Healthcare labor union activity gains steam: The consequences for hospitals and health systems

Note: The lead section of this article was updated Oct. 16 with news of a tentative agreement between Kaiser Permanente and the unions.

When around 75,000 staff at Kaiser Permanente went on strike for three days starting Oct. 4, they represented more than just the largest-ever labor stoppage in the healthcare industry.

They also exemplified a trend that is likely to have increasingly loud repercussions for the hospital and health system sector, which already has been grappling with steep labor costs and difficulty filling positions.

For union activity, “I definitely think healthcare is the ripest industry in the country right now,” said Kevin Carr, JD, a partner at Spilman Thomas and Battle, PLLC and co-chair of the firm’s Labor and Employment Practice Group.

Carr cited the likelihood that the Service Employees International Union (SEIU), which represents more than 40% of unionized healthcare workers and is a key player in the Kaiser Permanente showdown, will turn its attention to healthcare after focusing elsewhere in recent years. Another factor is rising concern among workers that the staffing challenges and other issues that hampered hospitals during the pandemic aren’t being resolved expeditiously.

The position staked out by the Coalition of Kaiser Permanente Unions illustrates why the unionization push will complicate efforts to return to something approaching a normal healthcare labor picture. The coalition has been urging Kaiser Permanente to bolster staffing and, unsurprisingly, has not acknowledged concerns about what that would cost.

In a letter to management earlier this year, the coalition wrote, “We are calling on you to join us and use our upcoming contract negotiations as an opportunity to heal our industry by ending the staffing crisis.”

A “longer, stronger strike” looms in November if the sides cannot reach an accord, the coalition said in a recent update.

Oct. 16 update: Kaiser Permanente and the Coalition of Kaiser Permanente Unions have reached a tentative agreement on a new labor deal. See details in the health system’s news release and the coalition’s summary.

Sidebar: Key players in the unionization push

The scope of the issue

The U.S. Bureau of Labor Statistics tracks work stoppages that involve 1,000 or more workers. There were 84 such stoppages at hospitals between 1993 and 2021, or one every 4.1 months. The pace has accelerated since the start of 2022, with 15 stoppages in an approximately 21-month span through early October — one every 1.4 months (see the chart below).

Even so, experts say the impact of unionization in healthcare is not yet as substantial as the buzz around the topic suggests.

“It’s more anecdotal than it is systemic,” said Bill Miossi, JD, who represents employers in labor and employment cases as a partner at Winston & Strawn, LLP. “The news has forced a lot of this stuff into people’s field of vision.”

Data indicates that about 13% of the healthcare industry workforce was unionized in 2009, with the share remaining virtually identical as of 2021.

Since the pandemic, “The noise level is up. The number of organizing activities is only up slightly,” said Paul Keckley, PhD, a longtime healthcare policy analyst and managing editor of The Keckley Report.

Miossi noted the impact is greater in certain markets, such as New York City and the San Francisco Bay Area. Regardless, statistics are no consolation to the provider at the center of the storm.

“Trends mean nothing when your staff are out there picketing or withholding their labor,” Miossi said. “That’s an all-hands-on-deck, DEFCON 5 situation for that provider. It’s very stressful, and they’re very concerned, as they should be, about the perception the public has [regarding] patient safety: ‘How am I going to be assured that care will be uninterrupted?’

“The unions appreciate that very much. They understand they have leverage in terms of the public perception, and they will utilize it.”

Hospital work stoppages involving at least 1,000 employees, January 2022-October 2023

Facility	State	Number of workers	Days
Sutter Health hospitals	California	8,000	5
Stanford Health Care/Lucile Packard Children’s Hospitals Stanford	California	5,000	6
Cedars-Sinai Medical Center	California	2,000	5
Kaiser Permanente LA Medical Center	California	1,200	1
Kaiser Permanente Northern California facilities	California	2,000	45
Twin Cities Hospitals Group, Essentia Health, Allina Health, St. Luke’s	Minnesota	15,000	3
Sutter Health hospitals	California	1,800	5
Alta Bates Summit Medical Center	California	1,800	4
Montefiore Medical Center, Mount Sinai Medical Center	New York	7,000	3
Providence Portland Medical Center	Oregon	1,800	4
Robert Wood Johnson University Hospital	New Jersey	1,700	67a
UCSF Benioff Children’s Hospital Oakland	California	1,200	1
The New England Healthcare Group	Connecticut	1,700	15
Ascension (3 hospitals)	Kansas, Texas	2,000	1
Kaiser Permanente	5 statesb	75,000	3

A conundrum for hospitals

Achieving stability in the healthcare labor economy will require a long-term strategy, and that dynamic potentially allows organized labor to step into the breach.

“What we’ve heard from places is that the labor and staffing issues are going to take a few years to work themselves through — either you get more efficiencies, or your supply increases on the labor side,” said Suzie Desai, director of not-for-profit healthcare in the U.S. Public Finance Ratings Group at S&P Global.

In the interim, she added, “It feels like the conditions are there for continued union activity.”

At a time when hospital cost structures widely are seen as untenable, unions increasingly want a say in what that means for staffing.

