizes profits but socializes risks. “It’s not like the CEO’s are taking pay cuts,” Davis says. In 2005, Tenet CEO Trevor Fetter collected $6.74 million in total compensation, including stock option grants, according to Securities and Exchange Commission filings. Triad CEO James D. Shelton raked in about $8 million-plus another $7.84 million in unexercised options from previous years. HCA CEO Jack O. Bovender-one of the highest-paid men in the industry-took home $11 million in 2005. According to regulatory filings collected by the Executive Pay Watch Database, he’s cashed out $9 million in previous options and has another $26 million in unexercised options from previous years. Now that HCA has gone private, who knows how much he’ll make next year?

Fueling the nurses’ ire is the waste in the system. In 2003, HMOs reported to the Texas Department of Insurance that their administrative costs exceeded $2 billion dollars-about 17 percent of total costs. That covers TV advertising, print marketing, overhead, billing, paperwork, and sales bonuses. Cutting that expense by just 1 percent would yield savings of $130 million a year-enough to treat the state’s poor or increase staffing. “Our patients don’t understand
hy they can’t get
he type of medical care that they deserve,” McElreath says. “And neither do we.”

Onto this emotionally charged stage stepped DeMoro and her nurses, carrying not bullhorns and banners, but blankets and bandages.

About 250 nurses protested at the Capitol in March

Days after Hurricane Katrina slammed the Gulf Coast in August 2005, NNOC’s national organizing committee sent e-mail alerts asking for volunteers to help the devastated region. A week later, 320 California nurses began streaming into refugee camps, including Houston’s Astrodome. On their own dime, the nurses worked long hours in horrific conditions. Texas nurses were impressed. According to Barbara Reece, chief nursing officer of the Harris County Hospital District, the committee was the only “planned group” that showed up at the Astrodome.

Friendships blossomed as local nurses swapped stories with the visiting nurses. “We have a lot of the same problems, but no one here was listening to us,” says Leonard, the Austin critical-care nurse. The California nurses had scored so many political coups and legal victories that power brokers listened to them. Texas nurses wanted that, too, so in December 2005, as hail pelted downtown Austin, national committee organizer Ed Burns met with registered nurse Cynthia Medlin of Austin and, later, a few more veteran RN’s. “I knew they didn’t want to overreach. So I told them they should go slow,” says the gray-haired Medlin. But some middle-aged nurses wanted swift action. “We flat out said ‘no,’” says Danielle Magana, a registered nurse from San Antonio. She and others wanted a safe patient-ratio bill like California’s. “Actually, we need federal standards,” Magana says. “But if we have to pass patients rights bill on a state-by-state basis, so be it.”

Other labor groups were eyeing Texas, too. The Service Employees International Union, with 1.8 million members, organizes health care workers, but at the time hadn’t enlisted Texas nurses. (By March 2007, it would sign up 100.) The American Federation of State, County, and Municipal Employees represents 1.4 million workers in public facilities, including some in Texas, but doesn’t organize private hospitals. Only DeMoro’s national committee, with its 80,000 members, sent letters to Texas nurses inviting them to meet.

The committee hosted two information meetings in March 2006, one in Austin and another in San Antonio. The 85 attendees had thousands of pent-up grievances, Leonard recalls, ranging from rising corporate profits to their own shrinking ranks. “Can you believe that most nurses, who’ve spent their lives taking care of sick people, have no pensions for their old age?” asks DeMoro. Her union had already begun securing contracts in California that included pensions and health care for retirees, and that appealed to the Texas nurses, too.

But it’s hard to prod nurses into public stands, says Julie Byers from Austin. “Nurses can be kind of wimpy. That’s because we’re one of the more beaten-down sectors of the labor market,” she says. Even in the best of times, it’s difficult to organize female professionals, adds Medlin. “We don’t know how to go out and fight for ourselves,” she says. After years of accepting downgrades from employers, RN’s joked that they’d become industry “enablers,” allowing hospitals to pump profits and cut services. Many nurses were afraid to speak out, fearing they’d lose their jobs. In Texas, a nurse who sees a patient being mistreated in some way can file a “safe harbor” complaint with her employer. But a spokeswoman at the Texas Hospital Association admits that the “onerous, nine-page (document) is a discouragement.” The safe harbor rule gives nurses and their supervisors two weeks to solve problems, after which the nurse’s job is no longer safe, according to several RN’s. “It’s a sure way to get written up and run off,” says a nurse who didn’t want to be identified.

