Under the Knife

Ask pretty much anyone working in the German health care system why resources are so thin on the ground and the answer is likely to be an English acronym: DRGs, short for Diagnosis Related Groups. “Ever since the new financing system for hospitals — the Diagnosis Related Groups — it’s like working in a factory,” said Silvia Habekost, an anesthesia nurse. “The time pressure is ridiculous.”

In the operating theater, that means getting the next patient anesthetized and ready for surgery while the previous one is still under the knife. “And for all that you only have one team,” explains Habekost. “You have a patient in the operating theater and a patient in the preparation room, but you can’t be in two places at the same time.”

In Germany, although health coverage is universal and mostly free at the point of use, it is not paid for directly by the state. Instead, health care is funded through a system of compulsory health insurance, in which most workers pay 15 percent of their wages into a Krankenkasse, or sickness fund.

Whereas previously, hospital budgets were negotiated with the sickness funds, the idea of DRGs is that when you walk into a hospital, the institution receives a set payment based on your condition. The system was dreamt up in the 1980s by Alain Enthoven, a former Pentagon economist, who suggested it could be used to rein in health care spending by following similar logic to his proposal to keep defense budgets in check.

Twenty years earlier, Enthoven had been working for the RAND Corporation and cowrote a pamphlet titled, “How Much Is Enough?” to explain his thinking. Ask a bomber pilot and an aircraft carrier captain to sit down and agree on whether the budget should be spent on bombers or aircraft carriers, and they’ll usually come up with the answer “more bombers and more carriers,” he wrote. “The same thing happens in hospitals among specialists dividing up the floor space and facilities.”

The answer in both cases was a way to move away from giving military men and top doctors a budget to spend how they deemed fit — with the inevitable need for more — and instead put an objective price on what was needed. Whether in defense or in health care, Enthoven’s recipe would allow priorities to be determined and deliver a rationale for saying no to certain requests for resources.

The idea of introducing a price list for health care was seized upon by politicians, first in the United States, then in Britain, then in Germany. Whether it was the state footing the bill, or individual patients and their insurance companies, these neoliberal reforms paved the way for the creation and expansion of lucrative markets in health care services. And they provided a scientific veneer for the slashing of public health spending.

In Germany, the effect was dramatic. The DRG system was introduced in the early 2000s and intensified the existing pressure on health care staffing. Between 2003 and 2006, almost eighteen thousand nurses’ posts were scrapped, according to a study by Dr Robin Mohan.

By the time Stella Merendino trained to become an emergency room nurse in 2016, the problem was entrenched. “I totally love my job,” she told Jacobin. “But the working conditions have been bad from the beginning. Too few staff, far too many patients.” She described a typical scenario: “On an early shift we are supposed to be seven people, and as it turns out there’s only three of us. Nonetheless, forty, fifty, or sixty patients are lying in the ER, with only three nurses. It just doesn’t work.”

Merendino is one of twenty-three hundred health care workers in Berlin who joined the union in the organizing drive, which began at the start of the year and was coordinated across the two major hospital groups in the German capital, Charité and Vivantes. She was approached by a colleague who said they were building a new campaign, not about better pay but about more staff and better working conditions.

“I said ‘yes, definitely, something’s got to change.’” Within three weeks, Merendino was not only herself a member of the service workers’ union Verdi, but had talked most of her forty colleagues in the Emergency Room into signing up too.

Key to the movement’s success has been a systematic approach to these conversations, which is as much about letting workers speak their minds as it is about selling the advantages of trade union membership. “It was important to say: How do you find our work at the moment?,” Merendino explains. “What is going wrong, as you see it?”

“The more you talked with them — or the more you allowed them to talk and just listened — the more they talked themselves into a fury and realized what a shit show we actually work in every day.”

Wetzel found that after the first devastating wave of the COVID-19 pandemic last spring, even skeptical colleagues could be won over by reminding them that universal praise for health care workers had failed to materialize in tangible improvements. “Everyone applauded but no politician has seriously instigated change,” he said, recounting a typical conversation with a colleague. “That will only happen when we as employees take it upon ourselves to force improvements.”

Building Toward a Strike

It was sitting around a computer screen in the Verdi union’s Berlin headquarters that Wetzel and his fellow campaigners first came up with the idea for the Krankenhausbewegung, or hospital movement. The group of about a dozen activists had been brought together by the union to watch an online seminar led by the US researcher and trainer Jane McAlevey.

