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Mortality Rates from Covid-19 Are Lower in Unionized Nursing Homes (healthaffairs.org)
162 points by ceejayoz 31 days ago | hide | past | favorite | 42 comments

Governor Cuomo of New York required nursing homes to take back all patients (covid positive or not) until mid-May. Did unionized nursing homes have comparable infection and re-admission rates?

"Just days later [mid-March] the governor pivoted: Cuomo announced that New York state nursing homes were required to readmit patients that had been sent to hospitals because they were infected with the coronavirus. Moreover, under the March 25 order, nursing homes weren’t allowed to test incoming patients for COVID-19."

Ref: https://www.realclearpolitics.com/articles/2020/09/10/nursin...

Just very generally speaking, a friend of mine works in a nursing home and is part of a nursing union. They work in PA where we had the same kinds of orders.

Generally their working conditions have been safer than I've read about in other homes and hospitals. They did not allow staff to interact with patients unmasked, as opposed to non-union work environments that required nurses to work unmasked or with insufficient PPE (often times forced to work with covid positive or suspected positive patients)

They established isolation units for covid suspected patients and provided proper PPE for those units (as opposed to other nursing homes that did not do this and allowed covid suspected cases to interact with other patients). Additionally the union worked independently to attempt to acquire PPE for their union members above what nursing homes/hospitals provided.

While that's only one example of a union environment my impression is that these things were not the norm during the start of the pandemic and existed primarily in union nursing environments.

All that said it wouldn't surprise me at all if the effect found in the study was caused by having a union.

This is way more interesting because (if true at scale) it's an example of a union working to protect their members in real, practical, day to day ways.

> union working to protect their members in real, practical, day to day ways.

Unions are normally really good at this.

One of the standard responses to managers asking for something stupid in a steel mill was "Get the book". "The book" defined the procedures, equipment, and training required for most tasks. This is fairly normal for most union shops.

It's a lot easier to tell a manager to pound sand when he asks you to do something stupid when you know the union will back you up.

I don't know about US unions but work safety is the bread and butter of unions in Australia.

Collective wage and benefit bargaining tends to be the main focus of many unions. I'd say in the instance of this particular Nurses Union the union also advocated well and often for the safety of their nurses. So yes they do ensure worker safety but I don't think it's thought of as much as collective bargaining.

But remember collective bargaining isn't just how much per hour you earn, it's also how many hours in a day you work, how many days a week you work.

It's also when you can retire, whether you get a pension.

In addition but very importantly how much effort does your employer need to put into keeping its employees safe.

These were work conditions that were first collectively bargained for before unions then lobbied governments to enact them into law

I just did a quick search on US workplace safety ( I assumed you were US sorry if I guessed wrong).


Worker deaths have halved since workplace safety came into play in 1970, this wouldn't have been enacted if left up to companies as it is much cheaper to find an uninjured worker than it is to implement safe working conditions (I'm generalising obviously but I think it holds). It would have been heavy collective bargaining from unions that made this happen.

Also thank you for sharing the original story it was a really interesting anecdote.

I mean... I'm not sure why that would be surprising? That's been a thing since the dawn of unions; for early industrial unions it would have been one of the biggest concerns.

That last sentence is false reporting by RCP. The actual order reads as follows:


> NHs are prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.

They were not forbidden from testing them. They were forbidden from requiring one be done as a precondition to come back to the home.

These patients should've been assumed to be potentially infectious by their nursing homes, and placed in dedicated COVID wings with dedicated staff. Nursing homes should be able to practice basic infection control; after all, they have flu season to manage every year.

(The likely reason for this order: limited testing availability, and overwhelmed hospitals in NYC needing beds for the unstable patients, not convalescing nursing home folks.)

I wouldn't call the RCP piece "reporting", it is an op-ed where one of the authors works at a conservative think tank. Neither of the authors has written more than 2 pieces for RCP. And obviously as you point out, they are not faithfully representing the facts.

> They were not forbidden from testing them. They were forbidden from requiring one be done as a precondition to come back to the home.

How much difference does this make? Nursing homes are (or have been shown) not suitable for holding patients that should be in quarantine, and not letting them deny sick people has cost many others their lives.

> Nursing homes should be able to practice basic infection control; after all, they have flu season to manage every year.

What is seems more important than what should be.

Also, applying science, logic, and epistemology at the layer where decisions are made that affect multiple downstream organizations (who may not have the in-house expertise to make optimum decisions) seems like a sub-optimal approach to me.

If nursing homes "should" be able to make such decisions competently, is it not fair to ask that those higher up the chain should be able to do the same? What is the best way to manage risk in scenarios such as this?

Noteworthy is the wide variability of reporting in the media about the degree to which Cuomo did a good job on covid.

As I noted, it's likely this order was issued because NYC hospitals were filling up, and testing was very limited.

