Multiple factors make it likely that the trend of rising labor activity in long-term care will continue in 2024, experts say.

In 2023, care workers and others across the US — from writers and actors, to auto workers — launched high-profile strikes, often successfully bargaining for higher pay and improved working conditions. 

These strikes capitalized on shifting workforce conditions and public opinion, Adam Dean, PhD, associate professor of political science at The George Washington University, told McKnight’s Long-Term Care News. 

Only 16% of nursing homes currently have workers that are represented by a union, but that number is likely to increase if today’s trends hold, he added.

“There’s enormous potential for the growth of unions in that sector and I think that the big labor wins that people have been following in the news … set the stage nationally for what’s possible when workers unionize,” he said. “I think that will set the stage for 2024. I expect to see more organizing and more strikes to come.”

Striking a good balance?

Dean was optimistic that such labor activity would benefit both workers and the long-term care industry as a whole.

“I expect that it will improve the quality of healthcare that residents or patients receive,” Dean noted, citing a study he coauthored that found unionized nursing homes were 78% more likely to comply with illness and injury reporting regulations. 

In skilled nursing, pressure from organized labor has been mounting since the early days of 2020, when workers threatened to strike over pandemic working conditions and the availability of safety equipment.

October 2023 saw the largest strike ever recorded in the healthcare sector as 75,000 Kaiser Permanente workers walked off the job for three days. That strike culminated in a 6% pay increase and promises of additional action to address staffing shortages.

Going into 2024, pay and staffing continue to top the list of labor issues that could become the spark for organized action

“The SEIU and other labor unions that represent healthcare workers have been pushing for higher nurse-to-patient ratios,” Dean noted.. “I expect those kinds of fights to continue.”

One key factor in the current labor upswing is the low rate of unemployment. 

Broad forces in play

“We have a low unemployment rate currently in the United States, which gives workers greater bargaining power with their employers,” Dean noted.

That rate sits at only 3.7%, giving workers the confidence to make demands of their employers since they are likely to be able to change jobs quickly if necessary. 

“It gets [workers] into a position of relative security,” Jason Resnikoff, PhD, assistant professor of contemporary history at the University of Groningen told NBC Washington. “It makes it much easier for them to go on strike.”

During 2023’s increase in strikes, public opinion shifted in favor of unions, especially among young Americans, some feel. 

“There’s a growing public support for unions and strikes,” Dean said, citing a study from the American Federation of Labor and Congress of Industrial Organizations. “88% of Americans 30 and younger have a favorable view of labor unions.”

The AFL-CIO study found that 71% of Americans supported unions overall. 

That was one warning from a panel of nursing experts who spoke during a KFF-hosted webinar late last week on strikes, shortages and staffing requirements.

“All of the healthcare system, all kinds of healthcare workers, are feeling this kind of stress right now,” not just the nurses Americans typically see on picket lines, said Bianca K. Frogner, director of the University of Washington’s Center for Health Workforce Studies.

The Kaiser Permanente threat, which followed a real and massive three-day strike earlier in October, won non-medical staff at Kaiser’s facilities major wage gains and staffing concessions alongside their frontline peers.

Increasingly, unions representing nursing home workers have been spearheading strikes or pickets for their therapists and support staff members, who say they too are being squeezed by chronic understaffing.

“There are clear signs of stress within the healthcare workforce, with shortages, strikes and burnout,” said webinar moderator Larry Levitt, executive vice president for health policy at KFF.

While he acknowledged healthcare is often recession-proof, Levitt said the pandemic employment shifts were different. And recovery hasn’t been easy, with certain sectors and parts of the country still limiting access to care because they don’t have enough staff. 

“We have many sectors in the healthcare space that are feeling the crunch of trying to find workers to fill the slots,” added Frogner, lumping long-term care in with behavioral health and primary care as the three sectors most in need.

She attributed much of the pain to a “maldistribution of workers” that has left rural providers and underserved communities with the greatest need. Nowhere might that be more apparent than in rural nursing homes, speakers noted.

