Trends in Labor Unionization Among US Health Care Workers, 2009-2021

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JAMA
JAMA. 2022 Dec 27; 328(24): 2404–2411. PMCID: PMC9856820
Published online 2022 Dec 27. doi: 10.1001/jama.2022.22790 PMID: 36573974
Trends in Labor Unionization Among US Health Care Workers, 2009-2021

Ahmed M. Ahmed, MPP, MSc, 1 Kushal Kadakia, MSc, 1 Alwiya Ahmed, MD, MPH, 2 Blake Shultz, MD, JD, 3 and
4
Xiaojuan Li, PhD
Key Points
Question
What was the prevalence of labor unionization among US health care workers over the past 12 years,
and was it associated with pay and benefits?
Findings
In this cross-sectional study of 14 298 US health care workers, the prevalence of reported labor union‐
ization was 13.2%, with no significant change from 2009 through 2021. Reported membership or cover‐
age by a labor union was significantly associated with higher weekly earnings and better noncash bene‐
fits but greater number of weekly work hours.
Meaning
From 2009 through 2021, labor unionization among US health care workers remained low.
Abstract
Importance
Labor unionization efforts have resurged in the US, and union membership has been shown to improve
worker conditions in some industries. However, little is known about labor unionization membership
and its economic effects across the health care workforce.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9856820/ 1/16
Objectives
To examine the prevalence of labor unionization among health care workers and its associations with
pay, noncash benefits, and work hours.
Design, Setting, and Participants
This cross-sectional study was conducted using data from the Current Population Survey and Annual
Social and Economic Supplement from 2009 through 2021. The US nationally representative, popula‐
tion-based household survey allowed for a sample of 14 298 self-identified health care workers (physi‐
cians and dentists, advanced practitioners, nurses, therapists, and technicians and support staff).
Exposures
Self-reported membership status or coverage in a labor union.
Main Outcomes and Measures
Prevalence and trend in labor unionization. Further comparisons included mean weekly pay, noncash
benefits (pension or other retirement benefits; employer-sponsored, full premium–covered health insur‐
ance; and employer’s contribution to the worker’s health insurance plan), and work hours.
Results
The 14 298 respondents (81.5% women; 7.1% Asian, 12.0% Black, 8.5% Hispanic, 70.4% White indi‐
viduals; mean [SD] age, 41.6 [13.4] years) included 1072 physicians and dentists, 981 advanced practi‐
tioners, 4931 nurses, 964 therapists, and 6350 technicians and support staff. After weighting, 13.2%
(95% CI, 12.5% to 13.8%) of respondents reported union membership or coverage, with no significant
trend from 2009 through 2021 (P = .75). Among health care workers, those who were members of a
racial or ethnic minority group (Asian, Black, or Hispanic individuals compared with White individu‐
als) and those living in metropolitan areas were more likely to report being labor unionized. Reported
unionization was associated with significantly higher reported weekly earnings ($1165 vs $1042; mean
difference, $123 [95% CI, $88 to $157]; P < .001) and higher likelihood of having a pension or other
retirement benefits at work (57.9% vs 43.4%; risk ratio [RR], 1.33 [95% CI, 1.26 to 1.41]; P < .001) and
having employer-sponsored, full premium–covered health insurance (22.2% vs 16.5%; RR, 1.35 [95%
CI, 1.17 to 1.53]; P < .001). Union members reported more work hours (37.4 vs 36.3; mean differences,
1.11 [95% CI, 0.46 to 1.75]; P < .001) per week. White workers reported mean weekly earnings that
were significantly more than members of racial and ethnic minority groups among nonunionized work‐
ers ($1066 vs $1001; mean difference, $65 [95% CI, $40 to $91]; P < .001), but there was no significant
difference between the 2 groups among unionized workers ($1157 vs $1170; mean difference, −$13
[95% CI, −$78 to $52]; P = .70).
Conclusions and Relevance
From 2009 through 2021, labor unionization among US health care workers remained low. Reported
union membership or coverage was significantly associated with higher weekly earnings and better non‐
