A New Direction at the NLRB, and Not a Moment Too Soon

BY CHRIS CIMINO, PRESIDENT AND CEO, CHESSBOARD CONSULTING, INC.

First, the good news! As the chart (below) indicates, healthcare union organizing — as measured by representation elections held by the National Labor Relations Board (NLRB) — declined by roughly 23% in the first half of 2025 (compared to the first six months of 2024).¹ The not-so-good news: unions still won an eye-popping 86% of all healthcare elections that took place in the first half of this calendar year.

The decline in healthcare union organizing follows a larger trend for all NLRB elections. The first six months of 2025 saw a total of 779 union representation elections involving both healthcare and non-healthcare private sector employers (unions won roughly 80%).¹ The January 1 through June 30, 2025, data represents a 27% decline in NLRB election activity over the same period in 2024. So, what’s going on?

A likely explanation for 2025’s decline in NLRB election activity

As much as unions enjoyed strong tailwinds in the form of regulatory support during the last administration, today, unions face regulatory headwinds:

• Budget cuts: It’s no secret that President Trump has a much different view of the NLRB than his predecessor. For example, in 2023 Biden fought for and won a $25 million increase in the NLRB’s budget; Trump has recently proposed a $14 million decrease in NLRB funding for 2026.^{2, 3}
• Lack of quorum leaves NLRB at standstill: More significant than funding issues, only days after taking office, Trump fired NLRB Board member Gwynne Wilcox-D which ultimately deprived the NLRB of its required three-member quorum. Without a quorum, the NLRB has been unable to function for most of 2025 (i.e., hear cases, issue decisions).
• New nominees and the confirmation process: In July, the Trump Administration nominated Scott Mayer-R (Chief Labor Counsel, Boeing) and James Murphy-R (former NLRB staff attorney) to fill two open NLRB seats.
  If these nominees are confirmed, the Board would have a three-to-one Republican majority, with David Prouty-D serving as the NLRB’s lone Democrat member. Gwynne Wilcox’s-D future at the Board continues to be the subject of ongoing litigation (as mentioned, Trump terminated Wilcox in January 2025 although her term wasn’t due to expire until August 2028).⁴

When new nominees are eventually confirmed by the Senate, the Board will work to resolve what could be a significant case backlog considering the NLRB "issued six published decisions since Trump’s inauguration, compared to 60 during the same six-month period in 2024."⁵

While the Trump Administration has recently taken steps to restore the Board’s normal operation, it is unclear when the current nominees may be confirmed. To further complicate matters, Marvin Kaplan-R is rumored to be stepping down at the end of August when his term expires. This means that if Mayer-R and Murphy-R are appointed to join Prouty-D as NLRB Board members, the new quorum likely "would encounter a longstanding Board tradition against altering precedent with less than three votes in the majority."⁶

All this means that while the new administration is taking steps to restore normal operations at the NLRB, the process may take time and employers could be stuck for the foreseeable future with Biden-era decisions that weigh heavily in favor of organized labor (e.g., Cemex, Starbucks, Amazon, etc.).

Physician union organizing and an assault on the NLRB’s Health Care Rule

At the end of May 2025, primary care physicians at Mass General Brigham Health System (MGB) in Boston, Massachusetts, voted in favor of union representation by the SEIU-Doctors Council. MGB’s 2,700 resident physicians, interns, and fellows had previously voted to join the Committee of Interns and Residents (CIR-SEIU) in 2023.

However, the situation with MGB’s primary care physicians is different from that involving MGB’s resident physicians. In the MGB primary care physician’s case, the NLRB’s Regional Director in Boston ordered an election involving a proposed bargaining unit that clearly violates the NLRB’s own Health Care Rule (originally established in 1989). Specifically, the Boston Regional Director ordered an election that, among other things, improperly: 1) carved out one group of physicians (i.e., primary care) while excluding all other employed physicians; and, 2) approved a single unit across three acute care hospitals (rather than treat each MGB acute-care hospital separately).^7,8

Understandably, unions seek larger units as a strategy to gain bargaining leverage over large healthcare employers. The MGB case is just one of several cases currently pending before the full NLRB in Washington, D.C. In these cases, unions have petitioned for large groups of employed physicians (or other providers) who work across both acute and non-acute settings spread out across large geographic areas and with job activities/functions that question a sufficient community of interest to comprise a single bargaining unit.