‘Scary’ defection plans

Gretchen Berlin, RN, senior partner at McKinsey & Company, has studied nurse sentiment since the start of the pandemic. One of the “scary” constants of healthcare staffing over the last three years is the 25% to 30% of nurses who’ve told McKinsey on multiple surveys that they plan to leave the profession.

Though it has moderated since the heart of the pandemic, nursing turnover is still hovering around 22% annually across settings, about 3% to 6% higher than before COVID, Berlin said.

“We project these trends will continue to lead to a shortage,” she said. “We could be short up to 20% of what we need by 2025.”

She noted the propensity to turn away from nursing jobs is a global phenomenon, and that while more immigration could help, it won’t be a cure-all, even if reform happens in this Congress.

Alice Burns, associate director of the Program on Medicaid and the Uninsured for KFF, said long-term care employment is still 10% below pre-pandemic levels, a fact that sector advocates have bemoaned even as federal regulators push a first-ever national staffing minimum for nursing homes.

Burns said nursing homes’ broader care needs, where staff may have to do anything from changing a catheter to giving an IV or feeding a resident dinner, can make it more difficult to attract and retain workers.

“That’s a really different skill set, and then another difference is the payer mix, over half of the expenses are paid by Medicaid and over 25%, people are paying out of their own pocket,” she said. “That really places this downward pressure on payment rates, which puts downward pressure on wages.”

By fostering a cultural shift toward home- and community-based services, some states also have made it more difficult for nursing homes to recruit and retain workers because both sectors are drawing from the same pool.

However, increasing pay rates (with Medicaid boosted by extra federal matching dollars through the pandemic) and building career ladders have helped.

Frogner, while backing the intent of staffing ratios and their ability to improve patient care and worker satisfaction, said they will undoubtedly create new tension between sectors as they battle for the same would-be workers. 

“The problem is, where is the supply of workers when you put those ratios into play,” she said. Ratios will create more movement and competition between hospitals and nursing homes, but if skilled nursing staffing remains low, that will exacerbate patient waits or backlogs in acute settings.

Growing demand for home health workers is also drawing staff away from long-term care  facilities, and when they capture new workers, they’re not doing a good enough job keeping them.

“We’re seeing people move in and out of these jobs that have low barriers of entry,” Frogner said. “Once they’re in there, these workers are understandably looking around and asking, ‘OK, which job gives me the next benefits beyond wages? … Are there jobs that are a little bit easier and maybe a little more fulfilling in other sectors?’”

Workers at 11 Chicago-area nursing homes on Thursday gave notice that they plan to strike in 10 days, following a breakdown in talks over staffing and wages.

The Labor Day strike would affect a group of nursing homes operated by Infinity Healthcare Management and owners Michael Blisko and Gubin Enterprises. Union officials have accused the company of intentionally staffing buildings below required state levels and continuing to pay “many” staff members minimum wage.

In November 2020, workers at some of the same facilities went on strike to protest chronic short staffing and failure to provide personal protective equipment and other safeguards for workers. They won some concessions then, but many of the same concerns have resurfaced.

They have been working to secure higher pay that workers say will help with recruitment and retention since before a contract expired June 30. They’re seeking wages in line with other local facilities and a pay scale that rewards longevity, a union spokeswoman told McKnight’s Long-Term Care News.

“Despite the consequences of paying poverty wages … Infinity owners seem far more concerned with their profit levels than their staffing levels in the homes,” a union official said during a press conference Thursday evening. “Their priorities are misplaced. While owners and their investors reap exorbitant profits off of the back of the workers and the residents that they take care of, Infinity turnover rates are extremely high.” 

Infinity executives could not be reached for comment Thursday. A voicemail box for the company’s Illinois office was full Thursday, and an email from McKnight’s sent to a publicly listed address was returned as undeliverable. 