cash benefits but greater number of weekly work hours.
This cross-sectional study examines the effect of unionization on pay, noncash benefit, and working
hours among health care workers.
Introduction
Labor unionization efforts have recently resurged throughout the US, with the National Labor Relations
Board receiving a 57% increase in union election petitions in the first half of 2022.1 Workers in multiple
industries, including those in health care, are unionizing to bargain for better pay, better noncash bene‐
fits, and safer work conditions.2,3 For health care workers, the toll of the COVID-19 pandemic—includ‐
ing 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 in‐
creasing burnout prior to the pandemic has amplified calls for labor unionization to improve working
conditions in the US health care system.4
Although labor unions have been shown to improve working conditions in other industries,5 empirical
evidence about their role in the health care workforce is limited. Previous studies reported improved
workplace safety and little effect on worker well-being; however, the studies were limited to specific
populations (eg, surgical residents) or care settings (eg, nursing homes).6,7 No study, to our knowledge,
has systematically investigated labor unions and their economic effects across the health care work‐
force. It remains unclear how labor unionization in health care has changed over the years and what
benefits, if any, health care workers gain from unionizing. To bridge this gap, the prevalence of labor
unionization among health care workers and its associations with employee pay, noncash benefits, and
work hours across the health care workforce were examined.
Methods
This cross-sectional study was exempt from review and informed consent by the institutional review
board at Harvard Pilgrim Health Care Institute because of the use of a publicly available, deidentified
data set.
Study Population and Data Source
Data from the US Census Bureau–sponsored Current Population Survey (CPS) outgoing rotation group
and Annual Social and Economic Supplement (ASEC) were used.8 The CPS is a nationally representa‐
tive survey administered to 60 000 US households monthly. Households are surveyed for 4 consecutive
months, given a break for 8 months and then sampled for another 4 months before leaving the sample
permanently.9 Households in the 4th (before break) or 16th month (before leaving the sample) are con‐
sidered the “outgoing rotation group.” Within this group, those aged 15 years or older who are currently
employed as a wage or salaried worker (ie, not self-employed or practice owner) are asked additional la‐
bor questions, including their union membership. In the analysis, unionized workers were defined as
those who reported labor union membership or coverage (ie, who reported being covered by a union but
not being a member); nonunionized workers were defined as those who reported no union membership
or coverage. The CPS survey collected information on sociodemographic characteristics, including age,
sex, race and ethnicity, education, occupation, residence, and region. Race and ethnicity were included
in the analyses because differences in compensation and union membership exist between racial and
ethnic groups.10,11 Race and ethnicity data were self-reported by participants choosing from fixed cate‐
gories, which were further categorized into 5 groups in this study: Asian, Hispanic, non-Hispanic
Black, non-Hispanic White, and other (including American Indian, multiracial, and other unspecified).
Five groups of health care workers (physicians and dentists, advanced practitioners, nurses, therapists,
and technicians and support staff) were categorized based on occupational codes (eTable 1 in
Supplement 1).
The ASEC is administered to CPS participants during the months of February, March, or April each
year, and collects supplementary data on income (eg, mean weekly earnings), noncash benefits (eg,
pension or other retirement benefits, employer-sponsored full premium–covered health insurance, and
employer’s contribution to the worker’s health insurance plan), and work hours (eg, mean hours worked
