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Trends in Unionization of Nursing HomesAuthor(s): Aaron J. Sojourner, David C. Grabowski, Min Chen and Robert J. TownSource: Inquiry, Vol. 47, No. 4 (Winter 2010/2011), pp. 331-342Published by: Excellus Health Plan, Inc.Stable URL: http://www.jstor.org/stable/29773457 .

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Aaron J. Sojourner David C. Grabowski Min Chen Robert J. Town

Trends in Unionization of Nursing Homes

Unionization may have important implications for the delivery of nursing home care,

but little is known about this phenomenon. Since 1985, the proportion of nursing home

workers covered by union contracts declined from 14.6% to 9.9%. The first national

scale data on facility-level unionization reveals that unions are more common in nursing homes with more residents, in hospital-based or chain-affiliated facilities, and in

facilities serving a higher proportion of Medicaid patients. With new federal policy proposals aimed at substantially lowering the cost of organizing workers, policymakers will want to consider the potential impact of nursing home unionization on worker,

patient, and market outcomes.

Since the November 2008 election, the U.S. health policy sphere has focused its attention on health care reform with the recent passage of the 2010 Patient Protection and Affordable Care Act. However, Congress is considering another set of reforms that has drawn less attention but also could have a significant impact on the health care industry. The pro? posed Employee Free Choice Act (EFCA) is the most significant labor legislation in 60 years (Epstein 2009; Fletcher 2008). Although prospects for EFCA as a stand? alone bill are fading, legislative and adminis? trative attempts to adopt elements of the reform will continue (Mascaro and Mishak

2010). Reform proposals have three main ele?

ments. First, "card check" provisions would enable the National Labor Relations Board

(NLRB) to certify a union whenever the

majority of a unit's workers sign union authorization cards. To achieve certification under the current law, a union must demon? strate majority support through an NLRB administered election. Second, EFCA would increase penalties for employer unfair labor

practices that interfere with employees' rights to organize. Currently, the only legal conse?

quence for illegally firing union supporters is

potentially having to rehire them with back

pay. Third, EFCA would require that bar?

gaining for an initial contract eventually be settled by arbitration rather than allowing negotiations to stall indefinitely.

Such reforms would meaningfully reduce the cost of organizing a workplace and likely lead more workers to unionize. Recognizing the high stakes of these reforms, labor unions

Aaron J. Sojourner, Ph.D.f is an assistant professor in the Department of Human Resources and Industrial Relations, Carlson School of Management, University of Minnesota. David C. Grabowski, Ph.D., is an associate professor in the

Department of Health Care Policy, Harvard Medical School. Min Chen, Ph.D., is a clinical assistant professor in the

College of Business Administration, Florida International University. Robert J. Town, Ph.D., is an associate professor and holder of the James A. Hamilton Professorship of Health Economics in the School of Public Health, University of

Minnesota, and a faculty associate at the National Bureau of Economic Research. Address correspondence to Dr. Chen at Florida International University, 11200 SW 8th St., RB 208A, Miami, FL 33199. Email: [email protected]

Inquiry 47: 331-342 (Winter 2010/2011). ? 2010 Excellus Health Plan, Inc. ISSN 0046-9580 10.5034/inquiryjrnl_47.04.331

www.inquiryjournal.org 331



InquiryIVolume 47, Winter 201012011

have made this their top national political priority and devoted tremendous resources

towards their promotion. The U.S. Chamber of Commerce, American Health Care Asso?

ciation, National Center for Assisted Living, and other employer lobbies have opposed the

proposed reforms with similar vigor (LaPorte 2009). These reforms would affect the heart of the nursing home industry: its workforce

(Bostick et al. 2006). Labor is the single most

important input into the production of

nursing home care. Labor compensation, turnover, and staffing ratios are all closely connected to both quality of care and to unionization.

This paper provides context for the pro?

posed labor law reform by shedding new light on the role of organized labor in the provision of nursing home care. We document the trends and distribution of unionized staff and new organizing activity across time, geogra?

phy, and nursing home characteristics.

