Uber's Bastards

On the ride-hail model and the gig economy's metastasis.

William Blake, The Punishment of the Thieves, 1824–27. Photo via Wikimedia Commons.

Hello everyone, I’ll keep this bit short this time! Thanks for all the emails with stories about your own experiences in Vegas, with gambling addiction, and with CES in response to my last piece, I read them all and responded to most except the ones pitching me Guaranteed Parlays That Will Hit! Thanks also for subscribing, we’ve jumped a bit and are just shy of 4,400 subscribers. If you like what you’ve read and want to support me further, you can become a paid subscriber for $7 a month or $70 a year. What do you get in return? My undying love, some recommendation posts every now and then, and paywalled essays/rants just as long as this one! Now, let’s get to today’s essay.

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I have long believed that one of the greatest threats we face is the proliferation of the on-demand labor platform. The so-called “gig economy” is one of the larger altars to greed and misery in our civilization where millions of people are sacrificed in order to grow Smaugian hoards that are then transmuted into this or that form of power.

My earliest introduction to this was through the work of labor ethnographer and legal scholar Veena Dubal via her law journal article “The Drive to Precarity,” which maps out how militant workers turned San Francisco’s precarious taxi sector into a stable line of work, how companies responded with a wave of deregulation and de-unionization that immiserated workers, and how Uber sealed the deal in returning ride-hail to its earlier insecure form: poor working conditions and starvation wages, with every possible cost (healthcare, fuel, maintenance, etc.) offloaded onto workers and consumers.

Key forms of on-demand labor—namely, ride-hail and food delivery—have proliferated over the past few years, but not because they are particularly profitable or innovative business ventures. Most of them either have no real path to profitability, report dubiously calculated profits, or are operating illegally in hopes of realizing or sustaining them after sufficient lobbying and monopolization and exploitation of consumers/workers. The lazy and incurious view has been that they will grow into profitability, but the transparent reality is that the firms at the vanguard of the gig economy have thrived because they take advantage of a few key phenomena: worker misclassification, algorithmic discrimination, anti-competitive capital-intensive strategies, impressive public relations, robust political lobbying, and shoddy journalism, to name a few.

The ride-hail business model is about subverting urban governance, about breaking New Deal era labor regimes, about subjecting workers and workplaces to more authoritarian forms of control and discipline, and about reshaping consumers, markets, firms, governments into forms less hostile to previously illegal-to-realize profits by leveraging investor subsidies and worker misclassification as competitive strategies. One way to understand this that I keep returning to and flirting with is it’s part of an ongoing attempt to find the legitimacy narrative for capitalism, to RETVRN to a purer and more orderly form that also happens resembles the violence and surveillance and hierarchy transferred from plantation to early industrial labor. Still, the question remains what does the application of this business model look like here and now, in various sectors of the economy or in slices of our daily lives?

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Four years ago, Uber gave us a masterclass on subverting democratic governance: in California, it led a coalition that spent over $200 million on a ballot measure (Proposition 22) constructed to deny gig workers basic labor rights by preserving the ability to misclassify them as contractors instead of employees. Uber and its allies were able to send out misleading voting guide mailers, lobby the public with extensive media tours, and cut checks large enough to convince civil rights organizations and activists to parrot corporate talking points. To what end? To ensure drivers were paid starvation wages and forced to bear the heavy cost of gig work on their well-being whether it be mental health, injury, accident, or physical health. After all, such labor costs would’ve cost already deeply unprofitable companies an additional hundreds of millions of dollars in a sensitive time. Proposition 22 was found unconstitutional before an appeal reversed this ruling and California’s Supreme Court affirmed the legality of Proposition 22 as well as its exemption of the so-called gig economy from the state’s labor laws.

Few financiers bothered to even hide the tent in their pants as all of this was happening. One of the earliest was Shawn Carolan—a partner at Menlo Ventures and early investor in Uber—who penned an op-ed in The Information six days after Proposition 22 passed that practically drooled over what could now be done to various industries (and investors):

Workers in all sorts of industries—from agriculture to zookeeping—could benefit from the structure that Prop. 22 provides, if it were extended to them. I think it could work for basically any industry where an ongoing relationship with a single employer isn’t essential to do the job well. It doesn’t seem viable in sports, for example, to have a different head coach each practice—the continuity of relationship and knowledge is too important to the core value. But the existence of flexible work arrangements in fields like nursing, executive assistance, tutoring, programming, restaurant work and design suggests that a Prop. 22 inspired approach could make sense there as well.