per week),12 which were the outcomes of interest. CPS outgoing rotation group members who self-re‐
ported as health care workers and also answered the ASEC questions from 2009 through 2021 were in‐
cluded in this study. ASEC response rates in the study period ranged from 61.1% to 85.9%.13
Statistical Analysis
The overall and annual prevalence of self-reported labor union coverage among US health care workers
was examined throughout the 2009-2021 study period. To assess whether there was an increasing or de‐
creasing trend of labor unionization across the last decade, trend analysis was conducted using the Cox-
Stuart trend test.14 The prevalence of unionization was estimated by state and types of health care work‐
ers. The prevalence odds ratios and their 95% CIs for being a unionized vs nonunionized worker by so‐
ciodemographic groups were estimated using multivariable logistic regression.
To evaluate associations between unionization with pay, noncash benefits, and work hours, each out‐
come was regressed on unionization status in separate models, adjusting for sociodemographic charac‐
teristics (age, sex, race and ethnicity, state of residence, metropolitan or rural area, central city status,
occupation, education, mean weekly work hours, public or private sector employee). Linear regression
was used for pay (ie, mean weekly earnings), employers’ contributions to workers’ health insurance
plan, and work hours outcomes, and logistic regression for noncash benefit outcomes to estimate multi‐
variable models and marginal means with 95% CIs. All dollars were inflation-adjusted to 2020 US dol‐
lars using the consumer price index.
Disparities in pay among sex and racial and ethnic subgroups have been documented in the
literature.10,11,15 Two-sided t tests were used to test for interactions between union membership and
mean weekly earnings by sex and by race and ethnicity groups. Because of the paucity of studies in di‐
verse populations, stratified analyses were prespecified and conducted by sex (male; female) and by
racial and ethnic groups (Asian, Hispanic, or non-Hispanic Black; non-Hispanic White).
Several sensitivity analyses were conducted. To examine the potential different effect of union member‐
ship and union coverage, individuals who reported being covered by a labor union but not being a
member were excluded from the unionized group. To provide a more generalized assessment of health
insurance benefits, analyses were conducted to examine the likelihood of having employer-sponsored
partial or full premium–covered health insurance plans compared with none. To determine whether
there remains residual influence of the cost of living on the association between unionization and pay
(ie, mean weekly earnings) besides state of residence and central city status, analyses were conducted in
the subsample of 2000 respondents living in major metropolitan areas.
All estimates were weighted to be nationally representative and correct for nonresponse bias. Less than
0.5% of data were missing for weekly earnings; therefore, missing data were classified as unknown in
our model for the pay outcome. Throughout, a 2-sided P < .05 was considered statistically significant.
Because of the potential for type I error due to multiple comparisons, findings should be interpreted as
exploratory. All analyses were performed using R version 3.6.3 (R Foundation).
Results
The analytical sample comprised 14 298 US health care workers (81.5% women; 1021 Asian [7.1%],
1222 Hispanic [8.5%], 1719 Non-Hispanic Black [12.0%], and 10 066 Non-Hispanic White [70.4%];
mean [SD] age, 41.6 [13.4] years) who responded to the survey from 2009 through 2021: 1072 physi‐
cians and dentists (7.5%), 981 advanced practitioners (6.9%), 4931 nurses (34.5%), 964 therapists
(6.7%), and 6350 technicians and support staff (44.4%). Of those respondents, 74.0% reported being
full-time workers and 80.7% living in a metropolitan area (Table 1).
Table 1.
Characteristics of Health Care Workers Who Participated in the Current Population Survey and Annual Social
and Economic Supplement and the Prevalence of Reported Unionization, 2009-2021a
Characteristics Participants, Prevalence of Unadjustedc Multivariable