Background: Unionization and

Nursing Homes

Since the early 1980s, unions have mounted

many campaigns to organize nursing homes. In 1983, Service Employees International Union (SEIU) President John Sweeney launched a campaign to organize hundreds of chain-affiliated nursing homes. Upon succeeding Sweeney as SEIU president in

1996, Andy Stern vowed to further ramp up SEIU organizing and to make nursing homes a strategic focus. This "Dignity, Rights, and

Respect" campaign aimed to organize at least 100 nursing facilities per year. In 1999,

United Food and Commercial Workers International (UFCW) started a "Care for the Caregivers" organizing campaign target? ing southern nursing facilities. Dozens of other unions also attempted to organize nursing homes during these years, including the Teamsters, the Association of Federal, State, County and Municipal Employees (AFSCME), and the Steel Workers.

To various degrees, the unions mounted

strategic campaigns that combined organiz? ing nonunion workers, building coalitions

with nursing home reform advocates around

higher standards of care, negotiating union

contracts with terms aimed at improving resident care standards and the skills and

stability of the workforce, and lobbying public agencies for changes in regulation and finance that would support organizing and bargaining goals. Issues where workers' and residents' interests overlapped?such as

professional development, minimum staffing ratio policies, and laws allowing nursing homes to defray the cost of wage increases

through increased reimbursements from

public finance agencies?were made central.

SEIU, in particular, also succeeded in build?

ing alliances with some elements of nursing home management to push for policy changes that would benefit unionized nursing homes or the industry in general (Stern 2006). In

return, management agreed to remain neutral

during organizing drives (Hurd 2008). These

cooperative efforts with some parts of man?

agement were often paired with negative, corporate campaigns attempting to label

uncooperative companies as bad actors

deserving extra scrutiny from regulators, consumers, and the public. With this strate?

gic carrot-and-stick approach, unions have

sought to shift the industry's policy environ?

ment, care standards, and labor standards in directions they prefer.

Managers pursue a range of strategies when faced with the prospect or the reality of an organizing campaign targeting their

nursing homes. Often, they view unions as an unwelcome third-party interfering in the

employer-employee relationship that could lead to the loss of unilateral control and erode

profitability (Simmons 1993; Benz 2005). Many managers pursue union-avoidance

strategies such as active campaigns against unionization. Others engage in union-substi? tution activities such as matching pay and other standards at union facilities in order to

preempt support for unionization (Logan 2006). It appears that management resistance can soften to the extent that unions' strategic campaigns moderate their bargaining pos? tures from conflict to cooperation and shift the industry's policy environment to minimize the economic costs of operating unionized

(Hurd 2008). Nursing homes are attractive organizing

targets for many reasons (Booth 1995).

332



Nursing homes employ more than 1.6 million

people and this workforce is projected to

grow by 24% over the next decade, based on

data from the Bureau of Labor Statistics

(BLS) National Employment Matrix for

nursing facilities. Organizing this industry can raise membership levels considerably. In contrast to many other sectors, nursing home

management has less ability to substitute

technology for labor or to shift operations to cheaper locales, removing threats com?

monly exercised against unions, lowering the

elasticity of labor demand, and increasing unions' ability to secure economic gains for members. The public's large role in financing nursing home care?roughly two-thirds of

nursing home revenues come from Medicare and Medicaid?can create opportunities for unions to leverage their political influence to facilitate organizing and bargaining.

Other characteristics of the nursing home

industry may make organizing nursing homes difficult. In many urbanized areas, the

nursing home market is relatively competi? tive. This limits the economic profits available for division through bargaining and unions'

ability to raise labor standards. To the extent that a union organizes an entire local labor

market and any labor cost increases are

uniformly applied across organizations, this is less of a factor. Nursing homes are labor intensive operations?nursing labor accounts for approximately two-thirds of the total cost of nursing home care. The large labor input share may make it harder for unions to secure economic gains for members. On the other

hand, when such a workforce successfully organizes, management has a harder time

ignoring members' demands than in indus? tries where labor makes up only a small piece of operations.

