Tuesday, Jul 30, 2019, 11:54 am
Inside the Bitter Battle to Defend Workers and Patients at a Low-Income Clinic
When Whittier Street Health Center unveiled its glass-sheathed, six-story, environmentally-advanced, state-of-the-art, new facility in 2012, it was seen by its Boston community as a commitment to the neighborhood and the people it serves. With brightly painted walls and expansive views across the city, it sits at the heart of Roxbury, extending an invitation of convenience and care to a population that is mostly Black or Latinx and among the poorest and least healthy in the city.
Of Whittier's patients, 91 percent live in poverty; 50 percent deal with food insecurity; two-thirds have been diagnosed with diabetes, hypertension, cancer, asthma or obesity; 35 percent of adults are without health insurance; and life expectancy for the area served is 58.9 years. Everyone agrees that this is a vulnerable population in need of highly trained, consistent and committed healthcare. Not everyone agrees that this population is getting it.
The reasons are a mix of difficulties shared by many community health centers, including political maneuvering, funding constraints and societal disregard for the poor. But some problems are distinct to Whittier: Staff and patients have complained that ill-advised, high-handed and destabilizing management practices interfere with and disrupt clinical care.
The dominant feelings among the many employees who have left or were pushed out seem to be anger and disappointment, much of that aimed at Frederica Williams, the president and CEO of Whittier since 2002. Last summer, increasingly sour management-clinician relations led to the formation of the first labor union of professional staff at a community health clinic in Massachusetts. The union became necessary, its supporters say, to protect their patients, their jobs and even the health center itself.
Through her then-P.R. consultant, Williams cited restrictions on what she can say about patients under HIPAA or the unionization effort under the Wagner Act. She responded to some questions in writing last October, but declined repeated requests to comment further, instead referring In These Times to the health center's published reports and her public statements and letters to patients and staff. That left medical providers who have moved on, been fired or forced to leave—and unhappy patients—to largely tell the story. That story is one of alleged intimidation and union-busting by Williams and her administration, which has roiled the health center and highlights the challenges to providing good patient care to an underserved community. It also points out the limitations of current labor laws to protect workers at any level.
Last month, a year since the union became a reality, the antagonism between its supporters and Whittier management reached a climax, as a trial, an advanced step in the National Labor Relations Board's unfair labor practice determination, got underway in Boston.
The union came from the organizing efforts of John Jewett, a doctor; Bill Dain, a clinical social worker; and Caitrin MacDonald, a nurse practitioner. Dain, who had been at Whittier for 14 years, had experience with another union, so he was all in when Jewett and MacDonald said, "Let's do it." In March 2018, the trio began getting signatures on cards authorizing a union election under the guidance of 1199 Service Employees International Union (SEIU), which represents some 56,000 healthcare workers in Massachusetts. In mid-May, they filed notice with the National Labor Relations Board (NLRB) to begin a union campaign among Whittier's professional clinical staff. The goal was to foster a working partnership with management, which would involve the entire staff, then numbering about 300, in the organizational decisions that controlled their work environment and the healthcare they provided. But as a practical decision, Jewett says, they started with this smaller, collegial group, several of whom had had issues with management and felt particularly frustrated by the responses they got. When the union began, it had more than 60 members; as of this May, it had 50. (The decrease reflects cutbacks in Whittier staffing
Jewett, age 62, has a degree in medicine with a focus on public health. He came to Whittier because he was fed up with the paperwork in private care and liked the one-to-one interaction in community health. Dain, 77, who loved the intense relationship of individual therapy and the chance to use his fluency in Spanish, also fell into this older category. Younger providers, including MacDonald and Sherar Andalcio—a doctor who was active in the union organizing from a different community health center, having been fired from Whittier the year before—were no less committed.
MacDonald, 40, came to Whittier in 2016, and said, "My dream work is community health…serving patients who represent all of Boston, not privileged people like me." For Andalcio, 36, who grew up nearby, "My dream job was to come back and give back to the community." These are highly-trained professionals who could opt for easier, more remunerative positions, but chose to work under the demanding and difficult conditions of community health care, where burnout is common.
Asked last November about the dissatisfaction among the clinicians, Williams answered in an email to In These Times, "Whittier Street is far from alone among Massachusetts health centers in experiencing financial challenges and employee turnover. … We have been enhancing our recruitment efforts to ensure that we are hiring staff who truly understand and are committed to fulfilling our mission of providing quality care to the vulnerable populations we serve." But the dispute, which resulted in the organizing drive, seemed less about mission buy-in on the part of providers than about how that mission would be carried out day-to-day. The providers charged that problems arose when they made suggestions, challenged abrupt and unexplained changes in policies, asked for greater involvement in decisions affecting their work and their patients, or held management to the terms of their contracts.