unweighted No. unionization, adjustedd
(weighted %) weighted % (95%
Nonunion Union CI)b Prevalence P value Prevalence P value

(n = 12 (n = OR (95% CI) OR (95% CI)
511) 1787)
Age, y
Mean (SD)e 41.3 (13.5) 43.7

(12.6)
15-29 2744 (24.0) 252 8.6 (7.4-9.8) 1 [Reference] 1 [Reference]

(14.9)
30-44 4515 (36.0) 661 14.0 (12.9-15.1) 1.73 (1.45- <.001 1.52 (1.26- <.001
(38.6) 2.06) 1.83)
45-59 3830 (29.3) 645 15.2 (14.0-16.4) 1.90 (1.60- <.001 1.67 (1.39- <.001
(34.6) 2.27) 2.01)
≥60 1422 (10.7) 229 14.5 (12.5-16.4) 1.80 (1.45- <.001 1.57 (1.24- <.001
(12.0) 2.24) 1.99)
Sex
Female 10 191 1462 13.1 (12.4-13.8) 1 [Reference] 1 [Reference]

(80.9) (80.5)
Male 2320 (19.1) 325 13.4 (11.9-14.9) 1.02 (0.89- .76 1.08 (0.92- .72
(19.5) 1.18) 1.27)
Race and
ethnicity
Asian 796 (7.5) 225 21.7 (18.9-24.4) 2.10 (1.76- <.001 1.72 (1.40- <.001
(13.8) 2.51) 2.10)
Hispanic 1063 (10.8) 159 13.9 (11.7-16.0) 1.22 (1.01- .04 1.18 (0.95- .14
(11.5) 1.48) 1.47)
Non-Hispanic 1473 (15.2) 246 14.8 (12.9-16.7) 1.32 (1.12- <.001 1.60 (1.33- <.001
Black (17.4) 1.55) 1.94)
Non-Hispanic 8946 (64.6) 1120 11.6 (10.9-12.4) 1 [Reference] 1 [Reference]

White (56.2)
Otherf 233 (1.9) 37 (1.1)
Regiong
South 4238 (38.6) 260 5.2 (4.5-5.9) 0.20 (0.17- <.001 0.16 (0.13- <.001
Abbreviation: OR, odds ratio.
a
Data were derived from the Integrated Public Use Microdata Series-Current Population Survey database maintained
by the University of Minnesota. All of the variables listed in this Table had no missing values.
b
Includes those who reported labor union membership or coverage (ie, who reported being covered by a union but not
being a member).
c Models included only the variable under consideration.
d
Model adjusted for all variables listed in the table.
e
Weighted means and standard deviations (SDs).
f Includes American Indians, multiracial individuals, and other unspecified racial and ethnic groups. This group was
excluded from the analysis due to the heterogeneity with this group.
g
Defined by the US Census Bureau Regions classification system.
h
A city population of at least 50 000 and includes surrounding suburbs; rural, everything else.
i
Full-time indicates working least 35 hours a week; 237 who reported “varying hours” per week were excluded due to
the uncertainty of hours worked.
j
Private sector of employment includes private for-profit and nonprofit institutions. Public sector of employment
includes government and armed forces health care institutions.
Prevalence of Reported Labor Unionization by Health Care Workers
Overall, 1787 health care workers (12.5%) reported being unionized during the study period; among
them, 1577 (88.2%) reported being labor union members and 210 (11.8%) reported being covered by a
labor union but not being a member. After survey weighting, 13.2% (95% CI, 12.5%-13.8%) of health
care workers reported being unionized. There was no apparent trend in unionization over the last 12
years, and the reported prevalence remained unchanged (P = .75; eTable 2 in Supplement 1).
Unionization varied by sociodemographic characteristics. Compared with those aged 15 through 29

