On October 3, workers at 37 different dialysis units across California announced their intention to go on an Unfair Labor Practice (ULP) strike for 6 days from October 14 to 19. Dialysis employees at Davita, Fresenius Kidney Care, Satellite Healthcare, and U.S. Renal Care started unionizing with SEIU United Healthcare Workers West in December 2022, but have faced intransigence from management in their negotiations. Management at all four companies have committed countless ULPs, going so far as terminating union leaders.
For profit and against patients
Dialysis stands out as a sector of the healthcare industry in need of drastic change. Dialysis caregivers provide routine care for patients with kidney failure, or End-Stage Renal Disease (ESRD), by taking their blood out of their body, cleaning it, and returning it. In the United States, there are 550,000 patients on dialysis, and ESRD patients are uniquely eligible for Medicare, meaning payments for the vast majority of dialysis patients come through public funding. In fact, one quarter of Medicare spending goes towards patients with kidney disease. In spite of this, the industry is incredibly privatized and monopolized. The two largest companies, Davita and Fresenius, are both for-profit and dominate around 75% of the market share.
Through their monopolization of the industry, Davita and Fresenius make massive profits. Davita is a Fortune 500 company that made $691 million in profit in 2023. In 2020, their CEO Javier Rodriguez received a $73.4 million compensation package. Fresenius is originally a German company, yet their most consistent source of profits has always been in the U.S. They made $540 million in profit in 2023. The monopolization of the industry goes beyond direct patient care—Fresenius also produces equipment, drugs, and machines that are used in the industry. In spite of all of the money these companies make, employees report regular short staffing and poverty wages.
The profit-driven nature of healthcare in the U.S. is laid completely bare in dialysis. While in other fields of healthcare, money hungry giants hide under the guise of non-profit status, dialysis companies are shameless. Satellite healthcare has been one of the few remaining significant non-profits, but employees report that it has been getting taken over by the private-equity run U.S. Renal Care since last year. Under capitalism, more profitable entities swallow up and take over less profitable entities, leading to monopolization and profits over patient care as an inevitable result.
Patients ultimately feel the impact of this callous system. The U.S. reports one of the worst mortality rates for dialysis patients of any industrialized nation, in spite of spending the most money per patient. The mortality rate of patients at Fresenius clinics is 17% higher and at Davita clinics 24% higher than at non-profit facilities. The former CEO of Davita, Kent Thiry, once famously said he manages dialysis clinics the same way he would if he were the CEO of Taco Bell. While corporations and CEOs make millions, patients report unsanitary and unsafe conditions such as blood from a past patient still being on their chair, cockroaches and other insects, and being rushed out while they are still dizzy and recovering. As frontline caregivers, the employees are pained to see such conditions for their patients, but understaffing and company policies leave them with little choice or power.
Dialysis workers fight back
The decision of workers to organize in an industry where there are so few employers has been heroic. Dialysis workers first began organizing in 2016, but they were held back for many years by the industry’s terror tactics of terminating union leaders. Two main factors led to workers finally winning their union in California in 2022. One was the massive surge of worker activity, and particularly the Starbucks union victories. Through their organizing efforts, Starbucks workers set stronger precedent with the National Labor Relations Board for workers to be able to vote in “single shop elections” as opposed to being forced into regional elections. Management at companies like Starbucks and Davita prefer regional elections because they know that they have the upper hand in such contexts. They can make sure management at each location is on message busting the union while pro-union workers do not have the ability to talk to coworkers at locations other than their own, and most often do not even know who they are.
The second factor that led to the organizing boom for dialysis workers was their experience during the COVID-19 pandemic. Workers often had no choice but to work in designated COVID clinics, and just as many other healthcare workers experienced, were left without proper PPE or staffing levels. The trauma that workers experienced through the pandemic exacerbated the grievances that have always existed: low pay, overwork, and understaffing.
The reaction of the dialysis industry towards organizing has been nasty and severe. At Davita, Fresenius, and Satellite, prominent union leaders have been terminated. In one particularly egregious example, Davita fired the main organizer at a clinic the day before a scheduled picket to protest Davita’s actions. Other ULPs have included bad faith bargaining, discriminatory increases to non-union clinics that they withheld from union clinics, and the offer of raises and promotions for workers to vote no in a union election.
The dialysis companies rely on a lengthy and drawn-out legal process through the National Labor Relations Board (NLRB), and one of their key messages to promote futility is that it will take too long for workers to win anything, so there is no point. While the Labor Board has picked up at least one of the unfair termination cases brought forth by the union, it has been over a year since the termination has passed and the damage has been done in a tight-knit community of workers. Furthermore, even when workers do win such cases, at best they will get their job back and receive back pay, but there is no significant financial penalty for the employer. In comparison, Davita and Fresenius have been willing to pay out hundreds of millions of dollars in settlements for various forms of fraud.
In spite of the intimidation, workers continue to organize. Last year, twenty-one dialysis clinics went on strike, and since then their numbers have grown dramatically. In part, dialysis workers have been spurred on by Kaiser workers that went on the largest healthcare strike in U.S. history last year and successfully protected their free family healthcare and pension benefits. A number of the dialysis clinics that are going on strike are clinics that have not even voted on unionizing yet, but they have also committed to striking due to the character of the industry-wide fight.
The implication of dialysis workers winning big in California go beyond the Golden State and go beyond dialysis. Dialysis represents two different trends: the privatization of healthcare, and the disaggregation of the worksite. Many unionists have long held that effective labor organizing only happens in densely congregated worksites like a factory, but as more and more jobs shift to the service sector, many workers work in offices, stores, and clinics of a few dozen employees. In healthcare, job growth in outpatient settings are set to far outpace growth in hospitals over a 10 year period. The united campaign of Starbucks workers has shown that it is possible for workers to win in new contexts and environments and dialysis workers are showing that it is also possible in the work of saving and extending life!