Williams’ description of the difficult context in which Whittier exists is accurate. Since it began as a well-baby clinic in 1933 and even in the late 1960s when Boston led the nation in neighborhood health centers, funding has been a challenge. Today, it relies heavily on grants and federal funding. Still, Williams could point then with well-earned pride to her accomplishments: running a health center with a $25 million budget, over 30,000 patients a year, some 40 programs, and a perfect score on its most recent federal audit measuring statutory and regulatory compliance; and building the new facility, which no one had managed to do before. "She's really brilliant at building programs and getting money for them," said Jewett. "She's great on the language of poverty and economic disparity," noted Andalcio. MacDonald added that when she interviewed for her job, Williams "seemed like an engaging and compelling human being."
Williams was born in 1958 in Sierra Leone and studied management in England and Massachusetts. As one of the city's few women of color in top management positions, she is a highly visible, much-awarded champion of women in leadership. She sits on corporate boards, appears on notable-leader lists, and cultivates friendships with local politicians and powerbrokers. She even appeared in Mitt Romney's infamous "binders full of women." It cannot be easy to be a powerful black woman in a Boston still reckoning with racism and sexism, but her detractors charge that having to deal with these obstacles doesn't excuse what they see as her demoralizing management style and actions; they claim these undermined their work at Whittier. Andalcio, who is also black, summed up this sentiment by saying, "If a man was doing what Frederica is doing, it would still be 110 percent wrong."
A typical response to feeling that you're losing control is to try for more control. In June 2018, less than a week before the union vote was scheduled, Williams abruptly fired Jewett, Dain, MacDonald and 11 others whom Jewett knew to be union supporters. They say they were hustled out of the building as their patients waited for appointments. Williams maintained that the firings were necessitated by a budget shortfall, and cited the loss of two anticipated grants, which she declined to name, equaling over $600,000. By the end of that fiscal year, the deficit would reach $1.35 million, Whittier's first operating loss in 18 years.
The next day, Friday, Whittier staff, patients, supporters and local politicians demonstrated resolutely outside the building, demanding that the staff members be rehired immediately. It was hard to miss the swarm of purple SEIU T-shirts, and the media soon arrived to cover the protest. In response to the outcry and bad optics, Boston's mayor, Martin J. Walsh, stepped in to craft a settlement, which Williams described in a letter to the WSHC community as "a pathway forward that will put Whittier on a stable financial footing for now." The employees were told on Sunday that they had been reinstated, though it is unclear by whom, as became clear in the testimony and cross-questioning of Ragan McNeely, a behavioral therapist, at the NLRB trial, and Williams announced publicly that she would take a voluntary pay cut. According to a report on WBUR, a local NPR station, her salary before the cut outstripped those of CEOs at community health centers in similar Boston neighborhoods, although they served more patients.
The drama continued on Monday, when several of the supposedly rehired staff tried to inquire about their status and, as McNeely testified, were not allowed to enter the building past the security desk. The employees were finally permitted to return to work on Wednesday, when the vote took place as planned. It was 50 to 9 in favor of unionizing. Less than three weeks later, in a remarkably tone-deaf move, the board of directors voted to honor Williams by naming the building after her.
Like most stories with differing perceptions of what's fair, right or necessary, trying to pin down who did what to whom is a study in yes-buts. Williams emailed, "The primary reason for this deficit was the failure of specific staffers to reach industry-standard productivity levels." Data compiled by Jewett for the pro-union website, "Whittier staff, union and community news," show WSHC's expected productivity levels for 2017 to 2018 to be higher than Massachusetts and national levels. Jewett worked with data from a 2017 report by the federal Health Resources and Services Administration (HRSA). However, both the Health Center Program at HRSA and the Massachusetts League of Community Health Centers, where Whittier is a member and Williams was on a board, said in separate emails that they have no productivity standards for providers.
And while there had been a decline in clinic visits from 2016 to 2017, they rose slightly to 115,448 in 2018. Jewett calculated that Whittier doctors generate significantly more revenue than they cost, so he argues that cutting their number is counterproductive to attracting and retaining patients.
In the summer of 2018, Williams eliminated the center's urgent care clinic and the orthodontics program that fall, cut some clinical and administrative positions and instituted a hiring freeze, defending her decisions, for instance, in a December 2018 letter to staff, as necessary cost-cutting measures. She announced then that Whittier was on a "break-even budget," and some vacancies have since been filled, though the current WSHC website shows a stripped-down clinical staff.
