When most of us think of mental health care, we think of seeing a therapist once per week. But at Kaiser Permanente facilities in California and Hawaii, clinicians — including psychologists, clinical social workers, marriage and family therapists, and addiction medicine counselors — say their patients routinely wait months between appointments. Not only that: There’s no limit to the number of patients that can be assigned to one therapist.
“You’re expected to follow anybody you have seen in the last two years. At times, the number of people I have seen in the last two years has been up to 600,” Sabrina Chaumette, a Kaiser therapist in Oakland, told Truthout.
Since July 2021, Kaiser mental health clinicians in California, who are members of the National Union of Healthcare Workers (NUHW), have attempted to use contract negotiations to demand the resources they need to provide better care for their patients. But workers say management has been unwilling to budge on changes necessary to reduce their unmanageable workloads and reverse understaffing, so on August 15 — nearly 14 months after their first bargaining session — over 2,000 Kaiser therapists in California went on strike. Nearing two months, it is the longest mental health strike in history. And on August 29, 57 of their colleagues in Hawaii, also NUHW members, joined them.
Kaiser is the largest nonprofit HMO in the United States, operating in eight states and the District of Columbia. It’s the largest health insurance plan in California, with more than half the market share, and the second-largest in Hawaii. However, despite reporting an $8.1 billion profit in 2021, Kaiser staffs only one full-time-equivalent mental health clinician for every 2,600 members in Northern California and just one therapist for every 5,500 patients in Hawaii, according to NUHW. Union members say this flies in the face of Kaiser’s key marketing promise: That by offering health insurance plans and operating hospitals and other facilities under one umbrella, patients receive better and more integrated care.
“I call it the glitter cloud,” Rachel Kaya, a Kaiser therapist in Hawaii, told Truthout. “They put out into the world how they promote mental health care, how they help people thrive, and how they do fair labor bargaining. But in my field, we talk a lot about the difference between talking the talk and walking the walk.” Unlike their colleagues in California, whose contract expired, Kaiser therapists in Hawaii are still without a first contract four years after joining NUHW.
“A strike is an absolute last resort. We have made numerous efforts to compel our employer to shift our model of care to reduce dangerous delays in terms of wait times that our patients face,” Ilana Marcucci-Morris, a Kaiser therapist in California and bargaining committee member, told Truthout. According to Marcucci-Morris, the union’s last contract cycle nearly ended in a strike over the same issues, but members ultimately accepted an offer from Kaiser when it agreed to form a committee, with equal participation between union members and management, that would make recommendations on how Kaiser could improve its model of care. After that committee met for over a year and made its final presentation, “Kaiser cherry-picked one or two pieces that they liked and then dumped the rest,” said Marcucci-Morris. Before walking out, NUHW members in Northern California accepted Kaiser’s financial terms. They’re not striking over their own compensation or benefits.
“Our patients are waiting three months in between appointments and flooding the emergency room because they’re in crisis, or paying out of pocket to go outside Kaiser. That extreme moral injury is the crux of our strike,” said Marcucci-Morris. We want our patients to get better and we need the resources to help them do that.” Kaya agrees. “I just want to be really clear that the reason why we are on strike is not a financial issue,” she said. “It is absolutely a social justice issue. Kaiser being a multibillion-dollar company, yet choosing to underfund mental health care in these communities, is wrong. The entire community pays the price when we underfund mental health care.”
Marcucci-Morris likens the Kaiser model, where there is no limit on the number of patients a therapist can be expected to take on, to “a house where you have a front door that’s wide open but no windows, no side door, or back door.” In addition to forcing clinicians to work many hours of overtime on non-patient-facing work like completing and reviewing notes and connecting with other members of a patient’s care team, union members say this approach actually compels them to break the law. In addition to recently strengthened federal law, California has some of the strongest mental health parity laws in the nation. SB 221, enacted in 2021, requires that mental health and substance use patients be offered return appointments within 10 business days, unless the treating therapist determines that a longer wait time is appropriate. If an appointment with an in-network provider is not available, insurers and HMOs are obligated to arrange for outside care at no additional cost to the patient. NUHW members say state regulatory bodies have been slow to enforce the new law, and that Kaiser was noncompliant even before their strike.
“Our current contract compels therapists to break mental health parity laws on the state and federal level,” said Marcucci-Morris. When she went on strike on August 15, said Chaumette, her next available intake appointment was in mid-November.
