[Excerpt] Despite extraordinary levels of spending and decades of reform efforts, the U.S. healthcare system continues to underperform on core indicators of access, quality, and equity. At the same time, many of the frontline jobs that power care delivery remain low paid, physically hazardous, and psychologically taxing. This report advances a central argument: patient care outcomes and workforce outcomes are inseparable, and durable healthcare transformation requires institutionalized worker voice, often delivered through unions.

This report synthesizes evidence on the role unions can play as agents of healthcare transformation. We (1) document the system’s performance for patients and workers; (2) map the U.S. healthcare labor-relations landscape and the strategic approaches unions use; (3) review U.S. and international evidence on union effects in healthcare; (4) analyze original data on unionization and employment outcomes for nurses and direct care workers (DCWs), including differences by race and ethnicity; and (5) translate these findings into actionable recommendations for funders, policymakers, unions, and healthcare leaders.