Carolan breezes through Uber's destructive business model, its war on labor laws and regulatory oversight, a long list of scandals, and outright illegal behavior to insist that it and Proposition 22 are unambiguous goods:

There is an opportunity for us to create a world in which the choice of being a gig worker versus an employee doesn’t feel like a trade-off, a world in which some or many of the legal benefits and protections employees enjoy extend to gig workers. In this scenario, workers across industries gain security, the relationship between employees and employers is strengthened, and the economy benefits from a more financially secure population, continued innovation and countless new efficiencies.

Everything Carolan—and every other venture capitalist—says in defense of misclassifying on-demand workers is, of course, Bullshit. Pablum. Gibberish. Jejune. For years, it has been clear that their framing is a deceptive one: Dubal's ethnographic research, for example, has documented that longtime drivers feel ambivalent about worker status because these firms have made workers feel trapped by algorithmic overseers in exploitative and grueling work schedules for perpetually declining wages; Dubal has also established how on-demand platforms have innovated a new form of price discrimination, shifting it from the consumer to laborer via algorithmic wage discrimination (which Uber admitted to doing last year) to ensure each worker gets the lowest compensation possible (though they also practice algorithmic price discrimination too).

Inconvenient truths, yes, but there’s no reason why any of this would stop so-called gig economy firms: again, companies whose business models deeply immoral and deeply committed to operating outside the boundaries of the law (in order to change the law). This has been clear for a long while, but was emphasized the day after Proposition 22 passed when Uber CEO Dara Khosrowshahi bragged on the Q3 earnings call that the ballot measure was just the beginning—the first iteration being its Independent Contractor Plus model (“IC+).

Since Uber, Lyft, Doordash, and Instacart bribed their way to a labor law exemption in California, how have things gone for the companies since? Pretty good, actually. In Massachusetts, Pennsylvania, Minneapolis, Washington, on-demand labor platforms have scored key victories securing their right to self-exempt from labor law. The United Kingdom's Supreme Court classified drivers as "workers" in 2021, but Uber was sued in 2023 for reneging on its promise. The European Union's Platform Work Directive, initially poised to give gig workers full labor rights, was successfully watered down into a "nothingburger." Brazil is debating how to regulate platform work, with the United States is positioning itself to export gig-economy labor exemptions to the country. Uber has inked a flurry of deals with dozens of taxi companies. Across the world and at home, Uber and its conspirators have enjoyed victory after victory since Proposition 22.

It’s hard to overstate the aggression with which Uber pursued its ambitions. The 2022 Uber Files (leaked by the company’s former top lobbyist in Europe, the Middle East, and Africa) revealed years of illegal behavior, aggressive attempts to evade accountability, and lobby various governments to rewrite laws in the company’s favor. We’ve also witnessed, in daylight, Uber’s impressive political machine; here’s Katie Wells, Declan Cullen, and Kafui Attoh put it in The New York Review of Books on Uber’s advocacy strategy:

The recent pattern is clear: Uber sells itself as pro-worker in name while opposing legislation that would require it to be so in practice. In 2020, after Seattle enacted a minimum wage for ride-hail drivers, the company went to the Washington statehouse to pressure legislators to alter the law, which they rewrote in a manner that at once denied gig workers employee status and established the country’s first paid sick leave program for ride-hail drivers. The national Teamsters union rejected the resulting 2022 law, but the local union supported it, maintaining that it was better to cut a deal and avoid a potential ballot initiative than fight for employee status. In 2023 in New York state, Uber similarly agreed to give UberEats drivers a minimum wage and paid sick leave but not treat its workers as employees. This year in Toronto, it celebrated a partnership with the United Food and Commercial Workers union to assist drivers with deactivation appeals, even as it campaigned against minimum wages for them.