These pending cases are an important part of the aforementioned growing case backlog waiting for a newly reconstituted NLRB when nominees are finally confirmed and seated to fill Board vacancies.

Physician organizing continues to gain momentum

Preserving the integrity of the healthcare bargaining unit rule is important to achieving the right balance between respecting the collective bargaining rights of physicians (and other providers) while protecting the needs of patients.

Physicians are unionizing in greater numbers than ever before. In fact, a recent study published in the Journal of the American Medical Association (JAMA) found that between 2023-2024 physician unionization exploded higher.⁹ The JAMA study excluded union organizing involving housestaff (i.e., resident physicians, interns, and fellows) and focused exclusively on attending physicians. The results of the study (Unionization Efforts by Physicians Between 2000-2024) are stunning:

• 2000-2024: There were 77 petitions for election involving physicians during the 24-year period.
• 2000-2022: There were 44 petitions for election involving 3,541 physicians during the 22-year period.
• 2023-2024: In the two-year period encompassing 2023 and 2024, there were 33 petitions for election involving 3,523 physicians.

The findings indicate that — in just two years (2023 and 2024) — the same number of employed physicians attempted unionization as the number of employed physicians who attempted unionization throughout the 22-year period preceding 2023!¹⁰

The importance of the NLRB’s Health Care Rule and its vital role in protecting patients will become more evident as more attending physicians unionize and — inevitably — more health systems face the threat of a physician’s strike, as experienced recently by Providence Health & Services in Portland, Oregon (January 2025).¹¹ More recently, physicians at Allina Health in Minnesota are threatening to strike if their first-time contract demands are not met; Allina Primary Care physicians elected Doctor’s Council-SEIU in October 2023.Display footnote number:12

Without the NLRB’s Health Care Rule, patients are at risk
Currently, the NLRB’s Health Care Rule separates acute and non-acute settings for purposes of collective bargaining. And, in acute care hospital settings, the Board recognizes eight units as appropriate bargaining units for collective bargaining, one of which is all employed physicians.¹³

In other words, employed physicians working in a hospital have the right to organize and bargain collectively. Similarly, physicians and/or other providers who work in non-acute ambulatory clinics and who share common interests also have the right to organize and bargain with their employer.

However, let’s imagine a situation in which one union — like the SEIU — is allowed to organize a single large group of physicians working across a large geographic region that includes all of a health system’s hospitals and ambulatory clinics. What would happen to patients in the event of a system-wide physician/provider strike? The answer is obvious: patients would face significant reductions in access to care or simply have to fend for themselves for the strike’s duration.

Healthcare employers have limited options when confronted with a physician strike. While organizations can, and often do, hire temporary replacement staff during strikes involving nurses or other healthcare workers, replacing credentialed physicians on a short-term basis is difficult if not impossible. For this reason, we hope that once the NLRB is fully reconstituted, it will affirm the NLRB’s Health Care Rule and reject union organizing attempts that seek greater union bargaining leverage and put patients at risk.

Now is the time to focus on physician/provider engagement

Physicians have made clear the issues that are important to them. In fact, the recent JAMA study included a list of issues physicians cited as driving their interest in organizing; these included: dissatisfaction with working conditions, dissatisfaction with physicians’ autonomy and voice in management, and dissatisfaction with physicians’ voice as it relates to delivering quality patient care.¹⁴

As the NLRB works through its transition, healthcare leaders should re-double their efforts to foster stronger engagement among employed physicians and other providers. The first step is to address physicians’/providers’ concerns with the following strategies to build provider engagement:

