If you get a check-up at any health clinic in America today, you may have no idea how much it will cost, but two things are virtually certain: The bill will be too high, and the nurse who saw you will be paid too little. The sickening paradox at the root of the American health-care system is that despite skyrocketing costs for patients, front-line workers like medical assistants and home-care aides are shockingly underpaid—while insurers and health-care corporations pocket the difference. The health-care-reform debate in Washington is finally starting to grapple with the equity gap in the health system for consumers, and momentum is gaining for a fairer government-run single-payer system. Yet, for all the promise of the “Medicare for All” proposal, there’s surprisingly little discussion on how an overhaul of our health-care system would affect the people delivering our care.
The new single-payer legislation in Congress, alongside parallel state-level proposals, promise free care for all. But, according to Center for Economic Policy Research (CEPR), however services are financed, hospital-based institutions are set to consolidate and downsize, and workers will be left with more work for less pay.
With or without an overhaul of Obamacare in Congress, the system is changing, for better or worse: For years the health-care industry has been shifting from a hospital-centered model of care to a more community-based infrastructure. If current trends in health-care restructuring continue, public and private facilities will undergo major cost-cutting measures, such as merging large corporate hospitals and moving basic services into simpler local facilities for outpatient care—emphasizing streamlined care, such as medication management or in-home nursing programs. That could mean leaner, more efficient services for patients. But the downsizing may also shift jobs to more precarious sectors, where, since 2005, according to CEPR, “wages are declining or stagnating, and inequality is increasing.”
As the employment structure devolves to outpatient facilities, workers tend to slip into lower-paying positions and, as a result of job disruption, perhaps lose union representation. Over time, researchers conclude, “the unraveling of hospital-based employment systems is associated with greater wage inequality.” While the health-care workforce has grown generally, real median earnings slipped from 2005 to 2015, falling on average 2.4 percent, and outpatient facility workers were especially hard hit, with median wages declining 6 percent. (Insurers’ profits and health-care costs grew steadily during the same period.)