Since Uber began selling off nearly every other line of business (self-driving cars, flying cars, freight, bikes, scooters, etc.), it and nearly every other extant on-demand labor platform committed to ride-hail and/or delivery. On-demand delivery working conditions are arguably as horrendous as ride-hail’s thanks to opaque and exploitative algorithmic decision-making. In the face of these overwhelming odds, couriers have organized revolt after revolt after revolt across the world in their fight for dignified working conditions—but it remains painfully clear that on-demand platforms are winning their war on workers, the general public, labor law, and urban governance itself.

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As Carolan observed, however, ride-hail and delivery are not the only places where the “business model” at the heart of on-demand labor can be applied.

Over the past few years, nursing has emerged as a juicy target for investors and firms eager to liberate entire industries of antiquated regulatory frameworks. Last month, the Roosevelt Institute published a great report on what the application of the on-demand model will mean for nurses and it paints a grim picture. While some hail the emergence of an "Uber for nursing" model as a salve for our nursing shortage, Katie J. Wells and Funda Ustek Spilda detail how these apps reliably degrade working conditions, wages, and care standards.

These apps encourage nurses to work for less pay, fail to provide certainty about scheduling and the amount or nature of work, take little to no accountability for worker safety, and can threaten patient well-being by placing nurses in unfamiliar clinical environments with no onboarding or facility training. On-demand nursing platforms are also using the Uber playbook to lobby state legislatures in an attempt to exempt themselves from existing labor regulations.

I’ll be going through the report section by section to highlight key points as I think the report is phenomenal, but I encourage you to read it in full (linked above).

Introduction

The premise of the “Uber for nursing” apps is relatively simple: lets use algorithmic systems to managing the scheduling, staffing, and management at medical facilities. For understaffed workplaces looking to cut costs and corners, this is attractive. For nurses and nursing assistants who want more control over their work, this is attractive. But this is especially enticing for investors who drool anytime a firm compares itself to Uber. Take ShiftMed—one of the darlings of this sector and a subject of the Roosevelt Institute report—which has raised hundreds of millions (but declines to share its valuation): $47 million in a May 2024 venture round, $200 million in a February 2023 round, $45 million in October 2021, and an early $6 million boost in an August 2019 round. What concretely are firms like ShiftMed offering to draw financing like this?

After a nurse downloads an on-demand nursing app and submits the requisite documents, they can use the app to indicate their interest in a 6-, 8-, or 12-hour shift at a hospital, nursing home, assisted living facility, surgical center, dental office, or, in some states, correctional facilities. An algorithmic scheduling software program, which is the heart of these new companies, then approves the worker for a shift, notifies both the medical facility and the worker, allows the worker to clock in and out, and, finally, sends a paycheck.

The on-demand nursing industry promises hospitals and medical administrators a different set of controls, namely the capacity to seamlessly staff facilities, reduce manager workloads, and lower labor costs.

On paper, this sounds lovely—the digital disruption of an old rickety system full of middlemen, inefficiencies, misallocation, overcharging, yadda yadda ya. But what’s the reality on the ground? Wells and Spilda found:

serious safety and health risks for workers and patients. The nurses and nursing assistants who use these apps must pay fees to bid on shifts, and they win those bids by offering to work for lower hourly rates than their fellow workers. Poor internet or cell service in rural areas can cause the apps to fail, resulting in missed paychecks for work performed. These apps also rate the nurses they hire based on facility feedback and internal algorithmic determinations. If a worker must cancel a shift due to sickness or personal conflict, their rating goes down, and they often lose out on future shifts or can be banned from the app altogether. In at least one case, a nursing assistant went into work at a hospital while sick with COVID-19 because she could not figure out how to cancel a shift without lowering her rating. At most hospitals and medical facilities, no orientations are required for gig nurses and nursing assistants. Workers do not know where supply closets are located, how to access patient portals with medical histories and current medication lists, and whom to contact in the chain of command. With gig nursing, there is often little to no continuity of care. Despite hospitals’ attempts to automate nursing, care work is inherently tricky to de-skill and predict. Shifts do not neatly end when the apps say they do as, of course, patients’ health-care needs do not end just because the clock says they should. Human frailty—the essential subject of nursing—defies algorithmic management.

As the report will detail, gig nursing has already proven itself to be an unmitigated disaster and we are still relatively early in its assault on our lethargic healthcare system.

