Policy Playbook: Labor Actions and Unionization in Healthcare

Author: Ryan Leone, MSc, Medical Student at Columbia University // Reviewed by: Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

What’s the issue?

Across several sectors, labor strikes and unionization were prominent throughout the last year. Despite a plateau in overall union membership of around 10% in 2023¹, major labor actions shook the U.S. and gained national attention, including high-profile strikes by the United Auto Workers (UAW), the Screen Actors Guild – American Federation of Television and Radio Artists (SAF-AFTRA), and the Writers Guild of America.² Another industry that was significantly affected by this trend in organized labor was healthcare; for doctors, nurses, and other health staff, unionization and labor actions are products of existing burdens on the American healthcare system— such as boarding, staff shortages, burnout, and pay concerns.³

Increasing Strikes and Unions

• Labor actions in healthcare can disrupt normal hospital operations, potentially impacting costs and threatening patient quality of care.
  • Cost: News reports suggest that a two-day nursing strike at Rochester Hospital cost over $6 million⁴, while the New York State Nurses Association estimated that the threat of a strike before it occurred cost up to $32 million in pay to temp agencies.⁵
  • Quality: Results on quality impacts are mixed. One study from the National Bureau of Economic Research on nursing strikes in New York State from 1984 to 2004 found that hospital mortality increased by 19.4% and readmissions increased by 6.5% for patients admitted during the strike.⁶ Other studies during doctor’s strikes, however, showed that morbidity and mortality did not increase and in some cases decreased, potentially due to staff reassignment, elective surgery maintenance or curtailment, and continuation of emergency care.^7-11 These findings held regardless of the striking profession, country, duration, or number of facilities.
• Healthcare strikes have been increasing in frequency and size.
  • Frequency: In the U.S., there were 31 recorded healthcare strikes in 2021, 39 recorded healthcare strikes in 2022, and 37 healthcare strikes in 2023 as of November 3rd.¹² Other numbers from the Bureau of Labor Statistics, which tracks work stoppages involving over 1,000 workers, suggested an acceleration from one strike every 4.1 months between 1993 and 2021 to one strike every 1.4 months since 2022.¹³
  • Size: The biggest healthcare strike in U.S. history occurred in October 2023 when 75,000 Kaiser Permanente workers across California, Colorado, Oregon, Virginia, and Washington, D.C. were on strike for 3 days.¹⁴
• Unionization is relatedly gaining attention, presenting healthcare staff with a communal way of negotiating over working conditions, pay, benefits, or other points of contention.
  • One study found that labor unionization among U.S. healthcare workers previously remained low and relatively stagnant between 2009 and 2021.¹⁵
  • However, that same survey showed that unionized workers reported higher weekly earnings and better benefits, but also more weekly hours worked.¹⁵
• Residents have formed unions nationwide, including at Mass General Brigham in Boston, George Washington University in Washington, D.C., Montefiore Hospital in New York, the University of Vermont Medical Center in Vermont, and Harbor-UCLA Medical Center in California.^16,17

Ethics and Legal Elements

• The ethics of provider strikes have been debated, with some saying that they violate a duty to “do no harm” to patients and others arguing that the right to strike is inherent across professions.^18-21
• Given the unique status of healthcare workers in saving lives, employees of non-profit hospitals were initially left out of the 1947 Taft-Hartley Act, which had amended the National Labor Relations Act to change collective bargaining regulations.²²
• This was changed through the 1974 Nonprofit Hospital Amendments to the Taft-Hartley Act, which gave healthcare employees the same rights as other employees.²²
• Regardless of one’s ethical stance on the issue, increases in strike frequency will pose challenges to health systems, while also putting pressure on administrators to offer better support to workers.

Why does it matter?

• Labor actions have already occurred in geographically diverse parts of the country and could affect hospital systems nationwide.
• Unionization of healthcare providers can create opportunities to improve staff’s financial and general well-being, but may also facilitate future strikes.
• Trainees and attending providers should be informed about both the opportunities that come with unionization, as well as the challenges that come with managing strikes.
• Patients should be aware of potential labor actions that may affect hospitals near them, choosing to visit facilities that are not under duress but also understanding and sympathizing with the pressures placed on providers that may lead to such strikes.

What can I do about it?

• Read: Stay abreast of current developments in labor actions within healthcare, as well as the formation of unions amongst healthcare providers.
• Listen: Communicate with providers and staff about their concerns, genuinely asking for feedback and working to make changes that improve their lives or reduce frustration.
• Inform: Relay information about existing or potential labor actions to hospital leaders, protecting the identity of concerned individuals and stressing the importance of taking concerns seriously.
• Plan: Develop a plan to deal with any labor action before it arises.

Helpful Resources or Links

• American College of Emergency Physicians (ACEP)
  • Reflections on the Response to a Resident Physician Strike in New York City (NYC)
• Administration for Strategic Preparedness and Readiness (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE)
  • Health Care Labor Action Preparation Checklist 
• Dr. Leon Adelman’s EM Workforce Newsletter
  • What Can an EM Union Do For You?
  • Physician Unionization is So Hot Right Now
• Dr. Lisa Rosenbaum’s NEJM Piece What Do Trainees Want? The Rise of House Staff Unions
• Forthcoming Publications:
  • Leone RM, Salway RJ, Silvestri D, Iavicoli LG. Healthcare Provider Strike Preparedness and Response: Lessons Learned from Physician Strikes in New York City. (Unpublished Manuscript, 2023).
  • Leone RM, Iavicoli LG, Silvestri D, Salway RJ. Development and Implementation of Rapid Discharge Plan in a Municipal Healthcare System. (Unpublished Manuscript, 2023).