1. Implement a communication program/practice that builds trust and credibility with physicians: The first step in improving physician engagement is for healthcare administrators to thoughtfully evaluate current communication processes and practices for directly engaging physicians across the enterprise. Don’t be afraid to ask physicians, "How can we do better?"
2. Ensure physicians have a meaningful voice in decision-making: Like shared governance structures that provide nurses with a meaningful voice in decision-making, employed physicians need to believe and experience that they have a meaningful voice in decisions that impact their clinical practice and workload.
   Ensure internal and external pay equity: Conducting regular market surveys and sharing results can be an essential step in building trust with physicians and demonstrating the organization’s willingness to be transparent when it comes to compensation and benefits. Beyond surveying the market, employers must ensure internal equity in compensation and benefits for physicians across the enterprise.
3. Demonstrate that work-life balance is an organizational priority: The culprits that undermine work-life balance are issues related to patient scheduling, patient volume, administrative tasks, and insufficient administrative support. While solutions to these issues have costs, these costs pale in comparison to the time, effort, and resources expended in response to physician unionization.
4. Provide labor education to physician leaders: It is imperative to ensure all leaders — especially those in physician leadership — understand how unionization and collective bargaining work. Physician leaders should not only understand the facts about how collective bargaining works, but they should also understand and be able to articulate what can go wrong in the process, including potential disruptions to patients’ ability to access healthcare services. Most of all, every leader in your organization — including physician leaders — should be able to articulate "the why" behind why a direct and collaborative work relationship is far preferable to the model of collective bargaining.
   Our professional providers need to know — and feel — that they are important partners in our health systems; partners who have a real voice in decisions that affect their professional practice and, by consequence, the lives and care of the patients they serve. Only then will they see value in building relationships with administrators instead of looking outside their organizations — and to organized labor — for solutions. ♦

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Author Bio

Chris Cimino is Chessboard Consulting’s Chief Executive Officer and directs all of Chessboard’s employee relations consulting services. Chris supports clients in their effort to increase employee engagement, achieve improved organizational performance, and respond to threats from organized labor. Few labor and employee relations consultants have the experience and knowledge Chris has amassed over more than 30 years, which is why professional associations frequently call on Chris as a content expert in the area of labor relations and employee engagement. As an ASHHRA partner since 2021, Chessboard has provided ASHHRA members with labor updates, research reports.

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References

1. 1. Bloomberg Law: NLRB Petitions and Elections Database
   2. Ibid
   3. Economic Policy Institute: The Biden Board, How President Biden’s NLRB appointees are restoring and supporting workers’ rights, Lynn Rhinehart, Celine McNicholas and Margaet Poydock, May 1, 2024
   4. Bloomberg Law: NLRB Plans to Cut Staffers, Save Money Without Mass Layoffs, Robert Iafolla and Parker Purifoy, May 30, 2025
   5. National Labor Relations Board, About NLRB, Gwynne A. Wilcox, https://www.nlrb.gov/bio/gwynne-a-wilcox
   6. Bloomberg Law: Trump Names NLRB Nominees, Paving Path to Functioning Quorum, Robert Iafolla, July 17, 2025
   7. Bloomberg Law: NLRB Facing Lost Year on New Precedents Despite Path to Quorum, Robert Iafolla, July 21, 2025
   8. Mass General Brigham and Doctors Council, SEIU Local 10MD, Employers Request for Review, Introduction
   9. Ibid
   10. JAMA: Unionization Efforts by Physicians Between 2002 and 2024, Richman, Bowling and Mapp, December 18, 2024
   11. Ibid
   12. McInally, Mike, Oregon Capital Chronicle, Providence says operations are smooth despite 5,000 striking at its hospitals, women’s clinics, January 10, 2025; https://oregoncapitalchronicle.com/2025/01/10/gov-kotek-criticizes-providence-over-the-largest-strike-of-health-care-workers-in-state-history/
   13. Doctors Council-SEIU, Keller, Josh, Allina Providers Vote to Authorize ULP Strike if Needed with 90% Support, June 30, 2025, https://www.doctorscouncil.org/news/allina-providers-vote-to-authorize-ulp-strike-if-needed-with-90-support
   14. NLRB Updated Rules and Regulations, Subpart C- Appropriate Bargaining Units, Section 103.30.
   15. Ibid