The targeted employees, however, read those moves as the kind of retaliatory measures that had been going on for a long time and added up to what MacDonald described as a toxic workplace. When Andalcio, the doctor who had come on staff with high expectations, felt underprepared to treat his HIV-positive patients and requested more training, he contended that his request was denied. When Jewett suggested ways to engage management productively—for example, instituting set meeting times for staff to exchange ideas and discuss problems—he was criticized for not going through channels and asking questions out of turn, a claim he reiterated in his affidavit for the NLRB. And MacDonald reported that after a goodbye party for Andalcio, a doctor and another staff member were sent a photograph taken there of the staff in attendance, with a black arrow and a question mark pointed at her head. Given the tensions at Whittier, it looked to her like a threat.
Perhaps most telling was the unusually high rate of turnover among clinicians. By Andalcio's count, 20 doctors, nurses and physician assistants in primary care and obstetrics left between October 2016 and October 2018. Of the 22 who had worked there in 2016, only three are still at Whittier less than three years later. Because new hires are less productive than experienced providers, Jewett estimated that the cost of turnover in primary care in that time was at least $1.4 million. Other, unquantifiable losses included institutional memory and shared knowledge of how things work, but a bigger problem was the damage to patients, who were shuffled from provider to provider, with missed follow-ups and tracking of cases.
Whittier touts its high scores on patient satisfaction surveys, but some patients have been skeptical of their validity. They lauded their providers, but complained about the culture. Shondell Davis came to Whittier in 2013 after a difficult search for responsive care. Her son had been killed and she was close to a breakdown when she found Ragan McNeely, the behavioral health therapist. He was a godsend. Over the next several years, Davis said, he provided "a comfort zone every Tuesday." Just looking at his phone number between appointments made her feel better. McNeely was fired last October, which Davis said she learned only when she came for her appointment. "No calls, no follow-up, no warning," she said a couple of months later. "To me it was unethical. I don't have a therapist now. I don't want to start over again. I just know from my experience, I really felt hurt. I don't think I will ever trust there again."
Marlon Wallen, a multiracial, HIV-positive activist from Trinidad, who lived nearby, became a patient at Whittier in 2016. Wallen reported that he was asked to be an outreach worker and appointed to the Patient Advisory Board. But when he objected that it was a conflict of interest for the chair of Whittier's board of directors to also sit on the patient board, in addition to raising other grievances, he said he was "fired"—from the board and as a patient—and banned from the building. With HIV patients, especially, he maintained, the constant shifting of doctors undermines trust and treatment. He suggested grimly that Whittier's patients put up with it because, "Where they come from, they're used to this stuff."
At a "patient rights hearing" organized by the labor-friendly coalition, Massachusetts Jobs With Justice, this past March, Davis and Wallen were among the some 60 people who testified about their experiences at Whittier. Nearly all talked of feeling betrayed and abandoned and reiterated complaints about valued clinicians disappearing without warning or explanation; difficulty getting someone to answer the phone, let alone getting an appointment; and undue burdens caused by closing urgent care and the orthodontics department. Some managers attended, but Williams did not.
Local politicians had rallied in support of the fired clinicians the summer before and met with union activists afterwards, but of several who were asked to speak to the issues in the following months, the only one who agreed to talk with In These Times was the doyen of Boston politics, Mel King, a former legislator and respected community activist. In a phone interview last October, he summarized the Whittier situation simply: "It's an incredibly important institution in the community. To have an issue like this continue is unconscionable. People's health is at stake."
Forming a union is one thing; successfully negotiating a contract is another.
Unlike many union fights, salaries are not a central concern here. Last fall, Filaine Deronnette, vice president of Health Systems at 1199SEIU, said in a phone interview, "The issues are dignity and respect." She emphasized that they were aiming for respectful lines of communication between management and staff. "The goal is to utilize the union to make it a better place for patients and staff." In the early days, management met with the union and its members as scheduled. Then, according to Marlishia Aho, regional communications manager for 1199SEIU, the union stopped talking publicly, management started challenging who could be on the union's negotiating committee, and one-by-one, union activists were pushed out. Dain and McNeely were fired; Jewett was placed on administrative leave, then laid off and also banned from the building; and MacDonald, needing stable employment, left for another job, albeit sooner than she wanted. By late October 2018, Jewett counted only a handful of the union supporters who had been fired and rehired that previous June still at Whittier.
