Physician Unionization : A Hot Topic at the American Medical Association

On June 12, 2024, the American Medical Association (AMA) House of Delegates adopted a resolution on unionization.

The resolution that came to a vote before the House of Delegates, the organization’s highest decision-making body, originated in state medical societies where frontline doctors are organizing or already organized. The resolution that was adopted was originated in part by a doctor from the Delaware Medical Society who is currently leading one of the largest doctor-led organizing campaigns in U.S. history. He and his fellow 500 doctors are voting in a National Labor Relations Board (NLRB) election later this month at the largest health system in that state, Christiana Care. They will be voting to be represented by Doctors Council SEIU.

Dr. Bryan Haimes is a hospitalist who also works in pediatric emergency medicine at Christiana Care. Here is what he said to me about the significance of the AMA resolution which he helped author:

“Our frontline physicians face significant challenges amidst the growth of large corporate healthcare monopolies and the ongoing trend for physicians to become employees rather than staying in private practice. This resolution aims to harness the collective strength of the American Medical Association to empower physicians, encouraging them to speak up, engage, and regain influence in their professional environment. As physicians our ability to organize and collectively bargain is more crucial than ever.

In a capitalistic society, corporate medicine has clearly reigned, and there are many administrators profiting off of the misfortunes of others. Healthcare costs continue to rise, yet frontline physicians are continuing to be asked to do more work with less support, less pay, and fewer benefits. This directly impacts patient care, outcomes, and patients feeling heard. Physicians organizing is one of our methods to advocate for our patients – so we can spend more time with our patients and have very needed resources to improve care and patient outcomes. “

Unionization of interns, residents, and fellows as well as attending physicians has accelerated recently. In the body of the AMA resolution, there is data illustrating that there was a 26% increase in physician unionization between 2014-2019. Post-pandemic, the Committee of Interns and Residents (CIR) has had unprecedented growth all across the nation, and attending physicians have organized at private sector health systems, such as Allina in Minnesota, Peace Health in Oregon, and Ascension in Detroit. The Christiana Care election, if successful will accelerate interest in the Mid-Atlantic Region and elsewhere.

Why is it significant that the AMA is advancing its discussions on unionization?

The AMA is the largest and historically most representative of the nation’s doctors. Founded in 1847, the AMA began as a professional association dedicated to promoting the art of medical science. Over its existence it included virtually all medical students who then joined the AMA when they became attending physicians.

Though the AMA initially opposed insurance as a barrier to the physician control over the relationship with patients, as medicine grew as a profession and as an industry, a major focus of the AMA turned toward a collaboration with insurance organizations for the purpose of establishing consistent payments to physicians for their services. Employment-based benefits became the norm in the U.S. especially after World War II. Whether collectively bargained or not, health insurance became a staple of the American employment experience. Through this period the AMA opposed most forms of government intervention into health care organization and financing The effort to establish Medicare to protect seniors’ ability to afford healthcare in retirement began a decade-long struggle to finally be signed into law in 1965. AMA opposition to Medicare was finally accommodated when the law allowed for the traditional fee-for-service payment model to continue.

This history is complex and not the subject of today’s article.

Nonetheless, it is very important to recognize how the foundations of medical practice, financing, and organization of healthcare delivery today has impacted physicians as articulated in the above quote from Dr. Haimes. So, the significance of the oldest and largest physicians’ organization to be in support of collective bargaining should not be underestimated. In fact, the trajectory for AMA support for unionization dates back to 1999.

At that time, concerned about the rapid growth and impact of HMOs on healthcare, the AMA created a union structure called Physicians for Responsible Negotiations (PRN). PRN had two purposes: to support employed physicians to achieve collective bargaining with their employer, and to support independent and group practice physicians to negotiate with insurance companies over rates of payment and related issues.

''It's a major step for an organization that had been slipping,'' said Dr. Barry Liebowitz, president of the National Doctors Alliance, a 15,000-member affiliate of the Service Employees International Union, and the Doctors Council, a union of 2,500 doctors based in New York that is the nation's oldest union of attending physicians. ''The endorsement of a doctors union by the A.M.A. gives an enormous psychological boost to the movement to unionize doctors.'' (emphasis added)

PRN was abandoned after five years. This happened because there was very little interest among private sector doctors to unionize, and most were not employees, but independent business owners. Additionally, anti-trust laws prohibited independent business owners to negotiate payment rates and other economic issues. Efforts to amend these laws and court decisions failed. PRN had no place to go, at that time.

We should pay attention to Dr. Barry Liebowitz’ prescient words from 1999: ''The endorsement of a doctors union by the A.M.A. gives an enormous psychological boost to the movement to unionize doctors.'' (emphasis added)

It is true that the AMA has lost significant membership, down from 600-700,000 in the post-World War II era to about 270,000 members today.

Today, about 75% of physicians are employees. And as employees working in larger and larger consolidated entities, for profit, and private equity ownership, they are realizing that they have little to no voice over what matters to them as doctors - the foundation of their practice: control over the patient-physician relationship.

It is also very significant that the AMA is organized as the national umbrella for state and local medical societies, made up of increasingly isolated and powerless employed rank-and-file physicians. If you read the body of the resolution on unionization passed at the AMA, it reads like a manifesto of urgency from the point of view of today’s employed doctors:

“Whereas, dominant hospitals, healthcare systems, and other corporate entities employing physicians may present limited alternatives to physicians working in a market largely controlled by their employer or where covenants-not-to-compete may further contribute to the employer’s bargaining advantage; and

Whereas, the transition from independent professional physician workforce to employed physician workforce fundamentally alters the dynamics between hospitals, health systems, corporate entities and physicians, with a risk of negatively affecting the conditions of care delivery and quality of care provided;

Whereas, the corporatization of medicine, including involvement of private equity in healthcare, raises questions about incentive alignment, costs, and downstream effects on patients; and

Whereas, recent years have seen an increase in physician burnout, which accelerated during which accelerated during the COVID-19 pandemic, directly related to time spent on electronic health record documentation, bureaucratic administrative tasks, and moral injury related to an incongruence between what physicians care about and what they are incentivized to do by the health care system; and

Whereas, physicians face a dominant power when negotiating with hospital employers and may not have countervailing influence without collective bargaining.”

I will continue to report on the work of the AMA as it carries out the organizational charge from the resolution: “that our American Medical Association convenes an updated study of opportunities for the AMA or physician associations to support physicians initiating a collective bargaining process, including but not limited to unionization”

In my work at the Scheinman Institute I have increasing engagement with individual physicians, professional associations, and unions all of whom are actively organizing or seeking information and ideas about organizing to confront the myriad issues that negatively impact their practice of the art of medicine.

The news of the resolution on collective bargaining from the AMA serves to highlight what is unprecedented action to increase the collective voice and power of one of the most powerful professions in the nation.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.