To provide institutional background and

insight into the challenge of study in this area, it is useful to understand that unions form in

workplaces by one of two avenues. First, workers can petition the NLRB to hold a union certification election. If the majority of workers vote for the union, then the employer is legally required to bargain with the union toward a first contract. Otherwise, the em?

ployer has no duty to bargain and the union is not certified. Alternatively, employers may

Nursing Homes

choose to voluntarily recognize a union as the

bargaining agent for its employees without an

election, due to a successful corporate or

card-check campaign run by a union and

employees at a specific workplace. Due to unions' mounting frustration with the NLRB election process, this second route to union? ization took off in popularity during the mid 1990s (Benz 2005). By 2001, the SEJU estimated that just over half of its successful

nursing home organizing campaigns occurred outside the NLRB process (Childs 2002). In any case, nursing homes and unions are

required to notify the Federal Mediation and Conciliation Service (FMCS) as they enter negotiations over first or subsequent contracts.

Study Data and Methods

Unionization rates among nursing home workers are straightforward to estimate; however, calculating unionization among nursing home facilities is more challenging. The Current Population Survey (CPS), a

long-standing survey carried out jointly by the Bureau of Labor Statistics and the Census

Bureau, gives insight into worker unioniza? tion. For monthly samples representing all

U.S. households, the CPS provides informa? tion on individuals' employment, union

status, and other variables. It offers a picture of the union and nonunion nursing home labor force over time and across states.

Publicly available measures of establish? ment-level unionization are not generally available. The CPS does not disclose the firms where individuals work, preventing its use in identifying particular nursing homes as union or nonunion. From the firm side, the Centers for Medicare and Medicaid Services'

(CMS) Online Survey, Certification, and

Reporting (OSCAR) system provides rich establishment-level data on all Medicaid and Medicare-certified nursing home facilities in the United States (96% of all facilities). The

OSCAR data include information about whether nursing homes are in compliance with federal regulatory requirements. Follow?

ing an initial survey, states are required to

survey each facility no less than every 15 months, and the average is about

333



Inquiry! Volume 47, Winter 201012011

12 months. Nursing homes submit facility, resident, and staffing information. However, the OSCAR database does not distinguish union from nonunion nursing homes.

To measure unionization at the facility level and describe differences in the popula? tion of union and nonunion nursing homes, we study OSCAR data linked to NLRB union election data and FMCS data on union contract negotiations. We began with data

provided by Holmes (2006) that links nursing home records from three sources: a) NLRB union elections held between 1978 and 2002, b) FMCS bargaining notices filed between 1986 and 2003, and c) CMS provider identifiers for nursing homes in the OSCAR

system in either 1991, 1996, or 2001. Using sources a and b, we measure nursing homes' unionization status over time. Using the CMS identifiers (c), we link unionization measures to a fourth data source, the complete OSCAR

panel data of facility characteristics from 1994 to 2002. Our measure of establishment

unionization indicates whether any of the

nursing home's workers are union. Because not all workers at a union nursing home are

necessarily in a union, the worker unioniza? tion rate from the CPS will be lower than the

employer-weighted rate from the merged NLRB, FMCS, and OSCAR data.

The NLRB and FMCS data cover only private (i.e., nongovernment) nursing homes. Thus, we exclude government-owned facilities

(about 8% of total) from the establishment level analysis of unionization. Our resulting sample consists of 22,357 unique licensed facilities; 14,556 were in operation in 1992, and 15,638 facilities in 2002. In our data, 2,088 facilities had at least one certification election between 1978 and 2001. Of these, 1,375 (66%) homes had at least one election

where a union won. In the other 713 facilities with elections, all elections went against the union.

This measure of establishment-level union? ization permits new insight into two main questions. First, how do the characteristics of unionized nursing homes compare to non? union nursing homes? With our data, we can best measure the presence of any union workers in a nursing home rather than the fraction of union workers in a nursing home.

In a given year, a nursing home is designated as union (having some unionized workers) if it previously experienced either an NLRB

representation election won by a union or an FMCS notice of union contract negotiations. Otherwise it is designated nonunion. Nursing homes are also designated as nonunion if an NLRB union decertification election inter? vened between the given year and the most recent prior certification election or FMCS

notice, and if the union lost the decertifica? tion election.

