Introduction

There is wide recognition that the U. S. healthcare system is in crisis. The clearest manifestations of this crisis are related to costs and health outcomes, although the United States spends more per capita on health care then any other nation in the world. This spending might well be worth it if it yielded the best health outcomes in the world but sadly, it does not. In 2000, the World Health Organization (WHO) ranked the United States thirty-seventh in overall health system performance (WHO 2000). This ranking comprises a number of indicators. For instance, among OECD nations, the United States has one of the lowest life-expectancy rates and one of the highest infant-mortality rates.¹ Not surprisingly, we fall even lower on fairness of health financing, which indicates how evenly health resources are distributed across the population. On this measure the WHO ranks us as fifty-fourth to fifty-fifth in the world (WHO 2000). In turn, the disparities in access to health care are reflected in the distribution of health outcomes, particularly across race and class lines.

A further dimension to the problem is that healthcare costs continue to rise at a rate well above overall inflation. (See the Nack and Clark and Clark papers in this volume for specific data on the growth in healthcare costs and spending.) While in any context an increase in costs of this nature would constitute a significant social problem, in the United States it becomes a "labor problem" because employer-provided health insurance has been the foundation of our system. Further, union workers are more likely to have health insurance through their employer. Because those benefits are more costly to the employer on average, this issue has become an important point of conflict in collective bargaining in recent years.² Thus, one of the two overarching areas mentioned in the call for papers for this volume concerned issues raised for workers and the labor movement by the employer-based system. This included such specific topics as collective bargaining over healthcare, trends in the percentage of the insured population, retiree coverage, and trends in cost-shifting or cost-containment. It also included union strategies for reform of the healthcare system including state and federal policy initiatives and incremental versus broad approaches. Finally, papers on the history and evolution of the U.S. system of employer-provided system of care were also welcomed.

The second major area in the call for papers was the study of the healthcare workplace itself. This area includes the organization of healthcare work, the nature of care-giving work, causes and consequences of the nursing "shortage," low income healthcare work, working conditions in the long-term care industry, unionization of healthcare workers, and labor-management partnerships in health care. This area too is affected by the crisis in the system where the healthcare workplace is essentially ground zero. Cost pressures in particular impact the terms and conditions under which health care workers earn a living and attempt to provide quality care. Unions, in turn, are responding with a variety of creative and innovative organizing and representation strategies.

Based on this call for papers, UALE held three conference sessions on Labor and Healthcare at the April 2005 meeting in Philadelphia. Four papers from those sessions appear in this special issue.

David Nack's paper describing the Wisconsin AFL-CIO's strategy for health care reform fits into the first broad theme relating to costs and, more clearly, access. The paper details the development of a particular strategy for health care reform that relies on employer funding but is more comprehensive than the proposals labor is backing in other states. Nack places the Wisconsin plan in the context of these other state-based proposals for reform and provides a detailed narrative of the campaign thus far.

Interestingly, Patrice Mareschal's paper on SEIU's home health care organizing shares with the Nack paper a focus on the political context of particular states and the ways in which unions must adapt to those contexts. Mareschal describes the structure and strategy of home health care organizing not just in the well-known...