THE PROVISION AND FUTURE OF HEALTHCARE IN THE UNITED STATES HAVE become hotly contested social issues, centered over whether the market or state will organize these services. Healthcare has steadily moved from a private industry toward a more highly bureaucratized and collective "managed care" system in lieu of a single-payer, state-run system (e.g., the failed Clinton reforms). At the same time, nurses have emerged as one of the most activist occupational groups in the labor movement. More highly visible in opposition to managed healthcare and their working conditions, nurses have increasingly relied on public protests and strike activity to express their grievances (witness the California Nurses Association).
These developments are not coincidental, though their relationship is far from clear. As the changing political economy of medicine alters the organization and provision of healthcare services, it also affects the work relations and culture that characterize nursing. Though globalization and capital flight have made it more difficult for workers in the manufacturing and industrial sectors to organize, service workers--especially nurses--are relatively shielded from these trends because they provide in-person services. However, if nursing jobs are not being exported overseas, immigrant nurses are, and have been, recruited from other countries in the context of imperialism and globalization.
Nursing has continued its historical efforts to professionalize despite external opposition and internal dissent. At the same time, bureaucratization of decision-making and segmentation within nursing have transformed the struggle for control over the practice and purpose of this occupation. Since the 1960s, concern over the success of professionalization has grown as nurses have increasingly looked to unionization and collective bargaining. For the labor movement in general, and union organizing in particular, nursing constitutes an important and strategic sector that deserves serious attention. With globalization shadowed by the rise of neoliberalism, political support has increased for government cutbacks and market-oriented reforms for social services, including healthcare. This threatens the public's right to receive healthcare, which we consider a social right, not a consumer privilege. In this context, the struggle of nurses is part and parcel of the struggle of working people throughout the United States. As workers grasp at the straws of fading employer health benefits and the mirage of affordable private insurance, they must also be concerned with the delivery and quality of stretched and overburdened health services--services that are increasingly provided by nurses. With demographic trends forecasting an aging population, the healthcare crisis looms as one of the most urgent in need of a solution.
It remains unclear whether these trends can be reversed. The Clinton healthcare plan of the early 1990s may have failed insofar as its defeat led to the hapless and inefficient market debacle of Health Maintenance Organization (HMO) managed care. It did, nonetheless, resurrect an ideal of single-payer healthcare that has remained salient, though submerged, in the national psyche since the 1940s. And progressive calls for universal healthcare have recently found support from former Vice President Al Gore and presidential aspirant John Kerry, among others. With the growth of physician groups such as Physicians for a National Health Program (see www.pnhp.org), it might appear that this ideal lives on and the harmful cuts in Medicaid might cease and be reversed.
On the other hand, the forces that doomed the Clinton plan remain resilient and must be reckoned with in the years ahead. As in the early 1990s, staunch fiscal conservatives in both political parties, joined by the Republican religious Right, stand vehemently opposed to universal care and expanding Medicaid services. Likewise, the core of the medical industry, including the American Medical Association, a majority of physicians, elite nurse specialists, and the pharmaceutical-hospital complex, continue to resist any inroads into their spheres of control and autonomy. …