“Comp and benefits are one thing, but they’re never at the top of the list,” Carr said. “They’ll work [themselves] ragged like they did during the pandemic because they care. But if they don’t perceive that the hospital’s doing enough to keep staffing where it is to serve patients, that to me is number one” on the list of concerns.

There’s a flip side in that labor interests sometimes clash with strategic initiatives to improve operations by increasing the utilization of technology. Unions support implementation of technology that eases strain, but they’ll push back if job loss is a perceived outcome.

“You can’t reengineer the future of a hospital without finding a way to reduce its labor intensity, which is like fighting words for labor unions,” Keckley said.

He added that hospitals already outsource various functions, and the day is fast approaching when AI will be able to handle any number of additional tasks.

“For unions, that’s like red meat,” he said.

The bigger picture

The prospective increase in union activity is, in part, a reflection of the political climate. President Joe Biden, who frequently touts his support of unions and even visited a picket line of the United Auto Workers in September, installed a pro-labor general counsel at the National Labor Relations Board (NLRB) in 2021.

In part as a result, “We have seen over the last couple of years an uptick greatly in union activity across almost all sectors,” said Mike Hughes, JD, partner in the firm of Amundsen Davis.

Hughes added that Jennifer Abruzzo, the general counsel, has sought to “remove any impediments for unions to organize.”

Arguably the most notable change has been an August decision that simplifies the process for unions to establish themselves as a bargaining representative. For about 50 years prior, employers could require the union to conduct a formal employee vote. Now, collecting authorization cards from a simple majority of employees is sufficient unless the employer promptly files a petition with the NLRB.

The upshot of the change: “We can expect a lot more demands for recognition and bargaining,” Hughes said. “This also allows and encourages the unit to do a lot more clandestine organizing.”

Another development to watch is whether SEIU looks to healthcare as a next frontier for organizing, as expected, Carr said. Had SEIU concentrated more on the industry over the last couple of years, the number of union filings “really would have increased dramatically,” he said.

Still, the long-term outlook could change if a Republican candidate wins the White House in 2024 and puts his or her imprint on the NLRB.

How hospitals can respond

The best way for a hospital to avoid getting caught up in a unionization push is to ensure its employee relations are in a good place.

“There’s an old saying: The best union organizer is a bad supervisor,” Miossi said. “In an institution, if you really want to avoid unionization, make sure you have good, effective leadership in place.

“Good leadership means individuals who develop relationships with their employees, people they’re supervising. They listen, they give them feedback, they treat them with respect. All the stuff you learned in kindergarten, but it’s hard to do day-to-day as the stresses pile on.”

Indeed, understanding the need to work on employee relations is different from devoting the time and resources to do so in a substantive way.

“At the risk of being overly simplistic, I think there’s not a CEO and a C-suite team in [any] hospital that doesn’t genuinely think they’re doing that,” Keckley said. “They may not be doing it the way employees would like it done.”

Supervisors, including those with scheduling duties, should be trained on communication best practices. They specifically should know how to flag and respond to employee concerns — and to ensure they treat everyone fairly.

Trusted supervisors also can impart messaging about difficulties the hospital may be encountering with scheduling, staffing and other issues, Hughes noted. Such communication can mitigate a labor-organizing drive.

Said Carr, “[Hospitals] have to work on communication: objectives, challenges, what are we expecting? And not just on some screen in the hallway that [employees] walk by, but cascading that down through the people they know, love and trust — their unit supervisors. That communication tool was stress-tested during the pandemic, and I’m not sure every hospital in the country has gotten its hands back around that.”

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Key players in the unionization push

As seen at Kaiser Permanente, the Service Employees International Union (SEIU), representing employees in roles ranging from clinicians and technicians to environmental services workers, is the “point of the spear” in the healthcare unionization movement, said Paul Keckley, PhD, a healthcare policy analyst and managing editor of The Keckley Report.

Nurse unions also have made their presence felt. Of the 14 recorded work stoppages involving at least 1,000 healthcare workers between January 2022 and August 2023, the California Nurses Association or National Nurses United had a role in seven, and other nurse unions were behind two more.

Although their numbers within a bargaining unit are typically lower compared with SEIU members, nurses have obvious clout because their roles are so specialized.

“When it is your clinical staff, it’s your patients, it’s the bread and butter of what you’re doing every day,” said Suzie Desai, director of not-for-profit healthcare in the U.S. Public Finance Ratings Group at S&P Global. “And then there becomes headline risk if it affects patients.”

However, nurse unions “suffer a little bit from specificity,” said Kevin Carr, JD, of the law firm Spilman Thomas and Battle. “A reason SEIU is successful is they look wall to wall a lot of times within the organization. Nurses sometimes do, but not always. Those entities that are better able to look at the hospital’s employees as a unit are probably a little more formidable right now.”

Even physician residents have begun to organize in modestly greater numbers, seeking accommodations in pay and hours. In 2022, an Association of American Medical Colleges article quoted a spokesperson for the Committee of Interns and Residents as saying the number of new organizing campaigns had tripled during the pandemic from one or two per year.