'We're Drowning': Why Kaiser Mental Health Workers Are Striking

On Friday, the fifth day of an open-ended strike by Kaiser Permanente mental health workers across Northern California, some 200 employees and supporters marched to the health care giant's Oakland headquarters, demanding that management increase staffing and resources.

They were among the roughly 2,000 Kaiser therapists, social workers and other mental health care staffers across Northern California — represented by the National Union of Healthcare Workers — who formed picket lines outside Kaiser facilities this week, after negotiations with management ended without resolution last weekend. Those striking said employee morale is dangerously low and patient care has become substandard due to long wait times for treatment.

Kaiser officials have called the strike unethical to patients and counterproductive, pointing to the shortage of mental health professionals nationwide. A company representative declined to participate in an interview, citing ongoing negotiations.

But in a statement issued Friday, Deb Catsavas, senior vice president of human resources at Kaiser Permanente Northern California, reiterated the company's stance that the strike and "disruption to patient care" were unnecessary.

"While [the National Union of Healthcare Workers] claims it is fighting for increased access to care, its primary demand is for union members to spend less time seeing patients," said Catsavas. "Our patients cannot afford a proposal that significantly reduces the time available to care for our patients and their mental health needs."

The strike comes amid what the White House has described as an unprecedented mental health crisis among Americans of all ages.

Why are Kaiser mental health care workers striking?

"We're striking because it's demoralizing to work for a company that actively does things to capitalize on burnout," Naomi Johnson, an associate clinical social worker for Kaiser, told KQED Forum. "We're really working very hard as clinicians to try to see patients as frequently as we can, and to provide the care that we're trained [for] and good at providing. And we're not supported in doing that by the company."

Kaiser tells patients that "if you have any sort of concerns or you want to come to therapy, please reach out," added Johnson. "And then as providers, we're told, 'Only treat people who meet medical necessity.' So it's really difficult because we have this huge influx of people trying to seek services, but there aren't enough of us to actually meet the demand, so we're just completely overwhelmed. ... We're drowning, as clinicians."

How does understaffing affect patients seeking treatment?

"There are currently 2,600 Kaiser patients for every mental health worker in (the) Northern California Kaiser system," Ilana Marcucci-Morris, a licensed clinical social worker in Kaiser's psychiatry department in Oakland, told Forum. That means the average Kaiser therapist sees between seven and 12 patients per day, while someone in private practice might see between three and six. After a series of initial intake calls, the majority of Kaiser patients calling with a "nonurgent" need wait between two and three months to see a therapist.

The National Union of Healthcare Workers points to internal Kaiser documents illustrating that "patients who received an initial mental health assessment on June 13 weren’t scheduled for follow-up appointments for a month in San Francisco, more than two months in Sacramento and three months or more in other parts of Northern California." That length of time, experts say, does a disservice to those who have already taken the often-difficult first step of seeking support.

"The goal is to help people get better and terminate," said Marcucci-Morris. "But the system within Kaiser does not allow for that. It's the opposite. People are waiting longer, and deteriorating to where they either give up and pay [for therapy] out of pocket, which sets up a system for folks who have those resources to pay a private practice therapist and get better." She said people who can't afford private therapy and insurance premiums aren't able to get better. "They get worse and they stay in Kaiser and they just stay sick," she said.

What is causing the understaffing?

Kaiser administrators point to what they describe as a nationwide staffing shortage. "Across the country, there are not enough mental health care professionals to meet the increased demand for care," said Kaiser's Catsavas in an Aug. 15 statement. "This has created challenges for Kaiser Permanente and mental health care providers everywhere."

Company administrators say they have worked to combat the shortage by hiring new mental health clinicians, including nearly 200 new clinicians since January 2021; improving mental health care access through virtual care; and launching a $500,000 initiative to recruit new employees.

But those on strike said the severity of the shortage is specific to Kaiser, and that burnout and poor working conditions are contributing to low retention of existing employees, and making it difficult for the company to recruit new ones.