The particular conversational technique that worked so well is part of McAlevey’s tool kit for building mass-participation strikes, developed by drawing on the tactics of the radical Congress of Industrial Organizations (CIO) unions of 1930s America. The seminar was designed to train workers not just how to have effective conversations with their colleagues, but a whole range of tactics for going further than the bureaucratized and limited conception of trade union activity that has become routine in Germany and much of the world.

A key aim is to organize across traditional workplace boundaries that set colleagues against each other. At Vivantes, outsourcing had meant some workers being employed through subsidiaries where they were paid less than their colleagues. But the united approach set out by McAlevey offered the prospect of overcoming the divisions. And the makeup of the meeting in the Verdi building was promising.

“There were people from the waste disposal service, from telecoms, but also from both Vivantes and Charité,” explains Wetzel. The group became convinced, above all, when McAlevey told her pupils how the tool kit had been used successfully by workers in the United States. “Jane talked about the big teachers’ strike in Los Angeles,” Wetzel recalls. “That was totally impressive for us, many of us were completely taken by that.”

McAlevey provides a blueprint for how to build up the forces needed for a successful strike. Key to the process is going through repeated “structure tests” — shows of strength that provide an indication of how far the organizing efforts have gone, and the appetite of the workforce for increasingly high-stakes action. One of the most visible manifestations of the structure tests are giant banner petitions — employed both by the teachers in LA and the nurses of Berlin — bearing the photographs of hundreds, if not thousands, of workers.

Over in Germany, it was the petition handed to Berlin politicians last May that started the countdown to the strike. Signatures from 8,397 health care workers provided confirmation that the organizing efforts had reached most of the workforce. Their demands were accompanied by a deadline: hospital management had a hundred days to agree a new contract guaranteeing minimum staffing numbers and leveling up pay — or they’d walk out indefinitely.

Sustained Action

A strike in the McAlevey school is no symbolic gesture. Her method calls for sustained action involving large numbers of workers to put the maximum possible pressure on management. For medical professionals, the dilemma was how to square that with the desire not to put patients at risk.

“The problem for us was that people always said that emergency rooms can’t strike,” explains Merendino. The solution came from the already dangerous situation created by cost cutting. The emergency room team decided that during the strike they would reduce their numbers to those of the most understaffed shift of the preceding six weeks. “The bosses couldn’t say no, that is too few people, because they already have us work under these conditions on a regular basis.”

Anything that wasn’t a real emergency or could wait was postponed — or handed over to those higher up the hospital hierarchy. “We delegated tasks back to doctors that we as nurses would normally do for them,” says Merendino. “That meant it was in the doctors’ interests that we were successful.”

There was a similar arrangement in every other department of the hospitals. Beds were closed, patients were referred to other hospitals or told to wait. The DRG system was weaponized against the hospital management, depriving it of income as patients were sent away. While earlier the strikes had involved perhaps a hundred fifty workers in each hospital, this time mass participation was assured. Votes for strike action were won with 98 percent in favor.

With management under this pressure, the union began an extraordinary negotiation process. Whereas previously talks to end a strike would be led by a small number of union officials behind closed doors, this time they brought the shop-floor workers with them — another hallmark of the McAlevey approach.

These team delegates had been elected in discussions like Wetzel’s meeting with his colleagues on the picnic blanket. In an exact reversal of the top-down budgeting envisioned by Enthoven, staff in every department had worked out exactly how many nurses were needed on each shift to get their jobs done properly. And their detailed knowledge of working conditions on the ground was brought into the negotiations at Verdi HQ.

The negotiations — and the strike — lasted a month. With each offer from management, union negotiators would consult the hundred or more delegates waiting in the room next door before returning to give their verdict. The final negotiation session lasted twenty hours. At 4:30 AM there were still eighty team delegates in the room waiting for news. “We presented all the results to them and said, ‘This is the state of play, should we accept that now?’” recalls Wetzel.

The deals guaranteed that for the first time, there would be not only minimum staffing numbers for each ward, but binding payments and paid time off as compensation for working understaffed shifts.

“Our strong strike, and that we were able to keep it up, plus this way of negotiating, led to winning this agreement,” says Habekost. “Our management did not expect that.”