This post was a collaboration between emDocs and the EMRA Health Policy Committee.

References/Further Reading:

1. Rubin A, Lysik T. More than 330K striking Americans help unions flex power. Axios. October 16, 2023. Retrieved from: https://www.axios.com/2023/10/16/union-strike-numbers-uaw-sag-wga-kaiser
2. Fortinsky F. Union membership plateaued in 2023 despite high-profile strikes. The Hill. January 23, 2024. Retrieved from: https://thehill.com/business/4424609-union-membership-2023-strikes/
3. Fischer S. Why Health Care Workers Are Striking. RAND Blog. 2023 October 9. Retrieved from: https://www.rand.org/pubs/commentary/2023/10/why-health-care-workers-are-striking.html#:~:text=Health%20workers’%20unions%20have%20said,stay%20in%20their%20jobs%20longer.
4. Marsh J. Rochester General Hospital responds to nurses strike vote. Rochester First. 11 October 2023. Retrieved from: https://www.rochesterfirst.com/news/top-stories/rochester-general-hospital-nurses-union-votes-to-strike/
5. Russo M. NYC Hospitals Start Moving Sick Babies, Diverting Ambulances as Nurse Strike Looms. NBC News. 5 January 2023. Retrieved from: https://www.nbcnewyork.com/news/local/nyc-hospitals-start-moving-sick-babies-diverting-ambulances-as-nurse-strike-looms/4030088/#:~:text=The%20New%20York%20State%20Nurses%20Association%20estimated%20that%20the%20mere,is%20raging%2C%22%20said%20Raske.
6. Gruber J, Kleiner SA. Do strikes kill? Evidence from New York state. American Economic Journal: Economic Policy. 2012 Feb 1;4(1):127-57.
7. Cunningham SA, Mitchell K, Narayan KV, Yusuf S. Doctors’ strikes and mortality: a review. Social science & medicine. 2008 Dec 1;67(11):1784-8.
8. Metcalfe D, Chowdhury R, Salim A. What are the consequences when doctors strike?. Bmj. 2015 Nov 25;351.
9. BMJ. “Patient deaths do not increase during doctor strikes: But action should be organized in such a way that patient safety is not compromised, say US experts.” ScienceDaily. Retrieved fromwww.sciencedaily.com/releases/2015/11/151125233018.htm
10. Essex R, Milligan W, Williams G, Weldon SM. The impact of strike action on patient morbidity: A systematic literature review. The International Journal of Health Planning and Management. 2022 May; 37(3):1311-26.
11. Essex R, Weldon SM, Thompson T, Kalocsányiová E, McCrone P, Deb S. The impact of health care strikes on patient mortality: A systematic review and meta‐analysis of observational studies. Health services research. 2022 Dec;57(6):1218-34.
12. Navarez, M. The Growing Impact of Healthcare Labor Strikes. Chartis. 3 November 2023. Retrieved from: https://www.chartis.com/insights/growing-impact-healthcare-labor-strikes#:~:text=The%20healthcare%20and%20social%20assistance,labor%20actions%20in%20the%20industry
13. Hut N. Healthcare labor union activity gains steam: The consequences for hospitals and health systems. Healthcare Financial Management Association. 10 October 2023. Retrieved from: https://www.hfma.org/finance-and-business-strategy/healthcare-business-trends/healthcare-labor-union-activity-gains-steam-the-consequences-for-hospitals-and-health-systems/
14. Kaye D. 75,000 Kaiser nurses, pharmacists and other workers have walked off the job. NPR. 4 October 2023. Retrieved from: https://www.npr.org/2023/10/04/1203225614/kaiser-permanente-historic-strike-health-care-workers-nationwide
15. Ahmed AM, Kadakia K, Ahmed A, Shultz B, Li X. Trends in labor unionization among US health care workers, 2009-2021. JAMA. 2022 Dec 27;328(24):2404-11
16. Weiner S. Thousands of medical residents are unionizing. Here’s what that means for doctors, hospitals, and the patients they serve. American Association of Medical Colleges. June 7, 2022. Retrieved from: https://www.aamc.org/news/thousands-medical-residents-are-unionizing-here-s-what-means-doctors-hospitals-and-patients-they
17.  Yu A. 80-hour weeks and roaches near your cot? More medical residents unionize. National Public Radio. March 23, 2023. Retrieved from: https://www.npr.org/sections/health-shots/2023/03/23/1165539846/80-hour-weeks-and-roaches-near-your-cot-more-medical-residents-unionize
18. Chima SC. Global medicine: Is it ethical or morally justifiable for doctors and other healthcare workers to go on strike?. BMC Medical Ethics. 2013 Dec;14:1-0.
19. Thompson SL, Salmon JW. Strikes by physicians: a historical perspective toward an ethical evaluation. International Journal of Health Services. 2006 Apr;36(2):331-54.
20. Smith J, Essex R, Issa R. On the politics and ethics of strike action by health professionals. The Lancet. 2022 Nov 9.
21. Becker ER, Rakich JS. Hospital union election activity, 1974-85. Health Care Financing Review. 1988;9(3):59