A core group of nurses was willing to risk it all for a little control. In August 2006, the national committee hosted its first leadership conference, drawing 25 nurses to the Alamo in blistering, 104-degree heat. When it came time for the nurses to publicly demonstrate under the committee banner, only a handful marched. “It was very discouraging,” says NNOC member Betty Bennett. Over the next few months, she and others continued talking to co-workers about patient ratios and gathering signatures to support the Coleman bill. “What’s remarkable is that Texas has a tremendous number of top-quality nurses who are ready to lead the charge,” says Ed Bruno, a national committee organizer. Medlin, Magana, McElreath, Leonard, Bennett, and others began holding strategy meetings in their homes.

By November 2006, they not only had a draft of HB 1707, but some sponsors: El Paso Republican Pat Haggerty and Houston’s Coleman. To mark the event, 100 nurses marched on the Capitol wielding union signs. Modeled on California’s law, the bill would establish minimum, safe nurse-to-patient ratios ranging from 1-4 in medical units to 1-1 in emergency rooms. It would also give nurses the legal obligation to advocate for patients, meaning they would have to stand up to executives and insurers if they believed it was in the patient’s best interest. The bill would also give nurses whistleblower protection.

The bill’s biggest opponent is industry lobbyist THA. “We have a severe nursing shortage, and we feel this ratio law does not address that,” association spokeswoman Elizabeth Sjoberg says. Texas already has a slew of federal, state, and local laws that guard whistleblowing nurses from retaliation, she explains. “It’s unfortunate,” she says, “that nurses do not know they already have these protections.” To drive home that point, THA is working on two other bills that would “clarify those professional protections,” Sjoberg says. THA recently proposed increasing fines for hospitals that violate rules from $1,000 to $10,000 (DeMoro’s national committee advocates $25,000). Since the birth of the ratio bill, THA has unleashed a flurry of other plans, including simplifying the nurses’ complaint process and educating them about their rights. To hear THA explain it, the main problem is ignorant nurses. As Sjoberg says, “Nurses need more guidance and assistance in understanding the laws.”

That attitude dismisses valid arguments for ratios. Even Schwarzenegger’s office has acknowledged that California’s law has produced some benefits. For one thing, it’s lured thousands of nurses back to work, easing that state’s shortage. But don’t count on that message getting through in Texas, as the nurses’ bill faces tremendous odds. “It’s a long shot,” admits Medlin. But Texas nurses know that DeMoro’s California nurses spent 10 years pushing their bill uphill. “If our bill doesn’t pass,” says veteran nurse Evelyn Posas from Dallas, “it will not diminish my faith and desire to keep going, no matter what.”

Texas nurses protesting for lower patient loads included Bev Leonard (l), Betty Bennett (2nd from right), and Danielle Magana (r)

On that overcast day in March, the surprisingly large crowd of 250 nurses advanced up Congress, drawing stares and bemused smiles from passersby. The chants grew louder as they approached the Capitol, where they added a little rhythm: “The nurses, united, will never be defeated.” DeMoro and her staff were already on the Capitol steps unfurling banners, plugging in microphones, and setting up a photogenic backdrop for the protesters. The hands-on leader was facing several other battles besides the one in Texas as national committee nurses were drafting similar ratio bills for Illinois, Ohio, Maine, and Missouri.

When the Texas marchers reached the Capitol steps, TV cameras started rolling tape for the evening news. San Antonio nurse Magana took the microphone and, in a voice trembling from stage fright, said: “We know the reality and truth of what’s happening in our hospitals, regardless of what the corporations and other organizations are telling you.” While she asked lawmakers to pass the ratio bill, other nurses arranged themselves on the steps and held up sheets of white paper that rippled like gauze. Each sheet contained a dozen nurses’ signatures supporting HB 1707. The women had managed to collect some 3,000 nurse signatures, an amazing number that shocked even this congregation. “Dang!” shouted one Dallas-based nurse. DeMoro beamed, knowing the Texas battle is well under way.

Kathleen Sharp is an award-winning journalist and filmmaker based in Santa Barbara, California, who covers the health care industry.