The Infinity nursing homes named in the strike notice are:

• City View Multicare Center in Cicero
• Niles Nursing and Rehabilitation Center in Niles
• Lakeview Nursing and Rehabilitation Center in Chicago
• Ambassador Nursing and Rehabilitation Center in Chicago
• Continental Nursing and Rehabilitation Center in Chicago
• Oak Lawn Respiratory and Rehabilitation Center in Oak Lawn
• Southpoint Nursing and Rehabilitation Center in Chicago
• West Suburban Nursing and Rehabilitation Center in Bloomingdale
• Forest View Center for Rehabilitation and Nursing in Itasca
• Momence Meadows Rehabilitation and Skilled Nursing Center in Momence
• Parker Nursing and Rehabilitation Center in Streator

During the press conference, workers complained about allegedly deplorable physical conditions at the facilities, in addition to resident care issues created by staffing levels.

In all, Infinity operates 53 facilities in five states, according to Centers for Medicare & Medicaid Services ownership data. Two of those facilities are on the Special Focus Facility list, and another four are candidates. Twenty-two facilities — more than a third — also have an abuse icon on Care Compare.
The union representing workers in the Chicago area accused the chain of paying “unlivable wages” that drive high turnover. SEIU put that rate at 80%; CMS reports a 60.3% total nurse turnover rate across the entire portfolio.

Seven nursing homes in Michigan are preparing for a strike, but their operator said employees’ 10-day notice of a labor walkout is premature. 

More than 500 workers at seven Ciena Healthcare facilities in the Detroit and Flint areas plan to start their strike Tuesday, local media reported. That’s down from threats last month to strike at 13 facilities. The Service Employees International Union Healthcare of Michigan has said the employees want better wages, benefits, and working environments. 

But Amy La Fleur, senior vice president for Operation at Ciena Healthcare told McKnight’s Long-Term Care News negotiations at each facility remained ongoing with none at an impasse. She said they have been pushing the union since late last year to add more bargaining sessions, but four of the seven facilities saw no talks from December through February “due to unavailability of the union negotiators.” 

“A strike now unnecessarily places residents at risk because our nursing homes are facing unprecedented challenges that limit our ability to solve all of the union’s demands and concerns in these contracts,” La Fleur said in her statement to McKnight’s, citing historic workforce challenges. “For three months, the union has stalled negotiations by being unavailable, and manufactured their now proclaimed urgency to move to a strike.”

La Fleur said negotiators at one facility — Regency at Westland — had their first bargaining session the first week of March and the union is already threatening to strike.

The Health Care Association of Michigan, which represents 358 nursing homes in the state, estimates that SNFs in the state have lost 10,000 workers since the start of the pandemic.  

In February 2022, Gov. Gretchen Whitmer (D) approved a budget supplemental that included $300 million for healthcare facilities for staff recruitment and retention. As McKnight’s reported in January, while the $225 million earmarked for hospitals and $8 million for federally qualified health care centers had been distributed, the $67 million for nursing homes was sitting untouched. 

Whitmer’s 2024 budget includes funding to add $3.85 per hour to wages for nursing home workers, which La Fleur said Ciena supports. She said that the company “is confident” leaders can resolve all open contracts without the union resorting to a strike as they did last year at five Ciena-managed facilities. 

The facilities at which workers voted to strike are: 

•  Regency of Livonia, Livonia

•  Sheffield Manor LPN/SM, Detroit

•  Hartford Nursing & Rehabilitation Center, Detroit

•  Regency at Whitmore Lake, Whitmore Lake

•  The Manor of Farmington Hills, Farmington Hills

•  Regency at Westland/Camelot, Westland

•  Willowbrook, Flint

Whether workers are voting on strikes, actually striking, or avoiding strikes through successful negotiations with providers, employees are leveraging operators’ need to staff up and stay open. 

The harsh conditions for workers during COVID-19 and perceived employer reactions to them have spurred some of the unrest as well, said Mark Tabakman, a labor and employment lawyer who handles both union and non-union matters for employers across the country.

