The Future of Labor Activism in Nursing Homes

Despite the nursing home industry being in the grips of a staffing crisis – with more leverage in the hands of direct care workers – unionization in the space hasn’t taken off across the country like many were expecting.

Instead, national unionization in the sector slowly increased from just under 10% in 2010 to 16.8% between 2020 and 2021, according to academic papers published in HealthAffairs and Sage Journals.

“I’ve always thought this sector was more ripe for unionization. There are some states that have pretty good union penetration like New York,” Harvard University Professor David Grabowski said. “It really hasn’t taken off in a major way.”

Still, a historically undervalued labor force is finally getting to have a voice in the space, or “much more of a voice” than they did pre-pandemic, he added. Aging services organizations like LeadingAge have developed programs to advance common goals between unions and operators just this summer, giving unions a seat at the table.

The Biden administration seems to be helping labor activism somewhat as part of its reform initiatives as well, including putting aside $80 million in federal funding to help develop union jobs across multiple industries, including skilled nursing.

In collaboration with the Department of Labor, the Centers for Medicare & Medicaid Services’ (CMS) national nursing career pathways campaign will involve working with labor unions to recruit, train, retain and transition workers into long-term care careers. Other entities involved in the campaign include training intermediaries, registered apprenticeship programs and labor management training programs, according to a White House memo issued earlier this year.

“I do think we’re seeing a lot of groups really come together and there’s been a lot more attention around, how do we improve working conditions and care conditions – I think those are often viewed very separately,” Grabowski said.

Activism and the staffing shortage

Historically, stakeholders on the labor and operator side haven’t always been aligned; operators and the organizations that represent them have worried about a balance between their operating margin and staff wages.

“Every dollar in the pocket of their staff is not a dollar to their bottom line,” Grabowski said. “[Operators are] trying to find that balance. It’s not clear to me that nursing homes have always treated staff well, paid them well; they haven’t given them benefits.”

That has changed due to the staffing shortage, with many operators wanting to pass rate increases directly to staff, he said. It’s a far cry from a lot of the historical tensions around how the money flows and who gets the incremental dollar from the government, according to Grabowski: “I think there is much greater alignment than there’s ever been.”

In other words, unions and advocacy groups feel there is not enough transparency when it comes to how government dollars are spent in the nursing home sector, and that more needs to be diverted directly to staff instead of offsetting operating margins.

Still, there’s a huge hurdle of deep-rooted distrust of management, the most recent example being Covid vaccine hesitation among nursing home staff.

“This was coming from management, even though ultimately the government mandated [the vaccine]. They’re being told to do this as part of their job and I don’t think there was always the best relationship there,” he added.

To their credit, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) developed a program to ease caregiver wariness regarding the vaccine. Directors of nursing (DONs), administrators and other leadership can take the multi-lesson course to better hone skills and build resources related to staff trust.

There’s still an opportunity to repair and reshape that relationship, noted Grabowski. Organizations like LeadingAge have extended the olive branch through coalitions that include unions.

“We share many of the goals with unions representing caregivers who serve older adults,” added Ruth Katz, senior vice president LeadingAge. “We advocate for professionalizing the workforce, paying a living wage, funding and development of career ladders, as they do.”

The group, which represents nonprofit nursing home operators and other mission-driven SNFs, formed the Moving Forward Coalition in June. The group intentionally brings together diverse stakeholders – including unions – to help advance common goals related to nursing home funding, quality regulation, and assessment and improvement, along with staffing.

Burnout and activism

It’s hard for frontline workers to advocate for themselves when they were pushed to their limits during the pandemic, Grabowski reasoned. The pay is much lower, a lot of staff are working around the clock and are often picking up extra jobs to make ends meet.

A member of SEIU 1199 New England, Mary Francis, said just as much in an interview with Skilled Nursing News. Francis has served as a certified nursing assistant (CNA) for 18 years, most recently at New Haven Center for Nursing and Rehabilitation.

“I don’t know if I can go out there and advocate for myself even, because I am exhausted,” she said. “If they can staff us properly, we will have the energy to go out there, encourage other people to advocate. I barely have time to cater to my family.”

Rob Baril, president of SEIU 1199 New England, echoed her thoughts. The realities of inflation, spiraling medical costs often associated with Covid medical debt, and the physical, mental and spiritual exhaustion over the past three years has taken an enormous toll on the workforce, Baril said in an email.

Still, nursing home union members are calling for help in realizing long-term Medicaid rate increases, and ensuring operators aren’t using increased funds to “drive down standards.”

“The Department of Health & Human Services (HHS) must urgently increase investment in nursing homes with incentives that reward living wages and quality jobs; adopt wage floors to ensure increased funds are going to workers; implement minimum safe staffing levels; and create funds to grow and train the nursing home workforce,” Baril said.

While the space is seeing some activism, it’s much slower in development, added Grabowski.

“Given how stressful the position is and that it’s not not well supported, all the issues that lead to turnover and poor quality also make it really challenging in the short-term to organize, even though it’s a group that I think would really benefit from that organization,” he said. “We need to hear their voices and I think we are hearing their voices for the first time in a lot of ways.”

Activism evolution adds family advocacy

Activism in the nursing home space has evolved during pandemic years to go beyond labor unions and advocacy groups – although those groups are still around and using the Biden administration reform initiatives as a jumping off point for better working conditions.

Family coalitions started popping up especially during lockdown as well, according to Patricia McGinnis, executive director of the California Advocates for Nursing Home Reform (CANHR), as loved ones turned to each other to get answers from staff and facility leadership.

“We had hundreds and hundreds of calls during that period of time,” said McGinnis. “We’ve been involved in family council organizing for over 30 years – I see more and more family members and relatives of nursing home residents who either were so disappointed at the quality of care, or were so concerned because they couldn’t get in to see their relatives.”

Resident’s family members are valued partners in the space, AHCA/NCAL told SNN in an email. The organization, which represents more than 14,000 long-term and post-acute care facilities, urges family members to continue to advocate for access to care and proper funding.

“We look forward to working together so that our nursing homes can innovate and implement reform, invest in our caregivers, and improve the lives of our residents,” AHCA said in a statement.

Organizations like CANHR, National Consumer Voice and the Center for Medicare Advocacy started regular calls with the Centers for Medicare & Medicaid Services (CMS) to advocate for families, residents and workers on topics like visitation, according to McGinnis.

While McGinnis said it’s “wonderful” that the Biden administration is seeking to improve financial and ownership transparency in the sector, along with efforts to establish a federal minimum staffing ratio, she’s unsure any initiatives will actually be carried out.

“The nursing home industry is already saying, we can’t possibly have staffing requirements, we can’t possibly require more staffing, we just don’t have the money,” said McGinnis. “We know better because there have been studies about how much profit so many of these facilities made during the pandemic.”

City-run Laguna Honda Hospital & Rehabilitation in San Francisco serves as a success story for other family coalitions, McGinnis said. Families organized when CMS initially moved to decertify one of the largest nursing homes in the country with 700 certified beds.

After the federal agency’s initial decision, officials agreed to grant Laguna an extended reprieve and keep its doors open through Nov. 13 2023. The facility will continue to receive Medicare and Medicaid funding as leadership works to address regulatory issues.

“That would not have happened without the community, without the family members,” added McGinnis. “[Laguna has] been one of the most valuable resources for people when they age out of community-based care. This was something that people wanted to keep in San Francisco, and they certainly wanted to prevent the transfers and discharges of their relatives.”

San Francisco City Attorney David Chiu dropped the city’s lawsuit against CMS, along with its appeals to overturn the facility’s decertification.