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California's powerful nurses' union is gearing up for a fight with Kaiser Permanente, the largest hospital system in the state and among the biggest in the country. Bargaining for a new nursing contract at hospitals in northern California begins tomorrow. As member station KQED's April Dembosky reports, the nurses are hoping for a result that resonates nationally.

APRIL DEMBOSKY, BYLINE: Going to a nurses' union meeting is a little bit like going to an evangelical church service. Nurses report grievances at their hospitals as though they're giving testimony. And the rest of the nurses respond with the passion of a devout congregation.

(APPLAUSE)

VERONICA CAMBRA: We all have to stand up. And it's a struggle but it never came out of our hearts. And we will still overcome this. OK?

(APPLAUSE)

DEMBOSKY: The California Nurses Association is rousing its troops for battle. The union is anticipating Kaiser Permanente will propose job and benefit cuts in the next nursing contract. Leaders want to make sure all 18,000 members at the hospital system are ready to fight back and, if necessary, go on strike. Four years ago, nurses ratified the first contract proposal Kaiser offered without objection. Joanne Spetz is an economics professor at the University of California, San Francisco. She says in 2010, the nursing shortage was still a recent memory, and Kaiser wanted to hold onto its experienced nurses. It was also the end of a recession, and nurses didn't want to appear greedy.

JOANNE SPETZ: You're not going to get a lot of public sympathy, you know, oh gee, you should give us a pay raise when everybody else in the Bay Area is basically taking pay cuts.

DEMBOSKY: But a lot has changed in the last four years. The economy in Northern California has improved. And the Affordable Care Act has fundamentally changed hospital economics. For starters, Spetz says, the health law is generating a lot of new customers for Kaiser.

SPETZ: If there is growth then they're doing exactly what the classic role of a union is which is to say, well, if there's going to be increased net revenue, we should get a cut of that.

DEMBOSKY: But the union isn't talking money yet. They're framing all their demands around patient care. Nurse practitioner Rachel Phillips says she's under unrelenting pressure to see more patients in less time.

RACHEL PHILLIIPS: When I first started at Kaiser, I wasn't rushed to see my patients. I could have 30 minutes with a new patient. And the time's kind of gotten whittled away. Currently, we are being asked to see patients every 15 minutes regardless of the complexity of their medical issues.

DEMBOSKY: Other ICU and ER nurses at Kaiser say the hospital system has been skimping on care - discharging patients who should be admitted and closing pediatric and cardiology units. Kaiser says these claims are misleading and that it is committed to providing high quality care. Barbara Crawford is Kaiser's vice president for quality.

BARBARA CRAWFORD: We actually need less nurses in the hospital.

DEMBOSKY: She says improvements in technology and reductions in hospital infections have shortened hospital stays. For example, earlier this year, her husband had foot surgery.

CRAWFORD: He was in and out the same day. And he did not have general anesthetic. I would say four years ago, he probably would've been in the hospital four or five days.

DEMBOSKY: She says yes, the Affordable Care Act has brought in a lot of new members. But the law also puts pressure on hospitals to cut costs. Medicare reimbursements are going down so hospitals are coping with less money. And health reform has made the insurance market a lot more competitive, so Kaiser has to keep prices low.

CRAWFORD: As consumers have opted to join us, our expectation and promise to them is that we keep their costs down.

DEMBOSKY: The union will rely on its 85,000 members in California to resist cuts. Professor Joanne Spetz says the nurses may even be using this local fight to help boost membership across the country.

SPETZ: There may be a broader strategy of trying to demonstrate their strength, demonstrate their willingness to fight, demonstrate their political power on a national stage.

DEMBOSKY: She says if the California nurses win on wages, benefits and patient care, they'll inspire their national network of nurses to push for similar fights in their own states. For NPR News, I'm April Dembosky in San Francisco.

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