Background

A Shortage of Decent Workplaces

Press them hard enough and most gig nursing firms will insist their raison d'être is a desire to fix America’s nursing shortage by making it easier to for understaffed facilities and underworked nurses to find one another. We do not actually have a nursing shortage, however. There are 187,000 open nursing jobs, 1.7 million registered nurses who are not employed, and the Department of Health and Human Services (HHS) predicts that by 2030 we’ll see 43 US States with a surplus of registered nurses. Despite this, nurses almost universally report “moderate to severe” levels of understaffing and HH has found “monumental” staffing issue at nursing home. So what’s the actual problem? Wells and Splinda write:

The problem, then, is not a shortage of available nurses and nursing assistants, explains Karen Lasater (2024). The problem is a growing number of nurses and nursing assistants who refuse to accept chronically understaffed, underpaid, unsafe, and high-stress workplaces (Muir et al. 2024). In other words, many nurses are not unwilling to work or unwilling to work full-time; they are simply unwilling to work with hazardous conditions, organizational failures, ill-maintained facilities, scheduling rigidity, and low pay (Muir et al. 2024; Lasater et al. 2024). During the COVID-19 pandemic, more than 100,000 registered nurses left the industry due to workplace stresses (Seow 2023; Auerbach et al. 2024). But this pandemic-induced exodus of mostly older workers was more than made up for by the arrival of younger workers, and the nursing workforce has not suffered any long-term shrinkage post-pandemic (Auerbach et al. 2024).

So what’s driving the shortage of decent workplaces?

Over the last 50 years, financialization, consolidations, and the rise of business administrators in medicine have built a new for-profit health-care empire organized around capital-intensive procedures, consolidated corporate power, and risk-intensive working conditions. In 1965, there were nearly no investor-owned hospitals in the US. But by the mid-1980s, about 15 percent of all US hospitals were owned by investors (Ermann and Gabel 1986). Forty years later, the percentage of investor-owned, for-profit hospitals had nearly doubled to 30 percent of community hospitals in 2022 (Lingel et al. 2022). Alongside this expansion of corporate ownership in the health-care industry, hospital profits ballooned by 411 percent from 1999 to an all-time high of $88 billion in 2017 (National Nurses United 2020). At the same time, rural areas have seen more than 100 hospitals close in the last decade and 700 more at risk of imminent closure (Olsen 2024). New management practices such as decreased lengths of stay for patients and increased responsibilities for nurses have taken hold across the health-care industry (Brewer 1998). Business endeavors to cut costs have kept nursing wages stagnant and led to an increasing number of medical facilities that are purposefully understaffed (Brewer 1998).

All of this has only grown even worse with the ascent of private equity, a type of capitalist parasite that leverages $$$ to buy up then restructure a business for the maximum possible return. One quick and vivid explanation of private equity can be found in Yanis Varoufakis' "Technofeudalism" where he uses an English private care provider acquired by a private equity firm as the example. The worker (Gillian) may not notice much at first, but behind the scenes the company has been split into two: CareCom, a care service provider that employs Gillian and her co-workers; and PropCom, which now owns all of hte property (buildings, equipment, vans, etc.) and charges CareCom for their use. PropCom not only hikes the rents it charges CareCom, but promises further hikes. CareCom's managers tell CareCom’s workers that they must accept longer working hours for no extra pay lest CareCom go under. PropCom goes to the bank and offers up its predatory rent scheme revenues as collateral for a big loan, then uses the loan to payout dividends to its shareholders.

This can only continue for so long, however, and in five years time CareCom goes belly up. Gillian and her co-workers are finally fired, but only after conditions and pay degraded substantially. And the communities which were promised care—paid for in advance with their taxes—are left royally fucked. PropCom, however, is doing better than ever. They'll sell off the property at a profit, pay back the loan from the bank, and pocket the difference (for their investors, of course). This is "straightforward asset-stripping" as Varoufakis explains—looting by financiers that is legal for some reason (and given a fancy-sounding name "dividend recapitalisation").