years (8.6% [95% CI, 7.4%-9.8%]), older health care workers were significantly more likely to report
being unionized: 14.0% among those aged 30 through 44 years (95% CI, 12.9%-15.1%; P < .001);
15.2% among those aged 45 through 59 years (95% CI, 14.0%-16.4%; P < .001); and 14.5% among
those aged 60 years or older (95% CI, 12.5%-16.4%; P < .001; Table 1). The reported prevalence of
unionization was not significantly different between men and women: 13.4% of men (95% CI,
11.9%-14.9%) vs 13.1% of women (95% CI, 12.4%-13.8%; P = .76).
Unionization differed by race and ethnicity; compared with non-Hispanic White workers, in order of
prevalence, 21.7% Asian workers were most likely to report being unionized (95% CI, 18.9%-24.4%; P
< .001), 14.8% Non-Hispanic Black workers (95% CI, 12.9%-16.7%; P < .001), and 13.9% Hispanic
workers (95% CI, 11.7%-16.0%; P = .04). Unionization also differed by state (Figure 1).
Figure 1.
The Prevalence of Labor Unionization in US Health Care Workers by State, 2009-2021
All values are survey weighted. Unionized health care workers were defined as those who reported labor union mem‐
bership or coverage (ie, who reported being covered by a union but not being a member).
Compared with the 21.5% of health care workers living in the Northeast (95% CI, 19.8%-23.3%) who
reported unionization, 20.7% in the West (95% CI, 19.0%-22.4%) reported unionization, which was not
statistically significantly different (P = .51). But 11.4% of health care workers in the Midwest reported
being unionized (95% CI, 10.1%-12.6%; P < .001) and 5.2% in the South (95% CI, 4.5-5.9; P < .001),
both of which showed statistically significant differences from the Northeast region. Similarly, health
care workers living in metropolitan areas (14.0% [95% CI, 13.2%-14.7%]) were also more likely to re‐
port being unionized than those in rural areas (8.3% [95% CI, 7.0%-9.5%]; P < .001).
Unionization also differed by occupation. Nurses had the highest prevalence of reporting being union‐
ized (17.5% [95% CI, 16.3%-18.8%]). Compared with nurses, physicians and dentists (9.8% [95% CI,
7.8%-11.8%]; P < .001) and technicians and support staff (9.9% [95% CI, 9.1%-10.8%]; P < .001) had
statistically significantly lower rates of reporting being unionized; whereas advanced practitioners
(14.7% [95% CI, 12.2%-17.3%]; P = .07) and therapists (15.2% [95% CI, 12.6%-17.8%]; P = .13) had
no significantly statistical difference from nurses in reporting being unionized.
Those working full-time (14.1% [95% CI, 13.4%-14.9%]) were more likely to report being unionized
than those working part-time (10.3% [95% CI, 9.1%-11.4%]; P < .001). Those working in the private
sector (10.6% [95% CI, 9.9%-11.1%]) were less likely to report being unionized than those working in
the public sector (33.5% [95% CI, 30.8%-36.1%]; P < .001). In multivariable analyses adjusting for oth‐
er factors, most of these sociodemographic factors remained associated with reported unionization (
Table 1). Of the statistically significant variables associated with reported labor unionization, the
strongest were race and ethnicity, region, age, occupation, metropolitan residence, and sector of
employment.
Reported Labor Unionization and Pay, Benefits, and Equity
Being unionized was associated with better pay and better benefits. Unionized health care workers had
significantly higher reported mean weekly earnings than nonunion workers ($1165 vs $1042; mean dif‐
ference, $123 [95% CI, $88-$157]; P < .001) (Figure 2). Sensitivity analysis of individuals living with‐
in metropolitan areas found similar association ($1169 vs $1019; mean difference, $150 [95% CI,
$63-$238]; P < .001; eTable 3 in Supplement 1). Unionized health care workers were more likely to re‐
port having a pension or other retirement benefits at work than nonunionized workers (57.9% vs 43.4%;
risk ratio [RR], 1.33 [95% CI, 1.26-1.41]; P < .001). Unionized workers were also more likely to report
having an employer paid-for, full premium–covered health insurance plan (22.2% vs 16.5%; RR, 1.35
[95% CI, 1.17-1.53]; P < .001). Unionized workers reported significantly higher annual employer con‐
tribution to their health insurance plans ($4561 vs $3455; mean difference, $1106 [95% CI,
$843-$1369]; P < .001). However, compared with nonunionized workers, those who were unionized re‐
ported more weekly work hours (37.4 vs 36.3 hours; mean differences, 1.11 [95% CI, 0.46-1.75]; P
< .001; Table 2).
Figure 2.
Associations of Unionization and Mean Weekly Earnings at Current Job Among Health Care Workers
Mean weekly earnings reports how much the survey respondent earned per week at their current job before deductions.
Interviewers asked, “How much do you usually earn per week at this job before deductions?” For workers paid by the
hour, they were also asked for their hourly wage rate and the number of hours they usually worked at their job. The
higher of the values derived from these 2 sources is reported. All values are survey-weighted to be nationally represen‐
tative. Multivariable linear regression models were used to compare reported mean weekly earnings, adjusting for so‐
ciodemographic factors associated with earnings (age, sex, race and ethnicity, education, occupation, public or private
sector of employment, US state of residence, metropolitan or rural area of residence, and central city status). All dol‐
lars were standardized to 2020 US dollars using the consumer price index. P values in the figure were from tests for
prespecified interactions between union membership and mean weekly earnings by sex and racial and ethnic groups
(defined as Asian, Hispanic, or non-Hispanic Black vs non-Hispanic White). t Tests were used to compare mean week‐
ly earnings between groups. Square data points represent the adjusted mean difference in weekly earnings between
union and nonunion workers within the group; whiskers, 95% CIs of the mean difference.
Table 2.
Association Between Labor Unionization and Pay, Work Hours, and Noncash Benefits, 2009-2021a
Outcomes Overall Occupational group
Estimate P value Physicians and Advanced Nurses Therapists