“We are seeing a distinct uptick in organizing in healthcare,” said Tabakman, a partner at Fox Rothschild. “COVID, I believe, is a big factor as healthcare workers complained constantly about understaffing and long hours of work with little appreciation by management. Unions were adept at picking up on these themes and preached ‘safety’ and ‘health’ as big issues for these workers. The unions capitalized on these issues and fears.”

About 13.5% of healthcare practitioners were represented by unions in 2020 and 2021, according to the Bureau of Labor Statistics.

Nursing home labor activity recently spiked in the Northeast, but there also was a labor win in Los Angeles and a threatened strike of 15,000 nurses in Minnesota. In addition, more than 6,000 healthcare workers employed by Kaleida Health in western New York, including many at skilled nursing facilities, will vote in mid-September on whether to authorize a strike.

“Workers across the Kaleida Health System have been raising concerns about chronic understaffing as Kaleida has more than 800 vacancies it must fulfill to cover open jobs and 436 to meet the state’s new staffing law requirement,” said a statement from 1199SEIU United Healthcare Workers East. 

Earlier this week, workers who are members of SEIU Healthcare Pennsylvania and Guardian Healthcare reached a tentative contract agreement that ended plans for strikes at 10 facilities. However, union workers from SEIU Healthcare PA are still in negotiations with about 20 other homes that are owned by Comprehensive and Priority. Some could strike as early as Friday.

Unions and providers came together on terms earlier this year to help the state pass a historic Medicaid funding increase. The union appears to be opening new lines of argument, said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association.

“To be clear: new demands need to be supported with funding,” Shamberg told McKnight’s on Wednesday. “And to meet every new demand, at least those outlined in negotiations thus far, our state legislature and governor would have needed to double the amount of funding allocated to long-term care — of which a single dollar has yet to be distributed.”

Pennsylvania’s providers agreed to increased staffing and new funding accountability, Shamberg pointed out.

“This is how good faith is built in partnerships, especially when the funding is there to support new initiatives,” he said. “The state will ensure those provisions are honored, and now it’s up to the union to follow-through with their end of the bargain.”

Tabakman said in addition to staffing needs and resentment from conditions at the height of COVID, the federal government’s pro-labor stance makes for fertile union grounds. 

“The Biden NLRB is distinctly pro-employee and pro-union, and is making it easier for unions to organize,” he said. “This president has stressed many times that he is a ‘friend’ to labor and his policies are pacing the way for easier organizing.”

All of the affected nursing homes have labor agreements that expired June 30, except one in Philadelphia, said Karen Applegate Gownley, spokeswoman for SEIU Healthcare Pennsylvania.

The single-day job action would include about 300 workers in Western Pennsylvania, according to the Pittsburgh Post-Gazette.

Among the targeted facilities are Beaver Elder Care & Rehabilitation Center in Aliquippa, Uniontown Healthcare & Rehabilitation Center and Oil City Healthcare & Rehabilitation, operated by Guardian Healthcare. The company said it had developed a contingency plan to cover its facilities in case of the work stoppage.

“We are troubled that the SEIU is using our invaluable team of caregivers in an attempt to manipulate the negotiation process,” said a statement supplied to the newspaper. “We have offered to negotiate with the SEIU around the clock to avoid any interruption of the provision of quality care at our sites, but the SEIU has refused all such offers at this time.”

SEIU Healthcare Pennsylvania President Matthew Yarnell said the walkout was a result of challenging working conditions in long-term care.

“When workers decide to go on strike, that’s a very clear indication of just how bad things are,” he said. “They have been demanding change for decades and then watched as their residents, coworkers and own families died of COVID-19.”

The strike threat comes despite a new state budget that contains more than $250 million in additional nursing home funding. Medicaid funding had been largely flat for about 15 years in the state, which one analysis found led to a $632-million loss that challenged nursing homes’ ability to provide high-quality care and recruit and retain staff.