Here is the second question we can address with these data: Among nursing homes that

experienced an NLRB union certification

election, what are the characteristics of facilities that are associated with a greater probability of a union victory? Put another

way, which contemporaneous nursing home characteristics predict union success in elec? tions? We analyze this question using more than 1,400 elections that occurred between 1994 and 2002 when the unionization data and nursing home characteristics data over?

lap.

The descriptive analyses are performed by simply graphing the variables of interest

along time and geographic dimensions. We also use a linear probability model to estimate the relationship between nursing home char? acteristics and the probability of two out? comes: that a facility is union rather than nonunion and that if an NLRB election is held, the union wins rather than loses. All

regression results are robust to the use of a

logistic model.

Results

Patterns in Worker Unionization across Time and Geography

We first document the trend in the share of workers covered by a union contract over time (see Table 1) based on the methods of

Hirsch and Macpherson (2003). The CPS data show that between 1985 and 2009, the fraction of nursing home workers covered by union contracts fell from 14.6% to 9.9%, a loss of about a third. Over this same period, the total number of nursing home workers grew by almost half, from 1.3 million to 1.8 million. However, the number of covered

334



Table 1. Percentage of workers covered by union contracts in entire private-sector

economy and nursing care facilities by year

Percent of worker union

coverage

Year

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Nursing homes

14.6

12.6

12.5

13.3

13.7

12.4

13.3

12.2

12.0

14.1

11.3

12.2

11.1

10.8

10.5

11.2

10.7

10.0

10.2

9.6

9.1

8.8

10.2

9.1

9.9

Private

sector

15.9

15.2

14.4

14.0

13.5

13.2

12.9

12.5

12.1

11.9

11.3

11.0

10.6

10.3

10.2

9.8

9.7

9.3

9.0

8.6

8.5

8.1

8.2

8.4

8.0

Difference (%)

-1.3

-2.6

-1.9

-.7

.2

-.8

.4

-.3

-.1

2.2

0.0

1.2

.5

.5

.3

1.4

1.0

.7

1.2

1.0

.6

.7

2.0

.7

1.9

Source: Current Population Survey, 1985-2009.

nursing home workers remained quite stable,

going from 188,803 in 1985 to 183,802 in 2009. This occurred in the context of an even

steeper decline in union coverage among

private-sector workers generally. In the broader economy, the share of private-sector workers covered by union contracts dropped from 15.9% to 8% over this period, a decline of about half. We next describe the union coverage rates

by census division using data from 2000 to 2009 (Table 2). Rates vary significantly across the nine census divisions. Northern and West Coast states with traditionally high rates of unionization in the broader economy also have higher rates of nursing home unioniza? tion. The difference between the divisions is

large. The Middle Atlantic states have the

highest percentage of unionized nursing home workers with union coverage rates in excess of

25%; the West South Central division has the

Nursing Homes

lowest unionization rates with slightly more

than 1% of their nursing home workforce

covered by a union contract.

Nursing Home Organization Elections

A primary pathway to unionizing a nursing home is via an NLRB election. Figure 1

presents trends in the number of NLRB

elections in nursing homes from 1983 to

2001. During this period, on average, more

than 160 elections occurred per year. Signif? icant volatility exists in the number of

elections across years. The highest number

of elections was 230 in 1997, and the lowest was 112 in 1983. On average, a majority of

workers voted in favor of a union in just over

55% of elections, and this rate is fairly constant over the span of our data. Further

analysis of the election data reveals that the

average pro-union vote share in elections was

just over 50% during this period. So the

elections were close on average. Election volume picked up substantially

after 1995. There were fewer than 70,000

nursing home workers involved in elections in the five years between 1991 and 1995, but

more than 100,000 in the five years from 1996 to 2000. This underestimates the increase in

organizing activity because campaigns outside the NLRB election process became increas?

ingly popular through the 1990s. The uptick in activity coincides with a period of tighter labor markets. The implicit employment security provided by strong labor markets likely made workers more willing to unionize. There is evidence in our data that this surge in elections was connected to the strategic campaigns mentioned earlier. SEIU and the UFCW accounted for an increasing share of workers involved in elections. Between these periods, SEIU's share of nursing home workers in? volved in elections increased from 25% to

36%, accounting for half the overall growth in workers involved. More modest but still

significant, the UFCW's share went from 10% to 12%, as the total number of elections

grew dramatically.

