Strikes like the massive one threatened by Kaiser Permanente’s California blue collar workers last month could be a sign of what’s to come for the broader healthcare sector, if providers can’t find ways to raise pay and otherwise improve working conditions.

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?’”