Brown: Rural health care providers go from the emergency room to the picket line

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Bria Schurke grew up in Ely, where her family’s health care provider was not a doctor but a certified nurse practitioner. This is common in rural areas where it’s hard to recruit physicians, and when cash-strapped clinics need to cut costs. And yet, the quality of care and compassion of her CNP inspired Schurke to pursue medicine.

Today, Schurke is a physician associate (PA) at the Essentia Virginia Hospital. She works in the emergency room, where the pressures of rural health care are constant.

“We are the forgotten part of this country,” said Schurke. “What I see in the ER, the spectrum of the lives people live, we are deep in poverty here. You need people who care not just to get a paycheck but to actually make a change in people’s lives on a day-to-day basis. That’s what we do as PAs and CNPs.”

Pressure intensified Thursday, as Schurke and many of her colleagues walked a picket line. It was the first day of an ongoing strike by Advanced Practice Providers (APP) at Essentia Health’s East District, which covers 69 Essentia facilities in northern Minnesota and northwest Wisconsin.

These certified nurse practitioners and physician associates (also known as physician assistants) voted to unionize with the Minnesota Nurses Association a year ago. Essentia declined to negotiate a collective bargaining agreement with the MNA pending an appeal to the National Labor Relations Board over the union’s desire to form such a large bargaining unit. They said a strike by such a large union would snarl an entire region’s health care.

Too late.

Now the union of 430 providers is on strike. MNA lawyers argue that negotiations can begin while the appeal is pending. This is the legal dispute at the heart of the strike, and it’s not clear how it ends without the two sides talking to each other.

“It goes back to wanting to be treated with dignity and respect,” said Schurke. “My colleagues go above and beyond to care for patients. I’ve driven patients home who would have had to walk 45 minutes in the dark. I’ve called them after my shift to make sure they’re OK. I sit with them when I have to share really terrible news. We do all of that. I gowned up many times during COVID to hold hands when someone takes their last breath. We care about people. It just feels so rotten to be ignored.”

Advanced Practice Providers only recently began organizing unions. Just last month, physicians, PAs and CNPs at 60 Allina facilities in Minnesota and Wisconsin became the first such union to conduct an informational picket in Minnesota. They were organized through the Doctors Council Service Employees International Union (SEIU). That union also authorized a strike, but Allina is negotiating with them.

Unions face a big challenge in explaining the differences between nurses, doctors and all the advanced practice providers (APPs) in between. The staffing problems overlap in complex ways and involve many different collective bargaining units and internal systems. A rural physician shortage also persists. So the problems become confusing for anyone who is not closely following the health care system.

The issue hits home for my family. We live near Hibbing. My family has health insurance, but no doctor. Our longtime family physician retired two years ago. We switched to his longtime certified nurse practitioner, but she left for another clinic earlier this year. There are no providers at our current clinic taking new patients, which means that we can only see the on-call provider.

We’re weighing our options for open enrollment next fall. In rural medicine, this kind of chaos is the norm, not the exception.

But I can make one observation. There was no drop-off in care between our beloved longtime doctor and the CNP who took on our family.

APPs provide about 44% of all the primary care in Essentia clinics and hospitals, according to Essentia data in MNA statements. Schurke said APPs provide a majority of care in the emergency room.

The union is striking for a voice, not money. But that voice will allow them to seek better pay and working conditions in a future that will also include Medicaid cuts and rising costs for rural providers.

This strike superheats a rising crisis in rural health care. Physician shortages and financial pressures cause hospitals and clinics to rely upon lower-cost providers like APPs. That’s not a bad thing. But as those professionals grow in number, they’re right to demand a seat at the table in discussions over operations, staffing and safety.

“We’re here because we want to do our jobs. I care about my patients, and I can speak their language,” said Schurke. “I’m from this community. I think a lot of APPs come back to their home community. We have no ulterior motive. We’re here because we care. We want to be recognized as members of the care team. We want to have constructive dialogue. It can be a civil discussion.”

Here’s what we’re doing in America. For decades, we’ve stalled needed repairs to rural health care because those in money and power say it costs too much. Now the president and Congress are squeezing people off Medicaid and passing the costs to local hospitals. Health care providers remain as stressed as ever, burnt out by long hours and cultural nastiness.

The more this continues, the more labor conflicts will ensue. Delay in solving the problem will become deadly.