Characteristics of Union and Nonunion

Nursing Homes

Table 3 presents summary statistics of nurs?

ing homes by an establishment's unionization

335



InquiryIVolume 47, Winter 201012011

Table 2. Percentage of nursing home workers covered by union contracts by census division

Census

division States

Mean

(%) Standard

deviation (%) New England

Middle Atlantic East North Central West North Central

South Atlantic

East South Central West South Central Mountain

Pacific

Connecticut, Massachusetts, Maine, New

Hampshire, Rhode Island, Vermont New Jersey, New York, Pennsylvania Illinois, Indiana, Michigan, Ohio, Wisconsin Iowa, Kansas, Minnesota, Missouri, Nebraska,

North Dakota, South Dakota District of Columbia, Delaware, Florida, Georgia,

Maryland, North Carolina, South Carolina,

Virginia, West Virginia Alabama, Kentucky, Mississippi, Tennessee Arkansas, Louisiana, Oklahoma, Texas

Arizona, Colorado, Idaho, Montana, New Mexico,

Nevada, Utah, Wyoming Alaska, California, Hawaii, Oregon, Washington

8.7

25.4

11.0

4.6

5.3

2.4

1.4

2.6

14.7

4.1

10.1

6.3

4.5

4.7

.7

.7

2.8

7.8

Source: Current Population Survey, 2000-2009.

Status. We focus on 2002 because this is the last year of data in the NLRB and FMCS records used to construct measures of estab? lishment-level unionization. Overall, about

18% of nursing homes had some union workers. On average, unionized nursing homes were significantly (p<.0l) larger as

measured by the number of beds, residents,

250

? Won by union ? Lost by union

Figure 1. Annual number of National Labor Review Board union certification elections in

nursing homes by election outcome, 1983-2001 (Source: Online Survey, Certification and

Reporting [OSCAR] data matched with NLRB data from Holmes 2006)

336



Table 3. Private-sector nursing home

characteristics by union status, 2002

Union Nonunion

Mean nursing home beds 135.3 102.4 (86.0) (58.2)

Mean total residents 113.2 82.3 (76.3) (47.7)

Percentage occupancy 84.1 81.4 (17.2) (19.0)

Percentage hospital-based 12.2 7.4 (32.7) (26.2)

Percentage chain-affiliated 50.3 56.6 (50.0) (49.6)

Residents by payer source

Percentage Medicaid 65.9 60.9 (25.9) (25.9)

Percentage Medicare 15.5 13.5 (21.1) (20.0)

Percentage private 18.6 25.6

pay/other (16.4) (20.1) By ownership type

Total N (15,638) 2,829 12,809 Percent (100.0) 18.1 81.9

Individually owned 23.2 76.8

Partnership 18.2 81.8

Corporation 16.9 83.1 Church-related 17.3 82.7 Nonprofit corporation 20.9 79.1 Other nonprofit 21.0 79.0

Source: The Online Survey, Certification, and Reporting database, 2002; NLRB election and FMCS data from Holmes (2006). Notes: Government-owned (i.e., state, county, city, city/ county, hospital district, and federal) nursing homes are

excluded because the NLRB and FMCS jurisdiction only covers privately owned facilities. Standard deviations are in parentheses.

and staff. For instance, union nursing homes

averaged 135 beds, while nonunion homes

averaged 102. Union nursing homes also had

significantly (/?<.01) higher occupancy rates than nonunion nursing homes and a larger (p<.0l) share of their residents' expenses financed by Medicaid and Medicare. Union

nursing homes were more likely (p<.01) to be

hospital-based than nonunion nursing homes and less likely (p<.01) to be chain-affiliated.

Unionization rates across different facility characteristics are presented in the bottom

panel of Table 3. Among for-proflt corporate homes, 16.9% were unionized. Among secular

nonprofit homes, almost 21% were unionized. On the other hand, the most striking fact may be how small these differences appear. Unionization rates among nursing homes

Nursing Homes

owned by for-profit partnerships, for-profit

companies, nonprofit churches, nonprofit

companies, and other nonprofits range in a

relatively narrow band between 16.9% and

21%. Individually owned for-profits had a

slightly higher unionization rate, 23.2%, but

these constituted only 2% of homes.

