A class of health care facility support staff, including nursing assistants, security guards, and janitors, has worked alongside doctors and nurses throughout the covid-19 pandemic keeping patients and medical buildings safe and clean. It’s an unassuming line of work that some people consider a calling.

Tony Ramirez, 39, a critical care technician at Garfield Medical Center in Monterey Park, California, finds more fulfillment in helping people in need than he once did editing technical documents for Disneyland. Before the pandemic, he would reposition and bathe patients and sometimes monitor their vital signs. After covid struck, he took on more duties, providing CPR or grabbing medications during an emergency, placing leads to monitor heart rhythms, and conducting post-mortem work. “We started doing that,” Ramirez said, “because of the influx of covid patients running very ill and in very intense situations.”

Through it all, his $19.40-an-hour pay hasn’t changed.

In Southern California, one labor union is trying to help by pushing for a $25 minimum wage at private hospitals, psychiatric facilities, and dialysis clinics. The Service Employees International Union-United Healthcare Workers West, which represents roughly 100,000 health care workers in California, says a raise would help the providers retain workers who could land comparable positions at Amazon or fast-food restaurants amid labor shortages. It would also allow Ramirez to give up one of the three jobs he works just to make rent.

What began as a 10-city campaign by the union has been winnowed to November ballot measures in just two cities in Los Angeles County, reflecting expensive political jockeying between labor and industry. And the $25 minimum wage isn’t the only campaign being waged by SEIU-UHW this cycle — the union is also trying for the third time to get dialysis industry reforms passed.

A ballot issue committee called the California Association of Hospitals and Health Systems — with funding from Kaiser Permanente of Northern California, Adventist Health, Cedars-Sinai, Dignity Health, and other hospitals and health systems — opposes a $25 minimum wage because it raises costs for private, but not public, hospitals and health care facilities. Opponents have latched on to this disparity by calling it the “unequal pay measure.” An analysis commissioned by the California Hospital Association estimated that the change would raise costs for private facilities by $392 million a year, a 6.9% increase, across the 10 cities.

“No one in hospitals and no one in health care is opposed to a living wage,” said George Greene, president and CEO of the Hospital Association of Southern California. “But we believe that this should be a statewide conversation that is measured and thoughtful.”

Earlier this year, city councils in Los Angeles, Downey, Monterey Park, and Long Beach adopted similar $25 minimum wage ordinances for health workers, but they were challenged by hospitals and health facilities, which pushed the issue to the ballot in 2024. Meanwhile, the union dropped its effort in Anaheim and failed to gather enough signatures in Culver City, Lynwood, or Baldwin Park to get a minimum wage measure on the fall ballot. As a result, only voters in Inglewood and Duarte will cast their votes — on Measure HC and Measure J, respectively — this November.

Spending on the fight over the minimum wage proposals in Southern California has reached nearly $22 million. According to state campaign finance filings, SEIU-UHW has spent nearly $11 million across all 10 cities. Hospitals and health facilities have also spent almost $11 million to defeat minimum wage proposals.

Unions have long agitated for across-the-board minimum wage increases. In 2016, labor played a key role in successfully lobbying then-Gov. Jerry Brown to make California the first state to set a $15 minimum wage, a graduated measure that as of this year applies to all employers with 26 or more workers. About 40 local governments set their own minimum wages above the state minimum. The federal minimum wage remains $7.25.

SEIU-UHW contemplated a statewide scope, as well as the current piecemeal strategy of targeting cities in and around Los Angeles. “At first we were looking at city by city,” said the union’s political director, Suzanne Jimenez. “And then a conversation around doing it statewide came up but ultimately didn’t move forward.”

That’s partly because a deal to set a statewide minimum wage at public and private hospitals fell apart at the end of the last legislative session, and wins like that are harder to pull off than they once were, said Bill Sokol, a labor lawyer who has worked with SEIU-UHW.

“It’s not about what we wish we could do, but about where can we win,” Sokol said. “The answer is in one city at a time.”

Union leaders said they targeted cities where internal polling showed support among residents. Jimenez said the proposal has majority support in Inglewood but Duarte is too small to sample. The measures need a majority vote in each city to pass, and if that happens, they will take effect 30 days after the results are certified.

Should the approach prove successful in Los Angeles County, the union will consider taking the proposal to other parts of the state, including the Inland Empire and Sacramento, Jimenez said. That could eventually build momentum for statewide change.

If voters in Inglewood and Duarte pass the $25 minimum wage, the effect would be limited. Workers at state- and county-run medical facilities aren’t covered by city ordinances, so the local measures wouldn’t apply. That means it excludes workers who do the same jobs at public hospitals, clinics, and health care facilities.

In Inglewood, the measure would apply only to Centinela Hospital Medical Center and several for-profit dialysis clinics. In Duarte, it would apply to City of Hope, a private cancer hospital.

Many labor economists agree that something must improve for this workforce: They need higher wages and better work conditions. But that comes at a cost to the health system, said Joanne Spetz, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco.

“In the end, who ends up paying for that? Consumers do,” Spetz said. “Maybe you’ll cut into the profit margins of a publicly traded company a little bit, but the reality is those companies have been pretty good at figuring out how to keep their revenues and profitability up.”

Still, the union says a $25 minimum wage would help members of the lowest-paid sector of the health care workforce, who are disproportionately women, immigrants, and people of color.

Andrew Kelly, assistant professor of public health at Cal State East Bay, said raising wages at one facility could have a cascade effect because surrounding facilities would then need to raise wages to compete.

Currently, a living wage in L.A. County for a single adult with no children is $21.89 hourly, or a little more than $45,500 a year, according to a tool from the Massachusetts Institute of Technology. Occupations like “healthcare support” generally pay around $33,000 annually in the county, according to the same tool.

Come Election Day, most Southern California health workers will have to watch from the sideline.

In Monterey Park, where Ramirez works, the city council approved the $25 minimum wage, but opponents got the vote invalidated by arguing that the council lacked a quorum at the time. The council ended up placing the question on the ballot in 2024, two years from now. Ramirez said that new hires at his medical center start at $15.30 an hour doing the dirtiest jobs in the hospital and that five workers have left his department this year.

“It’s disheartening, I’m not going to lie,” Ramirez said. “These elected officials know what’s going on.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.