Are U.S. Healthcare Workers Better Off Unionized?

Labor unionization among U.S. healthcare workers was low in recent years, even though union membership or coverage was tied to higher weekly earnings and better non-cash benefits, researchers reported.

Out of 14,298 healthcare workers surveyed, 13.2% reported union membership or coverage, with no significant trend from 2009 through 2021, according to Xiaojuan Li, PhD, of Harvard Medical School and Harvard Pilgrim Health Care Institute, both in Boston, and colleagues.

Unionized healthcare workers had significantly higher reported mean weekly earnings than non-union workers at $1,165 versus $1,042 (P<0.001), the researchers reported in JAMA.

And unionized workers were more likely to report having a pension or other retirement benefits at work than non-unionized workers at 57.9% versus 43.4% (risk ratio 1.33, 95% CI 1.26-1.41, P<0.001), the authors found. They also were more likely to report having a higher level of health insurance coverage and higher annual employer contributions to those health plans.

Unionized healthcare workers reported more weekly hours than non-unionized workers at 37.4 versus 36.3 hours (P<0.001), but Li’s group pointed that the mean differences of 1.11 hours did not indicate “much change in working hours.”

The study comes as labor unionization efforts have experienced a resurgence in the U.S., with the National Labor Relations Board receiving a 57% increase in union election petitions in the first half of 2022, according to Li and colleagues.

“For health care workers, the toll of the COVID-19 pandemic — including struggles obtaining personal protective equipment, inconsistent testing and notification of COVID-19-positive exposures, and inadequate pay with increased work hours — against the backdrop of increasing burnout prior to the pandemic, has amplified calls for labor unionization to improve working conditions in the U.S. healthcare system,” they wrote.

Labor unions have been shown to improve working conditions in other industries, but their role in the healthcare workforce remains limited, according to the authors, who stated that “[n]o study, to our knowledge, has systematically investigated labor unions and their economic effects across the healthcare workforce.”

In an accompanying editorial, Kevin Schulman, MD, of Stanford University in California, and Barak Richman, JD, PhD, of Duke University School of Law in Durham, North Carolina, noted that the current authors “focus on the health care workforce generally.” But they argued that “physician unions may deserve particular consideration.”

“Although only 6% to 8% of current physicians are union members or employed under a union contract, harnessing physician influence through unions might advance interests that extend beyond pay and benefits,” according to Schulman and Richman. “They might also improve the governance of healthcare systems and foster the delivery of ethical, high-value medical care,” as well as “bolster the input of physician-employees into how their hospital system employers deliver care and provide a counterforce to hospital corporatization.”

Li and colleagues used data from the U.S. Census Bureau-sponsored Current Population Survey (CPS) outgoing rotation group and Annual Social and Economic Supplement. The study sample included physicians and dentists (n=1,072), advanced practitioners (n=981), nurses (n=4,931), therapists (n=964), and technicians and support staff (n=6,350). Around 82% were women and 70% were white with a mean age of about 43.

In terms of health benefits, unionized workers were more likely to have employer paid-for, full premium-covered health insurance plan (22.2% vs 16.5% for non-union, RR 1.35, 95% CI 1.17-1.53, P<0.001). The authors also reported that unionized workers reported significantly higher annual employer contribution to their health insurance plans at $4,561 versus $3,455 (P<0.001).

Li’s group found that ties between unionization and pay differed significantly by racial and ethnic minority status in that being unionized was associated with significantly higher reported mean weekly earnings for:

• Non-Hispanic white workers: $1,157 vs $1,066 non-union (P<0.001)
• Racial and ethnic minority workers: $1,170 vs $1,001 (P<0.001)

When compared across racial and ethnic groups, non-Hispanic white workers reported significantly more mean weekly earnings than members of racial and ethnic minorities among non-unionized workers for a $65 mean difference (P<0.001). There was no significant difference between the two groups among unionized workers, the authors stated.

They also noted that for physicians and dentists in particular, there was no significant difference between unionized and non-unionized workers in reported mean weekly earnings, employer’s contribution to health insurance, mean weekly work hours, and likelihood of having a pension or other retirement benefits at work.

Study limitations included the fact that CPS data may have been susceptible to reporting bias. Also, the data did not indicate whether healthcare workers may have also been enrolled in graduate training programs, thus potentially not including the role of government subsidies and wage deflation for intern and resident salaries in certain cases. CPS data did not offer insight into workers’ experiences related to job satisfaction, stress, or mistreatment, Li’s group stated.

Finally, the “study findings do not allow inferring that associations with union membership are caused by union membership. They do not distinguish whether associations are related to membership or to the characteristics of the organization in which the workers were employed,” they wrote.