Although the variation in facility charac?

teristics is not huge, the variation that does

exist may be explained by multiple factors.

Larger nursing homes may be more profitable and thus the gains from organizing may be

larger. It is also possible that these patterns are driven by geographic differences in

unionization rates that happen to be corre?

lated with the size and ownership status of

nursing homes. States that have a higher

propensity toward unionization may also

have larger nursing homes. To explore these possibilities, we estimate a

linear probability model of the correlates of unionization (Table 4) using the full panel of nursing homes across years. Estimated coef? ficients of these characteristics on nursing homes' probability of being union are pre? sented in column 1, which excludes state fixed

effects, and column 2, which includes them. The results are largely consistent with those described previously from the simple analysis of mean differences. Nursing homes with more residents are more likely to be union, as are those with a higher share of resident care

financed through Medicaid (omitted catego? ry) and Medicare rather than private payers. For example, shifting from a 100% Medicaid

facility to a 100% private-pay facility would decrease the associated likelihood of unioni? zation by 23.8 percentage points. A hospital based facility has a 10.2-percentage-point higher likelihood of unionization, while a

chain-based facility has a 1.4% higher likeli? hood. The positive association of unioniza? tion with being chain-based conditional on state and other characteristics differs from the unconditional negative association in Ta? ble 3. Relative to corporate for-profit nursing homes, church-related nonprofits are 2.4

percentage points less likely to be unionized. Other ownership types do not have signifi? cantly different propensities to be union. The

contrasting results in columns 1 and 2 suggest that the association of unionization with

337




Table 4. Nursing home characteristics as predictors of union status and union victory in

certification elections

Union status Election outcome

(l)a (2f (3)a (4f Beds

Total residents

Occupancy rate

Hospital-based

Chain-affiliated

Percentage Medicare

Percentage private

pay/other Individually owned

Partnership

Church-related

Nonprofit

corporation Other nonprofit

State fixed effects i?-squared

N

.0001

(.0001) .001***

(.0001) -.0002

(.0001) 107***

(-012) _ 025***

(.005) .002

(.014) ?

190***

Coil) 072***

C014) -.005

(.008) .009

(.010) 039***

(.007) .022

(.017) No .072

204,809

.0001 (.0001) .001***

(.0001) _ ooio***

(.0001) .102***

(.011) .014***

(.004) -.042***

(.013) -.238***

(.011) .018

(.012) -.004

(.007) _ 024***

(.009) .002

(.006) .006

(.016) Yes

.203

204,809

-.0003

(.0003) .0002

(.0004) -.002**

(.001) .058

(.051) .041

(.028) -.350***

(.075) -.282***

(.078) -.076

(.088) -.060

(.053) .059

(.046) -.056

(.035) -.035

(.112) No .039

1,473

-.0002

(.0003) .0002

(.0004) -.003**

(.001) .055

(.055) .055*

(.029) -.366***

(.080) -.312***

(.079) -.062

(.093) -.081

(.053) .069

(.049) -.057

(.036) -.029

(.118) Yes

.100

1,473 Source: The Online Survey, Certification, and Reporting Database (1994-2006); NLRB election and FMCS data from

Holmes (2006). Notes: Standard errors are in parentheses and are clustered by nursing home. All four specifications include year fixed

effects. For years 2003-2006, the union status values are carried forward from 2002. a Excludes state fixed effects.

b Includes state fixed effects.

* Significant at 10%;

** significant at 5%;

*** significant at 1%.

individual or nonprofit corporate ownership is driven by differences in ownership preva? lence between states (these forms are more

likely in more highly unionized states) rather than within-state differences in unionization rates across ownership types. Payer mix is

predictive of union status. Controlling for interstate differences in the propensity to

unionize, institutions with a higher percent? age of private-pay residents are less likely to be covered by a union contract.