The same thing happens here, as Wells and Splinda write:

Private equity’s acquisition and subsequent raiding of two of the largest health-care staffing agencies in the country is an important piece of any story about why so many nurses turn to gig nursing. When the private equity companies Ares Management and Leonard Green and Partners acquired a majority stake in CHG Healthcare, a health-care staffing agency, the private equity companies did two things. First, they followed a routine private equity move of adding hundreds of millions of new debt to the staffing agency as a way to finance the acquisitions of other companies. Then, they extracted more than $1.5 billion in dividends from the staffing agency. Not long after, Moody’s lowered CHG’s credit rating from stable to negative. Just as private equity is looting and closing hospitals across the country, so too is it raiding travel nursing agencies (Bugbee 2022).

Gig nursing firms have not attracted significant funding because there is a nursing shortage, they’ve attracted significant funding because financialization has devastated our healthcare system in pursuit of excessive returns and other financiers are eager to replicate this destructive model of large private profits and even larger socialized losses.

Existing Research on Gig Nursing

Across the body of work looking at the impact of gig nursing and algorithmic management, there is little room for interpretation: the only true beneficiaries are the investors financing this clear attack on the quality of care provided by and working conditions of the US healthcare system. Wells and Splinda cite a study of the gig nursing industry by Chia Yu Lien and write:

Lien does not mince words: Gig nursing services have worsened, rather than alleviated, the quality and quantity of nursing jobs. In using gig nursing services, nursing home managers make a Faustian bargain: To offset the premium costs for gig nurses (who often command higher rates than in-house staff), a nursing home takes in more clients, resulting in more work for its employed staff. Employed staff then find “themselves receiving lower salaries, having higher caseloads, working on weekends and holidays and often providing extra services for which they [are] not compensated.” Lien concludes that gig nursing jobs hurt the quality of care in health-care facilities, ignite workplace tensions between gig nurses and full-time staff, and eliminate much-needed managerial oversight in these facilities.

Other research raises similar concerns: gig nursing degrades quality of care because it is not continuous, erodes worker rights, externalizes various risks from employers to app-based workers, and reinforces existing inequities in the name of cost-cutting.

A Brief Labor History

While algorithmically-mediated gig nursing platforms for medical facilities are a novel development, Wells and Splinda’s map out in this section how the use of third-party staffing entities is not novel in the industry. Until the 1950s, in fact, most nurses working at hospitals did it through women-run private-duty registries that organized collective agreements for nurse employment and allowed for pay, schedule, and working condition negotiation. Once hospitals began to hire and manage staff nurses from their own pools, the registry system (and its working conditions) quickly met its demise. Hospitals would also go on to intervene in policy debates, distracting from quality-of-workplace issues raised by nurses to instead push for the government to expand nursing education. As Wells and Splinda put it “Rather than asking why so many nurses had left their jobs in the 1950s, federal action focused on increasing the supply of new nurses to take open spots or using student nurses who would toil long hours for little to no pay.” The tension between nurses in workplaces with collectively-enforced standards and attempts to atomize workers such that they’re easier (and cheaper) to manage/schedule:

In recent years, a number of campaigns by unionized nurses have made important contributions to the labor movement by demanding decent patient care (Hirsch et al. 2024; Krachler et al. 2021; but see Givan 2016 on the fraught relationship between labor movements and nurses). National Nurses United, the largest union for registered nurses, held a June 2022 webinar on the topic of gig nursing and later warned that gig nursing firms will harm all nurses in the long run (National Nurses United n.d.; Coleman-Lochner 2023). However, when the union released in 2024 a guiding set of principles “for AI Justice in Nursing and Health Care,” the issue of gig nursing did not appear. Initial research suggests that gig nursing is most common in nonunionized medical facilities, which may contribute to the smaller amount of attention the issue has received so far from existing unions, whose workplace concerns for employed nurses are already considerable.

Worker Experiences

The Black Box of On-Demand Nursing Apps

Here we get to some of the personal testimonies which are frustrating, to say the least.