(95% CI) dentists practitioners
Estimate P value Estimate P value Estimate P value Estimate P

(95% CI) (95% CI) (95% CI) (95% CI)
Mean Mean Mean Mean Mean

difference difference difference difference difference
Mean 123 <.001 48 .65 31 .68 165 <.001 228 <.

weekly (88 to (−157 to (−115 to (113 to (71 to
b
earnings, $ 157) 253) 178) 216) 384)
Employer 1106 <.001 983 .11 1617 .003 1067 <.001 1274 .0
contribution (843 to (−214 to (554 to (647 to (112 to
to health 1369) 2179) 2679) 1487) 2437)
insurance,
$/yb,c
Mean work 1.11 <.001 0.63 .77 3.07 .03 0.21 .64 2.49 .04
hours per (0.46 to (−3.60 to (0.33 to (−0.66 to (0.10 to
wk 1.75) 4.85) 5.80) 1.07) 4.88)
Risk Risk Risk Risk Risk

ratio ratio ratio ratio ratio
Pension or 1.33 <.001 1.23 .06 1.57 <.001 1.28 <.001 1.13 .3
other (1.26 to (1.00 to (1.32 to (1.19 to (0.87 to
retirement 1.41) 1.46) 1.82) 1.37) 1.39)
benefits
Health 1.35 <.001 1.45 .005 1.59 .03 1.38 .005 0.97 .92
insurance (1.17 to (0.93 to (0.96 to (1.07 to (0.34 to
d
plan 1.53) 1.97) 2.22) 1.69) 1.59)
a
All results listed used the nonunion group as the reference group. All models adjusted for age, sex, race and ethnicity,
education, occupation, public or private sector employment, US state of residence, metropolitan or rural area of
residence, and central city status.
b
US dollars were inflation adjusted to 2020 US dollars using the consumer price index. Twenty-eight individuals (25
nonunionized, 3 unionized) did not report their mean weekly earnings and were removed from this analysis.
c
US dollars were inflation adjusted to 2020 US dollars using the consumer price index. Employer contribution to
health insurance premium was reported from 2009 through 2018.
d Employer paid-for full premium–covered health insurance plan.
Comparisons of the association between unionization and pay in subgroups are shown in Figure 2.
Although being unionized was associated with significantly higher reported mean weekly earnings for
female workers ($1148 vs $1008; mean difference, $140 [95% CI, $103 to $177]; P < .001) but was not
for male workers ($1238 vs $1187; mean difference, $51 [95% CI, −$33 to $135]; P = .24), the test for
interaction did not meet statistical significance (P = .052). Male workers reported significantly more
mean weekly earnings than female workers, regardless of unionization status. The mean difference be‐
tween sexes among nonunion workers was $179 (95% CI, $144 to $215; P < .001) but the mean differ‐
ence between sexes among union workers was $90 (95% CI, $6 to $174, P = .03). The association be‐
tween unionization and pay differed significantly by racial and ethnic minority status (test for interac‐
tion, P = .02). Stratified analysis showed that being unionized was associated with significantly higher
reported mean weekly earnings for non-Hispanic White ($1157 vs $1066; mean difference, $91 [95%
CI, $49 to $132]; P < .001) and for racial and ethnic minority workers ($1170 vs $1001; mean differ‐
ence, $169 [95% CI, $112 to $226]; P < .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 nonunionized workers (mean difference, $65 [95% CI, $40 to $91]; P < .001)
but there was no significant difference between the 2 groups among unionized workers (mean differ‐
ence, −$13 [95% CI, −$78 to $52]; P = .70).
The benefits associated with unionization differed by occupation (Table 2). Particularly for physicians
and dentists, there was no significant difference between unionized and nonunionized workers in report‐
ed mean weekly earnings ($2116 vs $2068; mean difference, $48 [95% CI, −$157 to $253]; P = .65),
employer’s contribution to health insurance ($7143 vs $6160; mean difference, $983 [95% CI, −$214 to
$2179; P = .11), mean weekly work hours (46.36 vs 45.73; mean difference, 0.63 [95% CI, −3.60 to
4.85]; P = .77), and likelihood of having a pension or other retirement benefits at work (67.3% vs
54.8%; RR, 1.23 [95% CI, 1.00-1.46]; P = .06).
Similar findings were observed in sensitivity analyses excluding individuals who reported being cov‐
ered by a labor union but not being a member (eTable 4 in Supplement 1). Unionized workers were sta‐
tistically significantly more likely to have full or partially covered health insurance plans, with a smaller
increase in magnitude when compared with the main analysis comparing full vs nonfull (partial or
none) premium covered health plans (eTable 5 in Supplement 1).
Discussion
In this cross-sectional study of 14 298 US health care workers, 13.2% of workers across health care pro‐
fessions reported being labor unionized, with most being labor union members. Unionization was asso‐
ciated with higher wages and better benefits for health care workers without much change in working
hours.
Previous studies have demonstrated an association between collective bargaining and wages and bene‐
fits for workers across different industries and skill levels.16,17 This literature has also documented how
rates of unionization are also associated with reductions in both sector-specific and economy-wide
wage inequality.18 In contrast, empirical evidence on unionization in health care has been limited to
date. The Bureau of Labor and Statistics only tracks union activities across broad categories (eg, occu‐
