As Home Care Workers Unionize, Key Questions Come Into Play For Providers

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Generally, employers aren’t thrilled at the idea of their workforces unionizing. In home-based care, that’s particularly the case.

Provider leaders see home care union demands as unrealistic. The most basic example of that is wage increase pleas, which are often tough to meet given most providers’ reliance on government-funded payer sources.

Private-pay home care is the exception, where agencies can pass additional wage costs onto the consumer. At least for now.


Home care unionization efforts ticked up prior to the pandemic, but slowed once COVID-19 began to spread. With that crisis mostly in the rearview, however, those efforts are bubbling back up to the surface.

Anecdotally, the stories have been cropping up much more often. New York has been dealing with home care worker strikes on a regular basis. Illinois home care workers held a rally at the state capitol earlier this month vying for higher wages. Just this week, University of Rochester Medicine Home Care (URMHC) workers elected to unionize. More than 2,300 University of Michigan Medicine health care workers joined the Service Employees International Union (SEIU), too, with many of them being home care workers. 

This week’s exclusive, members-only HHCN+ Update takes a further look at unionization within home care, and sets out to answer these questions:


– Is home care unionization actually ticking up?

– What would more unionization mean for home-based care providers?

A unionized workforce

Traditionally, home care workers have not been as unionized as other sects of health care workers because of their remote status.

Workers don’t generally gather at the same places, at the same time. Instead, they’re out at seniors’ homes. That’s begun to change of late, however, as union organizers have advanced their efforts with online campaigns, phone campaigns and legislation that has allowed them to gather more workers’ contact information.

It’s worth noting, too, that the changes to independent contractor statutes throw fuel on the union fire. Independent contractors cannot be organized, but employees can. For unions, the more workers classified as employees, the better.

The first question I asked Angelo Spinola – the co-chair of the home health and home care industry group at the law firm Polsinelli – was whether or not unionization was ticking up in home care.

“Yes,” he said.

How much so? There’s no real way to quantify it yet. I reached out to the SEIU for more direct details, but it had not gotten back to me by the time of this story being published.

For Spinola, it’s obvious due to the greatly increased number of phone calls he has been getting from home-based care provider clients related to union issues.

“There’s so much more activity with our clients,” he said. “They are reaching out because there’s a campaign going on, or soliciting for a union going on.”

It’s happening across the board: in personal care, home- and community-based services (HCBS) and home health care. Although, it’s likely happening the most right now in home health care, Spinola said.

The other area where union activity has become very prevalent is in consumer-directed models. Family caregivers are being picked up. Those unions are sometimes negotiating with the third-party providers in the middle of consumer-directed setups, and also negotiating with the states themselves.

Broadly, these unions aim to negotiate better wages, better fringe benefits and a less of a chance of termination for any reason.

Home care workers are a reasonable target for unionization. They have arduous jobs that require extreme effort and care. They are also regularly underpaid.

But that’s not all.

“When you look at unionization on the whole, the numbers are reducing,” Spinola said. “And then you look at this industry, which is rapidly growing and has always been a target industry, the union presence is minimal. It’s not nearly as significant as unions would like it to be. … The tea leaves are relatively clear that we’re going to be dealing with these issues for a long time to come.”

Provider takeaways

For providers, unionization can be an added headache in an already difficult operating environment.

As mentioned above, while many providers aim to give raises where they can, many are dependent on subsequent rate increases from Medicaid or Medicare. And those increases aren’t always there.

For smaller providers in particular, the legal fees alone associated with dealing with a union can be enough to submerge the bottom line.

“Generally and historically, unions have focused on larger businesses, but now we’re seeing smaller businesses being targeted,” Spinola said. “We’re seeing systems being targeted, and individual businesses within a system being targeted. Unions are targeting caregivers – more than we’ve seen in the past – because a lot of the time they work for multiple agencies. And they’re effectively using that caregiver as a seed to bring others in and start to generate interest.”

Spinola said he’s seen examples of providers throwing their hands up and calling it quits, particularly due to recent software hacks and unionization efforts.

Given the rate uncertainty – in fee-for-service Medicare and Medicare Advantage (MA) – home health providers aren’t in a great spot currently to be spending extra dollars on a new issue.

Private-pay home care providers, again, have more leeway. But even their billing rates are starting to price out more than 90% of Americans.

More sellers could emerge in M&A pipelines, with a lack of resources to keep up with the spending tied to union negotiations. That’ll especially be the case if the 80-20 rule passes as proposed in HCBS.

If caregivers can derive more benefits from joining a union than they would have otherwise – even taking dues into account – it’s a win for them.

But Spinola doesn’t always believe things turn out that way in home care.

“I think what’s often misunderstood is that there’s only so much you can do,” he said. “Capital forces are really dictating what the benefits and wages for caregivers are a lot more than any legislation or union. What often happens is, because there’s not enough to give, it creates too much pressure. And it’s not an effective technique to enhance the working conditions of the caregiver, and the caregivers often don’t realize that until after the fact.”

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