Going to a union meeting of nurses is a little bit like going to an evangelical church service.
"We all have to stand up, and it's a struggle," says Veronica Cambra, a nurse reporting a grievance at Kaiser Hospital in Fremont, Calif., as though she's giving testimony. "And we will overcome this, OK?"
The rest of the nurses respond with the passion of a devout congregation, humming "Mmm hmmm," and "That's right," through the series of speeches.
But this is no church service. The California Nurses Association is rousing its troops for battle. The powerful union will begin bargaining Thursday with Kaiser Permanente on a new four-year contract for nurses at its northern California hospitals. Kaiser operates the largest hospital system in the state — largest by number of hospitals and by number of hospital beds — and is the eighth largest health system in the country.
The union is anticipating that Kaiser will propose cuts at the negotiation, and leaders want to make sure nurses are ready to fight back — and, if necessary, go on strike.
Four years ago, nurses ratified the first contract proposal Kaiser offered without objection. Both sides had reason to keep tensions to a minimum, according to Joanne Spetz, an economics professor at the University of California, San Francisco School of Nursing.
Last time the nursing shortage was still a recent memory, she says, and Kaiser wanted to hold on to its experienced nurses. It was also the end of a recession, and nurses didn't want to appear greedy.
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.
And if there is growth, Spetz says, the nursing group is following a union's classic role, "which is to say, 'Well, if there's going to be increased net revenue, we should get a cut of that.' "
But the union isn't talking money yet. The leaders are framing all their demands around patient care. Nurse practitioner Rachel Phillips says she is under unrelenting pressure at work to see more patients in less time.
"When I first started at Kaiser, I wasn't rushed with my patients," Phillips says. "I could have 30 minutes with a new patient. That time has been whittled away. We're currently asked to see patients every 15 minutes, regardless of the complexity of their medical issues."
Nurses at Kaiser's intensive care units and emergency rooms say the hospital system has been skimping on care, discharging patients who should be admitted, or closing pediatric or cardiology units.
Kaiser says a lot of the union's claims are misleading or untrue.
Barbara Crawford, Kaiser's vice president for quality, says the overall demand for hospital care is going down.
"We actually need [fewer] nurses in the hospital," she says. Improvements in technology and reductions in hospital infections mean there are fewer patients staying in the hospital — 250 fewer now per day, on average, compared to a few years ago. She gives the example from earlier this year when her husband had foot surgery.
"He was in and out the same day, and he did not have general anesthetic — he didn't need general anesthetic — and he did beautifully," Crawford says. "I would say, four years ago, he probably would have been in the hospital four or five days."
The Affordable Care Act also puts pressure on hospitals to cut costs, she says. Medicare reimbursements are going down, which cuts into hospital revenues. And health reform has made the insurance market a lot more competitive, so Kaiser has to keep prices low.
"As consumers have opted to join us," Crawford says, "our expectation and promise to them is that we keep their costs down."
But the nurses have power in numbers, says Spetz. The California Nurses Association founded a national arm — National Nurses United — that has been gaining members across the country, most recently in right-to-work states like Florida and Texas. Spetz says this local fight likely has national aspirations.
"Given that Kaiser exists in multiple states, 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," Spetz says, "which could be beneficial in trying to get representation in other Kaiser regions, as well as other states."
She says if California nurses win on wages, benefits, and patient care, they'll inspire nurses in their national network to push for similar fights in their own states.
This story is part of a reporting partnership with NPR, KQED and Kaiser Health News. Kaiser Health News is not affiliated with the company Kaiser Permanente.
Georgia Republicans picked their Senate nominee Tuesday night. Former corporate CEO David Perdue will face Democrat Michelle Nunn in the November general election.
Nunn, the daughter of a popular former senator, is among several Democratic female candidates who are showing strength as the party tries to preserve its Senate majority. She's also considered a real contender to turn the Georgia seat Democratic.
Nunn has taken advantage of the Republicans' late runoff date, which gave her time to raise money for November, says Justin Barasky, press secretary for the Democratic Senatorial Campaign Committee in Washington.
The GOP "will be in a pretty bad financial position," Barasky says. "Meanwhile, Michelle Nunn has built her organization and her cash-on-hand advantage to a really strong place."
Thirty-three Senate seats are up in November. Georgia is one of just two states where Democrats might pick up a Republican seat. The other is Kentucky, where former Secretary of State Alison Lundergan Grimes is challenging Senate Minority Leader Mitch McConnell.
Grimes has a powerful fundraising operation. Her campaign manager, Jonathan Hurst, says she's catching up with McConnell.
"When we started this race, he had $10 million that he already had in his campaign," Grimes says.
But then McConnell had to wage a costly primary campaign, while Grimes succeeded in opening a lot of Democratic wallets in Kentucky and around the country.
Now, Grimes says, "We have 68 cents to every dollar he has."
"We don't suspect that Alison Lundergan Grimes is going to suffer from any lack of resources," says Josh Holmes, adviser to McConnell's campaign.
But, as Holmes points out, campaign cash isn't everything. Outside groups are important too — superPACs and so-called "social welfare" organizations. McConnell has more of them spending money on his behalf than Grimes does.
It's an imbalance that shows up in other races, too. Democratic candidates have had strong fundraising, while Republicans benefit from wealthier outside groups.
Barasky notes that funds in candidates' coffers are worth more, because candidates pay less for TV airtime.
"So the reality is that $6.2 million of candidate cash" — the amount Grimes reported as cash on hand — "is actually closer to $10 or $12 million of outside-group cash," he says.
Brian Walsh, consultant to the National Republican Senatorial Committee, predicts that by autumn, Democrats will be stretched thin protecting their incumbents.
"The national Democratic party's going to have some tough decisions to make," Walsh says. "I frankly would be a little surprised if, come September or October, they're spending serious money in either Kentucky or Georgia."
Even then, control of the Senate might not be settled till December. That's because one of the Democratic incumbents is Louisiana Sen. Mary Landrieu, and in Louisiana, Election Day is a wide-open primary, with a runoff in December.
Landrieu and the leading Republican, Rep. Bill Cassidy, have both reported about $6 million cash on hand.
"It's already kind of a wild and woolly race, with the outside spending, the superPAC money," says Jeremy Alford, a journalist who writes the blog LaPolitics. "Without a doubt, it's the most expensive race, period, that the state has ever seen."
How wild? How woolly? The attack ads started last December, and already, Landrieu and some outside groups are reserving TV time for the runoff election they're anticipating this December.