At the nation’s largest academic medical centers, resident physicians have rekindled a long-standing debate over health care worker unionization. According to the Committee of Interns and Residents, the number of unionization wins increased from one in 2020 to two in 2021 to five in 2022. This year alone, residents have voted in favor of unionization in landslide elections at Penn Medicine in Philadelphia (88 percent), Mass General Brigham in Boston (75 percent), Montefiore Medical Center in New York (82 percent), and George Washington University Hospital in Washington, DC (94 percent).

As unionization efforts have spread, they have renewed debate over the role of resident labor in hospitals, the rights of trainee-workers, the ethics of health care worker strike actions, and the financial priorities of C-suite executives in the modern hospital.

One of the major points of contention is what effect unionization will have on the most important people in any hospital: the patients. In this debate, supporters and detractors alike have tried to draw lessons from other health care worker unions. Opponents of unionization, on the other hand, accuse nursing unions of seeking to impose inflexible mandates that frustrates efforts to provide care in unavoidably fluid circumstances.

Advocates of unionization point to unsafe conditions when hospital executives pursue their priorities without effective worker input, as well as the very real threats of termination that hospital employees face when they speak out about these conditions without the protection of a union. Pro-union voices also cite econometric analyses that demonstrate a causal link between nursing unionization and improved patient outcomes.

There is, however, a longer history that we can draw from to understand how unions can advocate for patients. Hospitals have often painted themselves in this debate as the protectors of patient care against self-seeking workers, but when the decisions of hospital executives cause patients harm, unions have been a crucial countervailing force. The example of the Service Employees International Union (SEIU) at Yale New Haven Hospital (YNHH) provides such a case study.

In May 2001, the New Haven Advocate, an independent weekly magazine, published a story titled “Predator on the Hill” written by Paul Bass. The story detailed the hospital’s practice of foreclosing on the homes of patients, some of whom worked low-paying jobs at the hospital, over unpaid debts. When asked for comment, hospital executive Marna Borgstrom claimed the hospital only sued patients with the ability to pay and blamed debtors for their lax spending habits: “I’m always amazed at what people pay for discretionary items.”

Bass’s work caught the attention of Grace Rollins, a researcher for a local chapter of the SEIU, which was in the midst of a campaign to organize food service workers at YNHH. Alongside community advocates, legal aid groups, and other labor organizations, Rollins compiled a report, Uncharitable Care, on YNHH’s collection practices.

Released in January 2003, the document recounted the experiences of New Haven residents, many employed by Yale, who had been sued for overdue hospital bills. Some were uninsured, and others had been billed in error. But YNHH collectors were relentless in their pursuit of debts that totaled in the tens (and sometimes, hundreds) of thousands of dollars, even though YNHH was a tax-exempt institution that in 2001 alone reported revenues $20 million in excess of expenses. This was thanks in large part to public subsidies intended for the care of the uninsured.

In the YNHH cases, as in most medical debt-related lawsuits, the most common initial post-judgment action was wage garnishment: the court ordered the debtors’ employer to deduct a portion of the debtors’ weekly take-home earnings. YNHH was also among the many hospitals nationwide that sought civil arrest warrants if patients failed to appear in court; Rollins found that the hospital had obtained at least sixty-five warrants over a three-year period. Thus, a patient unable to pay a medical debt could end up in jail.

The SEIU helped organize protests against YNHH’s collection practices. During the most heady moments of these public demonstrations, clergy called on the hospital’s executives to “repent.” The SEIU also put up a billboard on I-95 highway with a message to YNHH: “SHAME.” Students working at a Yale legal clinic filed lawsuits against the hospital, claiming that it “wrongfully took, obtained or withheld the property” of patients.

In response, YNHH’s spokeswoman complained the hospital was being targeted by the union and that “we are probably better than a lot of hospitals.” After the Wall Street Journal began publishing stories on the lawsuits, the hospital did pledge to reexamine its practices and to cancel some debts outright. The SEIU was unsatisfied, demanding that YNHH forswear aggressive collection tactics. Andrew Stern, the union’s president, accused the hospital of “acting like a predatory lender and not a caring institution.” Finally, in November 2003, hospital executives promised to stop seeking to foreclose on homes and said they were placing strict limits on other aggressive collection practices.

The stories by Bass, the subsequent research by Rollins, and the high-profile coverage in the Wall Street Journal spurred a broader reexamination of medical debt collection practices elsewhere. A spokesperson for the American Hospital Association said that “every hospital has looked at what they’re doing” and some “are asking some very tough questions.” Rep. James Greenwood, a Republican member of the US House from Pennsylvania, was angered when he read about hospital debt collection practices in the Wall Street Journal. He initiated a congressional investigation that culminated in testimony from chief executives from the largest hospital systems in the United States. At the 2004 hearing, these executives announced changes to their practices to make charity-care policies clearer and decrease litigation against patients.

This is but one example of the role of unions in protecting patients when hospitals renege on their social responsibilities to patients. More recently, National Nurses United helped lead a campaign to halt Johns Hopkins Hospitals’ lawsuits against low-income patients over unpaid debts. Early in the COVID-19 pandemic, as hospital executives warned their workers not to speak publicly about the lack of personal protective equipment (PPE) or testing or staffing in their facilities, unions proved an important source of unvarnished information as well as advocacy at the local, state, and federal levels.

These examples show the socially and politically necessary position that health care worker unions occupy.

When hospitals fail to fulfill their social obligations, it is in unions’ interests to advocate on behalf of patients — after all, some patients are also hospital employees and members of the union. Hospitals are immensely powerful institutions, and the choices of management have a tremendous impact on the financial and physical health of the most vulnerable members of their communities. The proven role of an organized, vocal workforce in advocating for a more equitable and just health care system should be part of the ongoing debate over unionization.