In the gig nursing world, there is zero transparency about how jobs are algorithmically allocated or automatically scheduled. Different shifts will show up on different workers’ phones—often for different amounts of pay. On the same day, at the same hour, in the same hospital, two different gig nurses can be paid different amounts by the same app. The gig nursing industry looks more like a black box than a clear process or a fair set of rules. The industry’s opaque and personalized pay structures create what Veena Dubal (2023) terms “algorithmic wage discrimination,” a kind of discrimination in which workers are paid different hourly amounts based on ever-changing calculations and informational asymmetries. Gig nursing apps may determine pay by what the firm knows about how much a nurse was willing to accept for a previous assignment, how often they bid for shifts, or how much credit card or other kinds of debt they might hold. These uncertainties combine to create frustrating and precarious conditions for the workers who rely on these apps.

Wells and Splinda go on to highlight that gig nurses are not only expected to always be on call, but hospitals can suddenly cancel, shorten, or extend their shifts with little to no notice—nurses would be penalized if they tried to do the same on their end, however:

For Dana, a 29-year-old nurse in St. Louis, Missouri, one of the hardest parts of working on the CareRev app is not knowing whether she will actually get to work a shift that she accepted. Even after she is matched with a shift at a nearby hospital and arranges childcare for her son, she won’t know for sure if she’ll be able to earn money that day. She says, “It’s a gamble . . . I’ll wake up at 5:00 in the morning and I’ll find out if I’m canceled or not.”8 If a hospital cancels her shift more than two hours before the start time, CareRev does not compensate her at all. If the cancellation is closer to the planned start time, she sometimes earns two to four hours of what she was supposed to have earned if she worked the entire shift. Hospitals may also shorten shifts while a nurse is on the job; in these cases, the app does not pay the nurse for any of the unworked hours. (Of course, nurses are not paid for any unexpected additional hours they may work.) If Dana were to cancel a shift at the last minute or leave in the middle of a shift, she would be penalized. Her attendance rating would dip, which would negatively impact her access to future shifts or the app itself.

To work on the CareRev app, Dana must be on-call for all of the shifts she selects but is only paid for her actual hours worked. Almost all of the workers we interviewed shared frustrations about the way gig nursing companies do not compensate nurses for canceled or shortened shifts. Several workers described with resentment the experience of receiving a cancellation notice in the app just as they arrive at a facility’s parking lot. When this happened to Robin, a 41-year-old health-care worker living near Miami, Florida, she couldn’t find another shift and did not work that day.

On top of all this, gig nurses are not given equal pay for equal work!!

On ShiftKey, Ashley not only expresses her availability for a shift but bids for one against peers by indicating the lowest hourly rate for which she will work. To win the shift, she lowers and lowers her rate until it’s well below a living wage. Like other gig workers who spend a considerable amount of work time not being paid (see Attoh et al. 2024), Ashley is not paid for the time she spends each month updating her profile, reviewing available positions, bidding for shifts, and sending messages in the app about errors in her wages.

Ashley earns an average of $23 per hour on ShiftKey, but arbitrarily pays $6 per shift in hidden fees

Each day Ashley works, she is required to pay $3.67 for a “safety fee” (which the company describes as “costs associated with background checks, drug screens [if applicable], verification of credentials, and fraud detection and prevention”), $2.14 for occupational accident insurance, and $0.21 for medical malpractice insurance (ShiftKey 2024b; 2024c). It is not clear why these fees are priced per day, given that nurses do not get background checks or drug screens each day they work on the app. By the end of 2024, these fees will increase to a new total of $7 per shift. Ashley is also charged $2 per shift if she elects to cash out immediately rather than waiting a week for her pay to be transferred.

And while the rates on ShiftKey can be higher than what traditionally employed nurses and nursing assistants earn, this does not account for “material expenses”:

such as equipment, licenses, and uniforms, for which workers are responsible. Gig nurses, for instance, must pay for and maintain differently colored scrubs (and sometimes shoes) for different facilities. Moreover, the payout does not account for the significant payroll taxes for which workers are responsible. ShiftMed is a welcome outlier in this regard as it treats its workers as W-2 employees with some basic labor rights.

So gig nursing empowers employers to misclassify care workers—this frees those workers from the protection of various local, state, and federal labor laws, as well as the employers from the costs of providing materials and adequate wages. It also empowers the middlemen, these gig nursing platforms, to scalp each shift with hidden fees that push wages down and conditions into the shitter.