"There isn't a shortage of clinicians. There's only a shortage of clinicians that want to work for Kaiser," said Marcucci-Morris. "We get into this field to help people, and it's hard to recruit therapists when Kaiser's reputation is known to make people wait so long for therapy sessions. It's really, really not ethical. And I personally have a handful of colleagues and friends who are therapists with time in their schedules who I've tried to recruit for Kaiser. But the reputation is just so poor."

It's more appealing, said those striking, for qualified therapists to work for a private practice. "Workers just don't want to work for Kaiser anymore, and that's the real crisis we're facing," said Marcucci-Morris.

The union said the rate at which mental health clinicians are leaving Kaiser nearly doubled in the past year, with 668 clinicians leaving between June 2021 and May 2022, compared to 335 clinicians the previous year. In a union survey of 200 of those departing clinicians, 85% said they were leaving because their workload was unsustainable or because they felt they did not have enough time to complete the work, and 76% said they were unable to “treat patients in line with standards of care and medical necessity.”

"We need to grow the mental health workforce, there's no doubt about that," California state Senator Scott Wiener told KQED Forum. "It is also the case that the shortage is not as severe right now as the health plans say ... health plans can take steps to expand their workforce, including paying better, providing better reimbursements to private providers, and those are investments that they should be making that they have not made."

"I don't think it's the case that they can just throw up their hands and say, we have some challenges with the workforce, and so therefore, we're going to make people wait three months," he added. "We have real shortages of physical health care providers, but we don't tolerate around physical health what we have long tolerated around mental health, which is effectively denying people access to lifesaving care."

Has California passed any recent laws to address this shortage?

Senate Bill 221, which passed in 2021 and went into effect July 1, 2022, said that "health plans, including Kaiser, must provide timely access to mental health and addiction treatment," Senator Wiener told Forum. "And that means a prompt first visit."

The law codifies existing regulations from the Department of Managed Health Care and the Department of Insurance that require a health care service plan or an insurer to ensure that "for an enrollee requesting a non-urgent appointment with a non-physician mental health care provider ... appointments are offered within 10 business days of the request for an appointment." Follow-up visits have to happen within two weeks, added Wiener.

Senate Bill 858, which recently passed on the California State Assembly floor and will now move to Gov. Gavin Newsom's desk, would update the way health insurance companies are fined for violations, something that hasn't been updated or even adjusted for inflation since the 1970s, said Wiener. Currently, the maximum fine possible stands at $2,500 per violation; the bill, if passed, would increase that amount to $25,000.

"We think that will create a much larger incentive to actually follow the law and provide people with timely and appropriate access to health care," he said.

What exactly are the strikers asking for? What's the current status of negotiations?

In negotiations that led up to the strike, the National Union of Healthcare Workers accepted Kaiser's wage-increase offer. But the union held fast on its demand that nine hours per week — up from the current six hours — be allotted for administrative work. Kaiser rejected that demand, arguing it would not leave adequate time to see patients. The company's counteroffer, of an additional 1.2 hours for that work, was flatly rejected.

"We wouldn't be striking right now if money was the primary [issue]," said Marcucci-Morris, pointing to burnout, retention issues and poor morale — as well as what the union describes as the lack of a clear plan for how the company is going to meet the requirements laid out by SB 221.

"It's not going to fix the problems to buy the therapists out and pay us more," she said. "What good is more pay when you're drowning and can't come up for air?"

How is the strike affecting patients in need of care?

Kaiser is legally obligated to continue providing care for its members during a labor strike.

"Beginning this week, our patients will receive care from those mental health clinicians who choose patient needs over the strike, as well as from our psychiatrists, clinical managers, and other licensed professionals," said Catsavas in a statement on the first day of the strike, while noting that "some nonurgent appointments may need to be rescheduled" and that patients whose appointments might be affected "will be directly contacted prior to the date of the appointment to ensure they receive the care they need."