pation and industry) and lacks sufficient granularity to characterize individual groups of health care
workers (eg, nurses, physicians, and dentists).19
This study addresses gaps in the literature by presenting evidence on labor unionization across the
health care profession from 2009 through 2021, with the findings consistent with those documented by
the Bureau of Labor and Statistics and in existing labor scholarship. First, the overall rate of unioniza‐
tion among health care workers in the study sample was consistent with those reported in the Bureau of
Labor and Statistics data on workers categorized under “healthcare practitioners and technical occupa‐
tions” (13.2% vs 11.7%).19 Second, the geographic differences in unionization prevalence in this study
were aligned with those reported nationally in other sectors of the economy and may reflect the role of
broader policy and political factors (eg, existence of right-to-work laws) in collective bargaining.20
Third, the study sample reflected the demographics of the health care workforce documented in previ‐
ous literature, namely, that the sample was predominantly female and individuals working as nurses and
technicians and support staff.21 Fourth, the difference between the reported mean weekly wages of
unionized and nonunionized workers in this study sample were directionally similar to the Bureau of
Labor and Statistics data on workers in both health care occupations and workers in all industries.22,23
Fifth, the higher wages and rates of access to benefits such as pensions and fully covered health insur‐
ance among unionized health care workers in the study sample were also aligned with the trends docu‐
mented for unionized workers in other industries.24,25 Sixth, the associated benefits of unionization dif‐
fered by occupation, particularly for physicians and dentists, which is consistent with previous analyses
showing less benefit to those in higher income brackets.26 Additionally, physicians and dentists can be
reimbursed under different payment models (eg, salary, fee-for-service, or value-based payment), which
differs from other health care workers who typically earn an hourly wage from their employer.
To our knowledge, this is the first systematic examination of the relationship between unionization and
working conditions across all segments of the health care workforce. This study has several strengths.
First, the CPS data set captures rich data on demographic factors, occupation, pay, and noncash benefits
of a nationally representative sample. The quality of this data allowed for characterization of each re‐
spondent with high resolution, such that many factors associated with the outcomes of interest in this
study could be adjusted for. Second, the large sample size, and its national representation, allowed for
inferences to be made about labor unions across the US health care system. Third, consistent annual
survey data allowed for investigations of trends over time, to detect any changes in labor unionization
until 2021.
Limitations
This study has several limitations. First, responses to the CPS may be susceptible to reporting bias.
Second, CPS does not differentiate whether employed health care workers may also be enrolled in grad‐
uate training programs—a unique consideration for health care compared with other industries given
the role of government subsidies and wage deflation for intern and resident salaries.27 Third, CPS does
not offer insight into workers’ experiences with regards to job satisfaction, stress, or mistreatment. Such
factors are a key consideration given that unionization has been touted as a strategy for mitigating
burnout, although evidence to date has been mixed.7,28 Fourth, 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. Fifth, CPS does not capture data on the risks of labor unionization. Employers
have been reported to violate federal law in nearly half of all union election campaigns to thwart union‐
ization efforts.29 The harmful downstream actions by an employer on their health care employees are
unclear.
Conclusions
From 2009 through 2021, labor unionization among US health care workers remained low. Reported
union membership or coverage was significantly associated with higher weekly earnings and better non‐
cash benefits but greater number of weekly work hours.
Notes
Supplement 1.
eTable 1. Health Care Occupation Codes for Occupation Group Categorization
eTable 2. Prevalence of Labor Unionization Among Health Care Workers by Year, United States, 2009-2021
eTable 3. Association between Labor Unionization and Mean Weekly Earnings among 2,000 Health Care Workers
Living in Metropolitan Areas, 2009-2021
eTable 4. Association between Labor Union Membership and Pay, Work Hours, and Noncash Benefits, Overall and by
Occupational Group, 2009-2021a
eTable 5. Association between Labor Unionization and Having Employer-sponsored Health Insurance Plans
Click here for additional data file.(715K, pdf)
Supplement 2.
Data Sharing Statement
Click here for additional data file.(55K, pdf)
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25/10/2023, 10:13 Trends in Labor Unionization Among US Health Care Workers, 2009-2021 - PMC