When companies like CareRev, ShiftKey, and Clipboard Health classify nurses and nursing assistants as self-employed, many of the costs and risks of doing business are shifted onto the workers. These workers are excluded from the protections of local, state, and federal law on minimum wage, overtime pay, workers’ compensation, retirement benefits, employment-based health insurance, and paid sick days.

Safety and Health Risks for Workers

One theme that is painfully obvious in this section is the extent to which there is overlap with app-based delivery work, namely how unsafe it leaves the workers:

Aisha compares the risks of gig nursing work to those of app-based food delivery, which often takes her to strange neighborhoods at night. For ShiftKey, she has shown up late at night to facilities where the doors are locked and she can’t get in contact with anyone to open them. Even inside certain hospitals or nursing homes, she sometimes feels unsafe: “You really don’t know anything about the facilities.” Gig nurses are not required to complete any paid training or onboarding at most facilities. They are dropped into facilities like new avatars in a survivalist video game. The result of gig nurses’ isolation isn’t just a lack of solidarity with peers (be it other gig workers or employed staff) but exclusion from any sort of professional development or professional culture that maintains shared norms and practices.

There is little to no supervision offered by the facilities or the gig nursing companies. Instead of phone numbers, gig nurses are expected to communicate with chatbots if questions or concerns arise during a shift. Because facilities are often poorly run and desperate enough to use these firms, gig nurses bring their own vitals equipment because they aren’t sure the facility will have any. And because these facilities tend to be understaffed due to horrendous working conditions, gig nurses are expected to work that would normally be divided between multiple people but for no extra pay. To make matters worse, antagonism emerges between gig nurses and any regular staff present that assumes these on-demand workers are earning more for equal work.

As a reminder, gig nurses and gig nursing assistants are often paid higher wages per hour than employed staff, but, unlike most employed staff, are responsible for significant expenses and earn no benefits.

As most of the existing body of research on gig work across industries points out, this sort of antagonism not only undermines the capacity for solidarity between gig workers as well as across worker classifications but is exploited by on-demand labor platforms to keep workers too isolated, atomized, and vulnerable to collectively challenge such abysmal conditions.

Safety and Health Risks for Patients

Workers aren’t the only ones who are hurt by gig nursing, however. Take Shakayla, a 38 year old nurse in Los Angeles:

For the last year, she has picked up shifts using ShiftMed to supplement her income as a regular travel nurse for a health-care staffing agency. The difference between the kinds of facilities where she works as a travel nurse and a gig nurse are stark. On ShiftMed shifts, she says: “There have been times when I’ve been unable to access patient records or find supply closets.”25 There are also broken machines and missing equipment, she says. By contrast, “You go to a hospital in a different area that has funds and resources . . . It’s just like night and day, honestly.” Shakayla likes the stability, benefits, and rapport with her coworkers at her regular job and dislikes how work booked through ShiftMed can pose risks to patient safety, but inflation and increases in the cost of living mean that she keeps opening the ShiftMed app.

As highlighted in earlier sections, gig nursing’s core model is incompatible with continuous care. No matter what gig nursing platforms might argue, quality care cannot be discontinuous. When it is, we see major lapses in care: inconsistent updates on patient medication, treatment or assistance that patients need, whether controlled substances are adequately secured, and so on.

Gig Nursing Retention

One of the key takeaways here for Wells and Splinda is that even though the gig nursing sector is dominated by such poor working conditions and such high risk to patients and nurses, it is still pursued by nurses who need flexible schedules. Why?

The fact that many workers are willing to take on the risks of the health-care sector via unregulated technology should be a reflection of the failures of the existing labor market in general and the erosion of labor standards in the health-care industry in particular—not merely the design failures of gig nursing. In other words, the risks and concerns that workers expressed will not be automated away if the current algorithmic systems are replaced by better ones and trained on more data with more use cases. For many workers, the possibility of employment that involves flexible schedules is enticing and worth pursuing. The question before civic leaders and government officials is how to balance the flexibility that attracts gig nurses while also addressing the workplace concerns of those same workers and patients who need care.

Policy Landscape

On the policy side, Uber opened the door and gig nursing platforms will eagerly run through it.