On March 25, NY saw 5,146 new cases, and 12,209 tests. (https://covidtracking.com/data/state/new-york; click "full range) They didn't have the testing capacity to test stable nursing home patients before sending them home, and they didn't have enough hospital beds to let them sit around for weeks for that to change. Having them convalesce back at the nursing homes seems like a reasonable move given that.

March in NY was "which of these bad options kills the least people" time.

They had giant medical tents which were constructed and then ended up being quickly torn down. They had the USS comfort.

The predicted hospital overrun scenario never happened. One hospital in NY would be full to the brim, but a nearby hospital would be at 50% capacity. It was a shuffling problem at best.

No, what happened here was the hysteria got so severe that irrational decisions were made to try to mitigate a problem that didn’t truly exist.

> They had giant medical tents which were constructed and then ended up being quickly torn down.

Staffing was a problem. Tents don't magically make doctors and nurses arrive. Travel nurses were being offered $10k/week to come. https://nurse.org/articles/new-york-travel-nurse-jobs-covid1...

> They had the USS comfort.


"On top of its strict rules preventing people infected with the virus from coming on board, the Navy is also refusing to treat a host of other conditions. Guidelines disseminated to hospitals included a list of 49 medical conditions that would exclude a patient from admittance to the ship."

"Ambulances cannot take patients directly to the Comfort; they must first deliver patients to a city hospital for a lengthy evaluation — including a test for the virus — and then pick them up again for transport to the ship."

That's in early April. They later changed tack on those restrictions, but as of the order, those restrictions were still in place.


“The ship is fitted out for battlefield injuries — it was not designed for dealing with a highly infectious and highly transmissible outbreak.”

The USS Theodore Roosevelt later demonstrated just how bad the tight quarters of a ship can be for infection control.

> The predicted hospital overrun scenario never happened.

On March 25th, knowing that would've required time travel. The peak was still weeks away, and it was reasonable to worry about it; Italy hit that point in areas.

And I think when people were talking about hospitals being full, they were referring to ICUs. The rest of the hospital was essentially empty as every elective procedures had been cancelled, the mayo clinic was even furloughing workers.

> March in NY was "which of these bad options kills the least people" time.

They seem to have calculated wrong. But via the magic of the media to bend people's perception of reality, have been reputationally rewarded for it.

These decisions and their portrayal in the media is what passes for expertise in medicine, science, politics, journalism, and authority in 2020, and people seem to genuinely wonder why we have so many conspiracy theorists.

> They seem to have calculated wrong. But via the magic of the media to bend people's perception of reality, have been reputationally rewarded for it.

The magic of media, or the relatively favorable comparison to the federal response at the time, which was largely "lalala can't hear you"?

Folks are more inclined to accept "we tried stuff, and some of it wound up being unnecessary in hindsight" than denial.

I'm referring to Cuomo's decision on sending covid infected people into nursing homes, and the apparently counter-intuitive public opinion of his performance. However...

> the federal response at the time, which was largely "lalala can't hear you"?

...is actually a good example of how how media coverage can shape even intelligent people's perception of reality - Trump's response was indeed characterized as resembling "lalala can't hear you", which you'd think would immediately fail the sniff test truth filter of any reasonable person...but perhaps the human mind doesn't work quite how we think it does.


Feb 26: "And again, when you have 15 people, and the 15 within a couple of days is going to be down to close to zero, that's a pretty good job we've done."

Mar 6: "Anybody that wants a test can get a test. ... The tests are all perfect, like the letter was perfect, the transcription was perfect, right?"

Mar 13: "We have 40 people right now. Forty. Compare that with other countries that have many, many times that amount. And one of the reasons we have 40 and others have — and, again, that number is going up, just so you understand. And a number of cases, which are very small, relatively speaking — it's going up. But we've done a great job because we acted quickly. We acted early. And there's nothing we could have done that was better than closing our borders to highly infected areas."

Mar 24: "I think Easter Sunday — you'll have packed churches all over our country."

Mar 24: "We begin to see the light at the end of the tunnel."

What about these quotes imply "we're taking this seriously"? He's still mocking folks for wearing masks and is holding public rallies where people aren't wearing masks or distancing to this day.

This is an interesting detour from the topic.

It's this sort of thing that I think believe deserves more study in case it lies at the root of several of the important issues facing humanity.

I'll leave it at that lest I get warned for "starting" a flamewar.

Is there a reason to expect union membership would change the decisions of patients? Data can be wrong always, but I don't understand the confounding effect you're imagining. Generally chasing correlations like that leads to more noise, not less.

Correlations can happen by chance or via a common cause. If it's not a randomized controlled trial then you need to be wary of any correlations that might distort the data.

Not imaging, asking:

- Were unionized nursing homes covered by the same orders?

- Did they have separate/additional staff/patient safeguards that allowed for testing and/or redirecting patients elsewhere?

