Healthcare Workers, Especially Physicians, Slow to Unionize in Past Decade: Study

Avery Hurt

January 04, 2023

Unionization is having a moment. The National Labor Relations Board recently reported a 53% increase in union election petitions from fiscal year 2021 to 2022.

But what about healthcare workers? Stresses from COVID-19 have added to already high rates of burnout and dissatisfaction, creating what would seem a powerful impetus for forming or joining a union.

Yet a recent study in JAMA found that despite several benefits of union membership for healthcare workers, physicians in particular have been slow to organize ― even as many more of them have become employees in recent years.

Better Pay, Better Benefits

The cross-sectional study, published December 27, evaluated trends in labor union membership among about 14,300 healthcare workers from 2009 through 2021. It showed that about 13% of the workers surveyed were unionized. Nurses (17.5 %) were more likely to report union membership than workers in any other healthcare occupation. Physicians and dentists (9.8%) and technicians and support staff (9.9 %) reported the lowest rates of membership.

Geographic differences were notable as well. Unionization was far more common in the Northeast (21.5%) and West (20.7%) than in the Midwest (11.4%) or South (5.2%) and were higher in metropolitan areas (14%) than in rural areas (8.3%).

Unionization rates did not change significantly between 2009 and 2021, even though union membership was associated with better pay (mean weekly earnings of $1165 for unionized workers compared with $1042 for nonunion workers).

Union workers also reported better retirement plans and more generous healthcare coverage than their nonunionized counterparts. However, union workers did work about 1.1 hours more per week than did their nonunion counterparts.

Ahmed Ahmed, MPP, fourth-year medical student at Harvard Medical School and first author on the study, and Xiaojuan Li, PhD, senior author and instructor in population medicine at Harvard Medical School, told Medscape by email that they were particularly struck by the finding that union membership was associated with more equitable compensation across racial and ethnic groups.

"Given ongoing challenges with inequities in compensation, unionization may be a helpful tool to ensure more fair pay for all workers," they write.

Reasons for Reluctance

Emily Onello, MD, now associate professor of medicine at the University of Minnesota, was one of a group of physicians at Lake Superior Community Health Center in Duluth who in 2013 formed a union.

She was surprised to hear that union membership among healthcare workers hadn't increased in recent years, particularly now that nearly 75% of physicians are employees rather than owners of their own practices. One of the most powerful motivations for organizing is the prevalence of contracts in which the worker can be fired at will for no cause, Onello said.

"For physicians," she said, "it's not as much about the money or benefits as about job security."

Li and Ahmed agree that the changing business model of medicine may motivate doctors in particular to unionize.

"As recently as 2012, physicians had more professional independence, with most clinical practices being physician-owned," they point out. "Most physicians now, however, work for large healthcare organizations, which could make it challenging for physicians to meaningfully participate in organizational governance and maintain independence."

The authors of an accompanying editorial agree, suggesting, "Physician unions offer one possible mechanism to channel physician authority against the harmful trends of hospital-based medicine."

Some physicians, however, may oppose unions because of the cost of union dues or fears that union goals might not align with their responsibility to patients. Doctors and other healthcare workers are often concerned about the ethics of unionizing, Onello said.

"They see this looming tactic of a strike or work stoppage and think, 'I could never do that to my patients,' " Onello said. "But the process of collective bargaining, when it's working well, should not lead to a strike if both sides are negotiating in good faith to reach a fair and workable agreement."

JAMA. Published online December 27, 2022. Abstract, Editorial

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