Design, Setting, and Participants

Self-reported membership status or coverage in a labor union.

Main Outcomes and Measures

Conclusions and Relevance

Study Population and Data Source

Characteristics Participants, Prevalence of Unadjustedc Multivariable

Nonunion Union CI)b Prevalence P value Prevalence P value

Mean (SD)e 41.3 (13.5) 43.7

15-29 2744 (24.0) 252 8.6 (7.4-9.8) 1 [Reference] 1 [Reference]

Female 10 191 1462 13.1 (12.4-13.8) 1 [Reference] 1 [Reference]

Non-Hispanic 8946 (64.6) 1120 11.6 (10.9-12.4) 1 [Reference] 1 [Reference]

Otherf 233 (1.9) 37 (1.1)

Abbreviation: OR, odds ratio.

Prevalence of Reported Labor Unionization by Health Care Workers

Unionization varied by sociodemographic characteristics. Compared with those aged 15 through 29

The Prevalence of Labor Unionization in US Health Care Workers by State, 2009-2021

Reported Labor Unionization and Pay, Benefits, and Equity

Outcomes Overall Occupational group

Estimate P value Physicians and Advanced Nurses Therapists

Estimate P value Estimate P value Estimate P value Estimate P

Mean Mean Mean Mean Mean

Mean 123 <.001 48 .65 31 .68 165 <.001 228 <.

Risk Risk Risk Risk Risk

eTable 1. Health Care Occupation Codes for Occupation Group Categorization

Click here for additional data file.(715K, pdf)

Data Sharing Statement

Click here for additional data file.(55K, pdf)

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