Barbara McDonald is a single parent to two daughters with mental health challenges. McDonald told Truthout that getting her younger daughter an appropriate diagnosis within the Kaiser system took so long that she was forced to pay out of pocket to go outside Kaiser. Once her daughter did have a diagnosis of borderline personality disorder, the only treatment she was offered within Kaiser was a series of classes — which were then canceled. After her daughter was hospitalized multiple times for self-harm, McDonald paid out of pocket again to get her the treatment she needed outside of Kaiser. All told, she has spent around $50,000. “I don’t think my daughter would be alive if I hadn’t been able to provide outside care for her,” she said. “And I’m still digging myself out of a financial hole because of that.”
“My older daughter said, ‘Do I have to cut my throat to get a therapy appointment?’ She sees her sister only getting care if she escalates and hurts herself. That must feel really scary, that nobody cares unless you’re hurting yourself or threatening yourself,” said McDonald.
Chaumette said that in her experience, it’s often patients with less severe symptoms who do manage to get a referral for covered care outside the Kaiser system. “If I’m seeing somebody with depression and they’re having a difficult time getting out of bed, dressing, bathing, eating, they’re not going to have the energy to be on the phone with Kaiser fighting for an outside referral. This system disproportionately hurts the people with more severe symptoms,” she said. Kaiser also encourages therapists to keep more severe cases in-house, purportedly to better manage care for those patients, and because they might be rejected by therapists in private practice. But Kaiser’s mental health providers are so overwhelmed that McDonald questions the safety of that approach. “Even though Kaiser is dispensing my daughter’s medication, they don’t have anybody following up with her. She can go six months between meetings with her psychiatrist,” McDonald said. “That’s just dangerous.”
In California, Kaiser contracts with Medi-Cal, the state’s Medicaid program, and its failures to deliver timely care disproportionately affect people who can’t afford to go outside the system. “Any marginalized community that has been unused to advocating for itself is not going to fight the system to give them a referral to an outside provider,” said Chaumette.
These untenable conditions have therapists leaving Kaiser in droves, according to NUHW. Between June 2021 and May 2022, said the union, 668 California clinicians left Kaiser — nearly double the 335 clinicians who left the previous year. In a survey conducted by NUHW, 85 percent of those clinicians said they had an unsustainable workload, and 76 percent said their inability to “treat patients in line with standards of care and medical necessity” influenced their decision to leave.
In California, NUHW members are asking for several key changes: Up to an additional 30 minutes per day to perform indirect patient care tasks such as returning phone calls and emails from patients and communicating with other members of a patient’s care team; the ability for clinicians to stop taking new patients when they have no available appointments for new patients within two weeks; a ratio of one appointment for a new patient to every six appointments with current patients; and a requirement that Kaiser hire enough staff to comply with federal and state law. The only concession Kaiser management has offered, according to Marcucci-Morris, is an increase in indirect patient care time of just 12 minutes per day, applying to generalist therapists only, which would exclude a majority of the union. Representatives for Kaiser Permenente did not return a request for comment.
In May, the National Committee for Quality Assurance, an independent nonprofit organization that accredits health plans, placed Kaiser under “corrective action” because of its violations of national mental health standards. Two California state agencies are also investigating Kaiser’s failures to follow state mental health parity law, though those investigations are not expected to conclude until next year. “I’d like to see them hit them with fines big enough to get their attention and to make it worth it for them to turn this around, because clearly they’re only interested in the money they make,” said McDonald. “Or if they’re not going to provide mental health care, then they should just say that rather than pretending they do.”
In Hawaii, NUHW filed a complaint in November 2021 with the Department of Commerce and Consumer Affairs regarding Kaiser’s failure to address serious patient care problems. In its formal response in December, Kaiser pledged to hire 44 additional therapists. According to NUHW, the number of full-time Kaiser clinicians in Hawaii has actually decreased from 51 to 48 since then.
Chaumette says that, because of its poor practices, Kaiser faces a reputational crisis among therapists. “They are never going to be able to hire enough therapists to treat all these patients, because nobody wants to work for Kaiser,” she said. “Our reputation in the community among therapists is bad. When I tell people I work for Kaiser, their first response is, ‘You don’t do therapy.’ I think this strike has increased my reputation within our community of therapists. We’re doing advocacy in ways I’ve never done before as a therapist.”
Though roughly half of the clinicians who went on strike in California have returned to work out of financial necessity, Marcucci-Morris said support for the strike remains high — in a recent vote, 85.9 percent of union members voted to reject Kaiser’s latest offer. “It’s important to note what a union is. We are a collection of workers. This is not one or two people telling us what to do,” she said.
According to Marcucci-Morris, therapists who have gone back to work informed the union that Kaiser is still booking appointments for patients with therapists who are out on strike, then canceling and rescheduling them. “If Kaiser felt following the law was a priority, they’d follow our proposal,” she said. “We’re ready to negotiate around the clock to get an agreement.”