Last fall, the union filed a series of complaints about unfair labor practices at Whittier with the National Labor Relations Board, charging that three members—Jewett, Dain and McNeely—had been laid off in retaliation for their union activities. The NLRB eventually determined that 30 of the 32 complaints about how Whittier responded to the unionization effort, an unusually long list, were substantiated enough to be brought to trial. While not a finding of guilt, this was a significant step, since the vast majority of complaints the board receives are dismissed, withdrawn or settled out of court.
As the trial began on June 17, both sides had dug in: Jewett described intense negotiations between the union and management the week before as progressing from very far apart to merely far apart, and at the trial, Jim Lee, Whittier Vice President, CFO and part of the management team representing the health center, declined to comment on the proceedings or a desired outcome.
For three intense days, the fired clinicians testified and were cross-examined by Whittier's legal team. Then, on the morning of the fourth day of testimony, the judge, Paul Bogas, put the trial on hold to allow for further negotiations. According to Laura Sacks, a regional attorney of the NLRB, administrative judges can have many reasons for temporarily disrupting a trial for settlement discussions, but it may be because they expect it to be extremely long and complicated with risk for both sides. Sacks outlined the many potential steps to a final decision, which include appeals, briefs, and an open-ended timeline for a judge to issue an opinion. "I can only agree that it's a lengthy process," she concluded.
Most everyone else involved seems to have underestimated how lengthy this particular process would be. Originally calculated in months, it is now talking several years. In a difficult conversation, Jewett, McNeely and Dain considered their options. What made it so hard was that all three had to agree to the same response and, until recently, they had held out hope of returning to their jobs, their patients and their colleagues. Ultimately, they bowed to reality and forged a settlement: They would not return to Whittier and Whittier would pay each 15 months’ salary. When those pay-outs are added to Whittier's legal fees for the case, resisting a union will have been an expensive battle to pursue.
On the rest of the NLRB charges, Whittier must post at the health center a short list of employee rights and a long list of "we will nots." A few provisions are ameliorative, while most are pledges that Whittier will not do in the future what the NLRB alleged they had done in the past to discourage the union and punish its supporters. It is not clear what would happen if the health center did not live up to these promises. Williams, through her former P.R. consultant, again respectfully declined to comment.
Last winter, Jewett said he would go back to Whittier in a heartbeat. "I feel like I started something," he explained. "It's an opportunity to build something I could be proud of, if it gets done." He fluctuated then between hope that pressure from the NLRB and the union would result in providers having a greater say in how care is delivered at Whittier and worry that Williams would just wait out the union until no supporters were left working there. He recalled "shooting the bull with [Williams] in the hall," when he claimed she said, "John, I will never negotiate with the union."
These days, contract negotiations are progressing, and one of the most postive outcomes of the settlement is that Whittier agreed to meet for bargaining sessions more than twice as often as before. But with so many of the original members gone and a significantly smaller staff, it's an open question how committed to the union new hires or those who have stayed will be.
"You can't just assume that if you vote for a [union] election it's going to work out," Jewett said, ruefully, a few days after agreeing to the settlement. "One sobering realization is that the NLRB legal system is not really set up to protect workers. It was fairly amazing to me to learn that that safety net isn't there."
Jewett's partners in the labor complaint aren't exactly singing a rousing chorus of "Union Maid" either. McNeely—who likes to quote Dain's saying about the drawn-out NLRB process, "Slow justice is no justice"—is ready to move on. "There's nothing to go back to," he said. He and Dain count only four people remaining of the 18 who were in their Behavioral Health department when they formed the union. "I'm fearful for what's left," he concluded.
Dain, has a slightly more optimistic take on the outcome. Although their agreement allows Whittier to avoid culpability for the way they were fired, he believes they are vindicated because it points up the contradiction in Whittier's public statements. "Their claim was that they needed to cut back on staff, unrelated to union activity," he said. "Then why would you pay us off not to come back when you have all these job openings?"
As for the other problems the dispute highlighted—the high rate of clinician turnover, fraught management-staff relations, inconsistent patient care—it appears to be a matter of solving the legal issues while leaving the human ones raw. Yet, when asked if their fight was worth it, all three men give a qualified yes. For McNeely, because it can encourage "professional and knowledge worker groups" to organize, which he thinks is the future for unions. For Dain, "You keep up the struggle, even if you lose a particular battle."
And for Jewett, who had staked so much on the success of the union? "Yes, it was worth it," he agreed. "But it was much harder than I ever imagined."
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Nan Levinson is a journalist in Boston. Her latest book is War Is Not a Game: The New Antiwar Soldiers and the Movement They Built.