Finally, we analyze the correlates of union success in NLRB elections using linear

probability models. We look at all nursing homes that experienced union certification elections over the period when OSCAR and

NLRB data are available (1994-2002) and

use the nursing home characteristics from the most recent OSCAR survey prior to the date of the election. Column 3 presents estimates without state fixed effects and column 4 with state fixed effects. Occupancy rate has a

significant but small negative association with union success. Elections in both hospital based and chain-affiliated homes are more

likely to be successful than elections in other

homes, although the estimates are somewhat

imprecise. A higher share of residents fi? nanced by Medicaid is strongly predictive of union success relative to the financed share of both Medicare and private payers. Specifical? ly, a shift from 100% Medicaid to 100%

Medicare would decrease the likelihood of union success by 36.6 percentage points,

338



while the shift to 100% private-pay would decrease the likelihood of union success by 31.2 percentage points. The correlation be? tween Medicaid and successful unionization

may be related to poorer working conditions in these low-resource facilities or unions'

greater ability to leverage political influence in support of organizing.

Discussion

Although unionization rates in the nursing home industry have been declining for the last 25 years, labor law reform has the potential to reverse this trend. If elements of EFCA are

adopted legislatively or administratively, our results suggest nursing homes caring for

greater numbers of Medicaid and Medicare residents are more likely to be unionized than

nursing homes treating private-pay residents. Our results also suggest a greater likelihood of unionization in larger nursing homes, hospital-based facilities, and chain-owned

nursing homes. A key issue arising from our results

concerns the decline in nursing home worker unionization. Unions' strategic efforts to

organize nursing home workers did slow the rate of decline compared to the private-sector economy generally, but clearly other forces

pushed the rate of unionization down. While shifts in employment away from highly unionized manufacturing to less-unionized industries may help explain decreasing union? ization in the overall economy, it cannot

explain declines within a particular sector, such as nursing homes. Low-cost foreign competition also is not a factor. More viable

explanations include: 1) employment shifts from more to less unionized states, 2) unionized workers dissolving their union

through decertification elections, and 3) shifts in the population of nursing homes toward new, unorganized entrants. As we subse?

quently discuss, only the third explanation holds up to analysis.

Regarding the first explanation, regional shifts in employment from the more heavily unionized Northeast and Midwest to other

regions within the United States could

potentially be a factor. In the South and Southwest, political and historical traditions

Nursing Homes

have produced lower unionization rates, and over the period of our study, these regions have gained population share. Northeast and Midwest states comprised 46% of the U.S.

population in 1983 and only 39% in 2008, according to census estimates. Similarly, their share of population age 65 and over went from 49% to 41%. This trend may have led to a shift in the location of those who may demand nursing home services, and hence a shift in nursing homes from unionized to nonunionized environments. To test this, we examine how much of the change in the national unionization rate over the last 25 years has been due to within-state declines in the unionization rate and how much to between state shifts in nursing home employment.

The national worker unionization rate decline is almost wholly attributable to declines within states rather than shifts in

employment across states. To analyze this, we

computed the unionization rate and employ? ment share in a base period (1984-1989) and a final period (2003-2008) for each state.

Using the years 1990-1995 as the base period produced very similar results. With this, we answer two hypothetical questions. First, what would the national unionization rate be in the final period if each state's unioni? zation rate remained fixed at its base level but its employment share shifted by the observed amount? In fact, the unionization rate would

barely have budged, going from the 14.0% base to 13.9%. In contrast, when we ask what the national rate would have been in the final

period if each state's employment share stayed fixed at its base level but its unionization rate shifted by the observed amount, we obtain a unionization rate that matches the observed one, 9.5%. This suggests that regional employ? ment shifts did not generate the decline in

nursing home worker unionization. The an? swer lies in changes going on within states.

A second possibility is that union nursing home workers decided to dissolve their union

through the NLRB's decertification process. Although this might have been a small contributor, it could not have been a main driver. Among the more than 12,800 non? union nursing homes operating in 2002, fewer than 100 became nonunion through union losses in decertification elections.

