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Institutional Legacies, Union Power, and

Organizational Restructuring in Healthcare

Rosemary Batt, Cornell University

John Kallas, Cornell University
Eileen Appelbaum, Center for Economic and Policy Research

Conference on Consequences of Changes in Healthcare

Rutgers University
January 11, 2019

[Paper available upon request]

Roadmap to Presentation

• Challenges facing healthcare unions

• Research question

• Contributions of the research

• Research methods and findings

• Implications and discussion

Background: Challenges facing Unions in Healthcare
• As a result of financial and regulatory change, healthcare systems are
shifting services out of hospitals and into outpatient care
• Jobs are still growing in hospitals, but at a much higher rate in ambulatory
facilities over the past decade
• Unionization in hospitals at 13.5% in 2015, higher than approximately 7%
at both national average and unionization in outpatient facilities
• Clear obstacle for unions, as employers set up legally separate outpatient
entities that remain part of the healthcare system but are no longer bound
by the union contract
• Variation in union success in extending and maintaining coverage beyond
traditional bargaining units
Research Question

• As healthcare organizations restructure, unions face difficult

obstacles to organizing and representing workers

• What explains the variation in union success?

Our Contribution
• Local institutional variation

• Thin institutional context of the U.S.

• Recent literature focuses on institutional change; we find that historical

continuity, path dependence are important determinants of outcomes

• In thin institutional environments where agency and entrepreneurship

are supposed to overcome institutional constraints, we show that
current outcomes for workers are rooted in power relations between
employers and unions that have deep local institutional roots
Theoretical Foundation and Contribution
• Build on social constructionist school and power resources theory
• Korpi (2006): employers act as antagonist, consenters, or protagonists
• E.G. virulent anti-unionism (antagonist), GM in postwar accord
(consenter), Saturn’s response to intense global competition with labor-
management cooperation (protagonist)
• Theorize three strategies by both unions and employers to expand their
power resources: economic, ideological, and political
• Importance of ideological…most of comparative employment relations
looks at the economic power of both employers and workers…need to
understand how unitarist and ideational strategies impact class conflict
Case Selection
• Unit of analysis is unions and healthcare employers in Rochester and
Buffalo, NY

• Two cities with many of the same characteristics

• Same state, state-level/national regulatory framework, < 75 miles

apart, top 25 in poverty rates, deindustrialization & deunionization

• Major healthcare unions (1199 SEIU in both Rochester and Buffalo,

CWA 1168 and CWA 1133 in Buffalo)

• Major health systems (University of Rochester Medical Center,

Rochester Regional, Kaleida Health, Catholic Health East)
Explanatory and Dependent Variables

• Dependent variables—union outcomes (density, extension to

outpatient, organizing victories)
• Explanatory variables—employer strategy and power
• Both are rooted in institutional legacies
• Distinct class relations or “societal effects”
• Working class identities forged at emergence of working class in each
city in late 19th/early 20th century
• Qualitative research approach

• Extensive review of secondary materials and analysis of national data

on employment and wage trends

• Archival data on union contracts and union and employer

organizational histories

• Key informant interviews and field interviews with union researchers,

union leaders, and industry specialists

• Thirty-six interviews over a two-year period

Our Findings: Historical Legacy
(Preexisting Legacy) Rochester Buffalo
Economic Corporate headquarter city Branch city

Eastman Kodak and Bausch Unions followed companies

& Lomb virulently anti- shifting production to
union Buffalo

Ideological Paternalism; employers Heavy manufacturing; blue-

forced cross-class alliances; collar identity; lack of
private welfare resources to implement
paternalistic policies

Political Employer organization to Employer and labor co-

oppose unionization operation to promote
(response to successful industrial peace (Buffalo-
clothing strike; Industrial Erie County Labor
Management Council) Management Council)
Our Findings: Current Situation

Healthcare: Legacy and Rochester Buffalo

Current Situation
Economic Labor militancy to win first Labor militancy to win first
contract contract at multiple
Employer opposition and
tactics to thwart Employers acquiesce to
unionization beyond further unionization; union
traditional bargaining unit power resources to
maintain and expand
beyond traditional
bargaining units

Ideological Employers resist Employers consent to, and

unionization, even when in occasionally facilitate, union
economic interest organization

Workers oppose
unionization, even when in
economic interest

Political Employer healthcare labor Community and political

relations committee pressure combine
effectively with economic
Community and political power to win contract fights
pressure fail against
employer ideological power
Influence of Historical Legacy in Current
• Legacy of paternalism in Rochester continues to reverberate in
current period
• Anti-union ideology associated with paternalism influences workers
and employers to act against own economic interests
• Anthony Jordan in Rochester: workers in offsite locations refuse to
organize despite knowing about better wages and working conditions;
employer resists new contract that would benefit the organization
• In Buffalo, employers consent to union gains when they feel
pressured to do so (e.g. Kaleida in 2011 and Catholic in 2016)
Current Situation Continued
• Rochester: focus on Strong Memorial, consenter at traditional hospital and antagonist
beyond inpatient unit.

• Anthony Jordan highlights ideological struggle in Rochester from both worker and
employer standpoint

• Buffalo: Kaleida, acted as protagonist in late-1990s and early-2000s and consenter since

• Catholic moved from antagonist to consenter and highlights ideological struggle in

Buffalo (CWA’s 2016 member mobilization/contract campaign)

• Clear difference in current period (2016-2018) highlighted by Anthony Jordan and

Catholic distinction which shows importance of ideological power
Race and Implications
• In Rochester, Black workers lacked access to good jobs and training
programs developed by major paternalistic employers until the 1960s
• Black workers led labor militancy with 1199 at Strong Memorial in
Rochester in the early-mid 1970s
• 1199 viewed as a Black union in both Rochester and Buffalo
• In Buffalo, 1199 had initial success organizing nurses in late-1970s, but
turned over organizing to CWA 1168, followed by labor militancy and
unionization at Buffalo General in the early-1980s
• 1199 SEIU continues to face difficulties organizing workers in Rochester
beyond the traditional bargaining unit at Strong Memorial, and nurses
remain overwhelmingly non-union throughout the city
• “URMC [University of Rochester Medical Center] doesn’t beat the shit out
of workers, they just drown them. Mid-80s in terms of percentage on
cards, seemed like a sure win. The CEO removed the administrator and
literally moved in…bought everyone food and just completely took over
everything. Every supervisor wore scrub tops that said ‘Vote No.’ They
called in every worker one-by-one. Every worker got guaranteed wage
increase of $0.25/hour for every year of seniority if the union lost…by the
time stuff got litigated it would have been a year. We lost 55-45%.”
• “[Workers at] other sites don’t have tuition benefits…pension plans…they
can tell you what is in our contract plus $3/hour more, but they still won’t
sign a card or organize.”
• One worker in a failed organizing drive remarked that 1199 SEIU is for
“lower-class workers—housekeeping, dietary.”

• As healthcare sector emerged in 1970s, healthcare unions adopted same

organizing strategies in both cities
• Initially won large gains at prestigious hospitals through direct action and militant social
movement organizing
• But success of unions in extending organizing beyond initial success depended on
• Relative power & strategies of employers
• Class identity of workers

• Contrast
• Rochester
• Buffalo

• Contrast between Rochester and Buffalo, 2016 through 2018, even more salient