Since 2022, a number of laws and legal amendments have been drafted to define digitally dispatched health-care workers as independent contractors. Just as Uber convinced municipal regulators in 2012 that digitally dispatched chauffeurs needed a new business category and exemptions from existing regulatory structures, so too are on-demand nursing companies trying to convince state-level regulators that there is something magically different about their business operations and thus they should be exempted from existing legislation.

In California, Minnesota, and Ohio, we see attempts to push through laws that self-exempt gig nursing platforms from labor laws—thankfully they’ve all failed. In 2022, however, Colorado adopted an industry-friendly gig nursing bill that will likely serve as a model in the years to come.

This new Colorado law tries to preempt both local regulation and the kinds of misclassification lawsuits that have entangled ShiftKey and Clipboard Health. In several states, ShiftKey workers contend that nursing homes have wrongly withheld their wages and overtime pay. What’s important to keep in mind about these legal battles is that the cases are not being brought directly against ShiftKey. The workers, who are prevented from filing class action lawsuits, are suing the nursing homes that treated them as employees (i.e., asked workers to stay late) but did not compensate them as such with overtime pay (Henreckson 2024). Of course, ShiftKey, as the entity that facilitates the recruitment, hiring, and scheduling of these workers, is implicated in the cases. In California, Clipboard Health has seen numerous wage claims filed against it and, in 2022, agreed to a $2.2 million settlement over unpaid overtime to its workers (Sumagaysay 2023).

And an important point emphasized by Wells and Splinda is that such regulatory arbitrage encourages more because firms that try to do the right thing are actually at a competitive disadvantage. Firms that, say, “avoid contributions to social programs and force the public to pay for essential services for their workforce” are more likely to attract investors (or able themselves to finance expansion) than those that pay fair wages and contribute to Social Security or unemployment or health insurance. Still, classification as employees will not fix every issue as the gig nursing model itself comes into conflict with the very nature of quality healthcare.

Conclusion

Across the US, gig companies present themselves as quick fixes to what many have argued are really structural problems in the contemporary health-care industry. In the wake of the COVID-19 pandemic, companies like ShiftKey, Clipboard Health, CareRev, and ShiftMed have seized an opportunity and appealed to our common sense. Just as the gig economy sold itself as offering workers some control over their lives, gig nursing companies promise to empower nurses. As such, we must see the rise of on-demand nursing as a symptom of a problem—not the problem itself. Nursing professor Karen Lasater (2024) is explicit:

Policymakers need not solve for a low workforce supply issue; the US has a robust and growing supply of registered nurses with enough new nurses to more than replace retiring nurses through 2035. Instead, policies are needed to address the low retention caused by employers’ chronic understaffing, rigid scheduling options, and lack of responsiveness to clinicians’ recommendations to improve care, which drives nurses to burnout and [to] depart for better working conditions.

Is gig nursing the solution to our dysfunctional healthcare system? Certainly not. If anything, the report details the ways in which it ignores every key issue, exacerbates existing ones, and creates novel ones as well, at great cost to everyone except employers and financiers whose interests have little to do with public health.

On-demand nursing companies exercise employer-like control over their workers yet ascribe to workers a “second-class status of nonemployees” (Sherer and Poydock 2023). These companies want the power that comes with being an employer while disowning the duties and responsibilities enacted over the past century by federal and state lawmakers. The companies, however, frame the question of worker misclassification not as an issue of eroded labor rights but as a referendum on freedom, empowerment, and progress.

Often the deployment of new technology is used as cover to rollback reforms and regulations that have made old levels of profiteering unrealizable or outright illegal. That tends to be a function of who is steering the design, development, and deployment of said technologies. It is one thing when managers and financiers are in the drivers seat, and it would be another thing entirely if care workers were in control. It is not clear to me why anyone other than nurses should be in control of what sort of technology is introduced into their workplaces, how this technology is designed, why it is deployed, and when it is used. To close out with Wells and Splinda:

It is important to not lose sight of the enormous amount of skill, coordination, understanding of human vulnerability and frailty, and treatment of patients with utmost decency required to provide good quality care. Technology could provide solutions to automate and unburden the nurses and health-care workers from the everyday management tasks of their work; however, decision-making around such solutions should include the nurses themselves, from design to deployment.