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InquiryI Volume 47, Winter 201012011

A third remaining explanation involves turnover in the population of nursing homes,

with new entrants remaining nonunion. This

explanation is more promising. In any given year in our data, no more than 5% of nursing homes exited the OSCAR database and no more than 6% were new entrants. However, over longer periods, this churning means that new entrants make up a significant share of

nursing homes. For instance, about a quarter of the homes active in 2002 were new entrants within the prior eight years. New entrants

generally require new organizing to become unionized. Most establishments start off as nonunion although some unionized compa? nies immediately recognize unions for work? ers in new facilities. It is unclear whether union avoidance is a precipitating factor to ownership turnover and we know of no evidence on this point. Regardless, new

organizing in the current legal environment has proven difficult, leading unions to prior? itize labor law reform through EFCA (Benz 2005). Holmes (2006) documents significant spillovers in unionization across industries. The decline in unionization across the broad? er economy may have affected the nursing home industry, making the policy and eco? nomic environments less conducive to orga? nizing and thus helping account for the

patterns we observe in our data.

Moving forward, an important issue in? volves whether unionization matters for the

delivery of nursing home services. In theory, unionization of the nursing home workforce

may have implications for the welfare of workers, patients, and the nursing home sector more generally. However, relatively little research to date has considered these issues. We briefly consider each issue with the idea that future research is needed in this area.

Unionization and Worker Outcomes

In general, unions seek changes that benefit their members, which usually entail a mix of richer compensation, better working condi? tions, increased training and professional development opportunities, and greater em?

ployment security. The hospital literature on unionization and nurse wages is generally inconclusive with some of the research

suggesting a significant positive impact of unionization and other research concluding that unions do not affect nurses' wages (e.g.,

Adamache and Sloan 1982; Hirsch and Schumacher 1995; Feldman and Scheffler

1982). To date, little is known empirically about the causal impact of unions on nursing homes and their workers. In theory, however, unions are expected to have a positive effect on the compensation of nursing home work? ers, which in turn can affect the size and

average quality of a nursing home's staff. That is, unionized workers should have better

pay, greater job stability, and better work environments (Temple, Dobbs, and Andel

2009). To the extent that union nursing homes cannot pass higher wages through to

customers, higher wages may translate into fewer nursing home staff. Thus, it could be the case that unionization leads to higher

wages for individuals able to obtain jobs in the nursing home sector, but there may be fewer jobs as a result. To escape this wage employment trade-off, unions have supported in more than 20 states wage pass-through laws that offset wage increases with higher state nursing home reimbursements and therefore make it less costly for nursing home

management to increase wages. Unions have also lobbied successfully for higher state

mandated minimum staff-patient ratios, which can improve working conditions across the industry while putting a floor under

negative employment effects (Chen 2008).

Unionization and Patient Outcomes

Through unions' effects on the quality and

quantity of nursing home staff and on the terms of employment, unions also have the

potential to meaningfully impact resident outcomes. The nursing home literature gen? erally suggests that the level and type of

staffing in nursing homes are related to

patient outcomes (Konetzka, Stearns, and Park 2008; Grabowski et al. 2008). Unions have argued that organized nursing staffs are better able to care for patients because they can attract, retain, and train higher-quality staff. Higher staff-patient ratios tend to benefit both patients and workers. Alterna?

tively, a union wage premium may have a

negative effect on the number of staff, which

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may lower the quality of care. Again, little is known about the impact of unions on the

quality of care in nursing homes. A study of California nursing homes in 1999 found that unionized facilities had more complaints than nonunionized facilities, but fewer substanti? ated serious violations (Swan and Harrington 2007).

Unionization and Firm Outcomes

By raising worker compensation, unioniza? tion may reduce the profitability of individual

nursing homes and increase the likelihood of closure. On the other hand, unions can act as

powerful allies with management in lobbying for policies that favor the industry, such as

higher Medicaid reimbursement rates. By this avenue, firms in markets with stronger unions

Nursing Homes

could prove more profitable than those in markets with weaker unions. Thus, the overall implications for revenue and profits are ambiguous.

Unions may have important implications for the welfare of both workers and patients, and also the financial health of the industry. As already noted, unionization of the nursing home workforce has been declining over the

past 25 years, but due to strategic efforts by a handful of unions the decline has been at a slower rate than in the rest of the economy. Proposed labor reform legislation has the

potential to greatly expand the number of unionized facilities. Future research will need to consider the potential impact of nursing home unionization on worker, patient, and firm outcomes.

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