- Did staff have quarantine/isolation policies as part of their contracts?

- Did they send patients out to hospitals at the same rate? Did they accept them back at the same rate?

If the mere existence of a union contract was key, that's beyond odd. I'd love to understand: WHAT about being unionized helped them?

The study states:

> Although labor unions may influence COVID-19 mortality rates in numerous ways, we hypothesized that two important mechanisms were successful demands for PPE and reduced COVID-19 infection rates. By increasing access to PPE, labor unions may reduce the spread of COVID-19 between health care workers and nursing home residents, thus reducing COVID-19 mortality rates for residents.


> Specifically, unions were associated with a 13.8% relative increase in access to N95 masks and a 7.3% relative increase in access to eye shields.

Wasn’t one of the problems that some workers were working shifts at multiple homes to make ends meet? I would be surprised if unionized workers did that as often.

This is mentioned in the study.

Sort of interesting. The effect size is just 1.2 percentage points, though the baseline rate was something like 4%. So not night and day, but not negligible. The metric is a little weird though. Excludes deaths from patients who were discharged to the hospital first. Also, I was under the impression that once COVID got in a nursing home, it tended to spread like wildfire. I wonder how sparse the data is on a nursing home by nursing home basis.

Nursing home staff seem like a good role for unionization whatever your take is on this.

I'm not really surprised by this. The pay and the work environment are shockingly poor in nursing homes.

A nursing home in Washington state that made national news in March coerced workers whose Covid tests had yet to come back to return to work in the home. All the while flying in corporate big wigs who have never stepped foot in the state to explain to the local media how sensitively and seriously they were handling the problem.

Very important caveat:

"First, even with the inclusion of a rich set of covariates and sensitivity analyses, the observational study design precludes causal interpretations."

I wonder about the confounders of Politics. In today’s America, the political party that opposes unions is also dismissive of Covid with such subgroups as “anti-maskers.” Could be correlated.

Also possible that states with better medical care tend to have more unions, as they tend to be richer blue states. No causal link to suggest that unionizing a nursing home will reduce mortality.

It is easier for unions to argue for safe working conditions than it is for individuals who work in non-union shops. Here is BC, where for the most part the government has done a decent job in trying to product us, it is the BC Teachers Union that is fighting for consistent safety protocols for schools. See for example: https://www.theglobeandmail.com/canada/british-columbia/arti...

If there was no teachers union, everything would depend on individual school administrations.

So there may not be an obvious causal link, but what has become clear is that good safety protocols reduce the rate of spread, and that implementing good protocols requires ongoing effort. I have no doubt that, in this situation, being unionized is better than not.

These were all in one state (NY).

One cause was presented: more PPE (presumably demanded by union).

Why turn everything political? Especially when it seems you didn't even read it. Just using the title as a jumping off point to put in political points.

The study, if you read it is mostly based on NY data. It specifically states as much in the limitations:

> this study may not be generalizable outside of the State of New York.

I personally think the study should have published the raw data as well as the aggregate data.

But the study seems to be quite open about it's limitations, listing one particularly limitation which to me is the greatest one if you want to critique the study:

> We are therefore unable to adjust for the possibility that unionized health care workers may transfer residents to hospitals earlier and thereby reduce their facility’s COVID-19 mortality rate.

Unions by definition and function are necessarily political, that doesn’t necessarily mean though it is itself necessarily a problem.

Something having political implications does not inherently make it political. The timing of solar eclipses have had important political implications, that doesn’t mean their political in nature.

Aka, Union vs Non Union means different practices in aggregate and studying the results of those differences is valuable real world data.

Of course most things have a political element.

That doesn't mean they are political.

The study is about New York. The comment is trying to make this a 'red state vs blue state' thing. There's no reasonable basis for such thinking if you actually read the study.

I wouldn’t draw any conclusions from this study. It is a study limited to NY state for one (strong government-union political relationships), and the authors themselves mention that the various limitations (like confounding variables) preclude causal interpretations of the correlation they observed.

Some relevant quotes:

> Even with these adjustments, the available data and observational research strategy preclude strong causal interpretations due to bias from unmeasured confounders and selection into our study sample.

> While our study design precludes causal interpretations, our results suggest that unions may have reduced COVID-19 deaths among nursing home residents by successfully demanding PPE for health care workers.

The study also claims it adjusts for some of the following variables but in the analyses it wasn’t clear exactly how they adjusted for it:

> Unionized facilities were also more likely to be for-profit, less likely to be associated with a chain, had lower LPN-to-resident ratios, and were located in more populous counties with higher per capita rates of confirmed COVID-19 cases (supplemental exhibit 1).

The higher levels of PPE access, which the study thinks may be a trait of unionized facilities, could be due to many factors such as random luck, facility size, political connections, etc. I wonder how causally predictive those would end up being in studies that dive deeper into those variables.

I don’t think that easy to dismiss findings.

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