Healthcare Insights: Collective Bargaining Success for Primary Care Doctors

Photo. Back row: Travis Lockwood, Robyn Gulley, (union staff),  Brenda Hilbrich (chief union negotiator), Chriss Filetti, Kelly McTeague, Sara Davis, (union staff) Chris Antolak, Matt Hoffman, Michelle Thorsness Front row: Britta Kasmerick, Dain Meyer, Kristen Medhenie, Katherine Oyster

The primary care providers in the above photograph represent a rare breakthrough in the history of U.S. labor relations and collective bargaining. These are private sector attending physicians, members of the bargaining team that successfully negotiated and ratified their first collective bargaining agreement at Allina Health, one of the largest health systems in the Twin Cities of Minnesota and Wisconsin. 

“I feel like we have our voices back,” said Dr. Nick VanOsdel, pediatrician at the Allina Hastings Clinic. He added: 

“I think it goes for all healthcare providers, but physicians in particular are losing their agency, influence and natural place as leaders in medicine with the advent and spread of a corporate medicine structure and the ever-increasing influences of for‐profit behavior. 

In my opinion, these changes have some of the biggest negative influences on physician burnout rates and retention. We have seen this for decades and thus far have yet to find a solution. We are seeing an ever-worsening physician shortage in the United States; higher burnout rates, earlier retirements, job turnover, etc. 

In short, we have been voting with our feet for years, but it doesn't seem to be making a difference. Meanwhile, things on the frontlines of medicine continue to rapidly deteriorate.  

Now that we have protection. We can speak out and stand up for ourselves and our patients without being reprimanded or disciplined, and our group certainly has shown that we won't be ignored.  

For me, this contract represents our new won ability to use our voices for change, to make progress in a time where we have been consistently losing ground, and to provide a bit more stability in uncertain times so that we as health care providers can regroup and make the future better for everyone.” 

Dr. VanOsdel and his 600 primary care colleagues achieved their first collective bargaining agreement on March 26, 2026. They voted in a National Labor Relations Board (NLRB) secret ballot vote in February 2023 to be represented by Doctors Council SEIU, the nation’s oldest and largest union of attending physicians. After more than two years at the bargaining table, informational picketing, a 1-day strike, and the threat of another strike, a settlement was reached and then ratified by a vote of the members by a 95% margin.

In this issue of Healthcare Insights, I want to share the specific achievements in the new contract.  Additionally, I want to place this accomplishment in the broader context of the unprecedented rising interest among physicians to achieve a collective voice.

First, what motivated the physicians and their Advanced Practice Professional colleagues (APPs)  Nurse Practitioners and Physicians Assistants to seek unionization?  

Here is a brief summary of the sentiments and concerns the providers had at the beginning of their union organizing efforts in 2022-2023:

Chronic understaffing was leading to burnout and compromising patient safety.

“In between patients, your doctor is dealing with prescription refills, phone calls and messages from patients, lab results,” said Dr. Cora Walsh, a family physician involved in the organizing campaign.

 “At an adequately staffed clinic, you have enough support to help take some of that workload,” Dr. Walsh added. “When staff levels fall, that work doesn’t go away.”

Dr. Walsh estimated that she and her colleagues often spend an hour or two each night handling “inbox load” and worried that the shortages were increasing backlogs and the risk of mistakes.

 “We feel like we’re not able to advocate for our patients,” said Dr. Matt Hoffman, another doctor involved in the organizing at Allina. Dr. Hoffman, referring to managers, added that “we’re not able to tell them what we need day to day.”

Doctors at Allina say that staffing was a concern before the pandemic, that Covid-19 pushed them to the brink and that staffing has never fully recovered to its pre-pandemic levels.

“We were promised that when we get through the acute phase of the pandemic, staffing would get better,” Dr. Walsh said. “But staffing never improved.”

Consolidation in the health care industry over the past two decades appears to underlie much of the frustration among doctors, many of whom now work for large health care systems.

Relatively low pay for clinical assistants and lab personnel appears to have contributed to the staffing issues, as these workers left for other fields in a tight job market. In some cases, doctors and other clinicians within the Allina system have quit or scaled back their hours, citing moral injury — a sense that they couldn’t perform their jobs in accordance with their values.

Now, after two years of intensive negotiations, here is a summary of the achievements in the first collective bargaining agreement:

• Schedules, changes to schedules, and templates are established by mutual agreement between the providers and the management. This is a very significant improvement, one sought as fundamental to progress by the providers.
• Formally established mentorship for all APPs.
• The establishment of a Labor-Management Committee, designed to resolve issues/barriers related to patient care. Labor Relations experts and practitioners know from many years of experience that such Committees when utilized in good faith and regularly go a long way to reducing conflict and promoting problem-solving mechanisms.
• Prohibition of Non-Compete Agreements. This is very significant in the event of a reduction in force enabling providers to freely seek employment that otherwise would have been prohibited in the local labor market
• A transparent and legally enforceable compensation plan. This is a major achievement from the past. For tens of thousands of doctors around the country who report that it has become quite common for compensation models to be unilaterally changed with no input from doctors, this protection at Allina will be a very important incentive for other doctors to consider unionization, in my view. 
• Compensation is impacted by required hours of work, which are also established by agreement in the new contract. 
• For the first time, all fringe benefits are guaranteed to continue for the life of the agreement
• Discipline only for just cause
• Protection of break time for lactation, and no reduction in compensation
• Strong safety and health protection regarding infectious disease and a thorough process for protection against violence in the workplace

“This union has given me hope,” said Kristen Medhanie, DNP, APRN, CNP. Forming a bond with colleagues to reach the same goal of sustaining primary care for years to come has been one of the most important aspects to me in reaching our first contract. It is a start, and definitely not the end, to provide protections for physicians, nurse practitioners, and physician assistants who care for patients daily. In an environment where healthcare has been molded to become a for-profit endeavor instead of focusing on patient, family, and community centered care first, we are redirecting the dialogue. We have to start by changing the way the system treats providers, so we can in turn better care for our neighbors.” 

Two additional facts are important to keep in mind about this collective bargaining experience:

First, Doctors Council SEIU which is based largely in New York City, contracted with SEIU Healthcare Minnesota, a large and established health care union, with many members who have union contracts with Allina to lead the bargaining and organizing for the contract. The lead negotiator for the union was Brenda Hilbrich, a top officer of the union there.  Her counterpart in bargaining was the labor relations lead for Allina Health. While the bargaining was very difficult on the issues, the members of the union and Doctors Council benefited from this alliance with the local union.

Second, late in the bargaining process, Sutter Health, based in Sacramento, CA acquired Allina Health. It remains to be seen how this integration of two large systems will evolve. The acquisition comes at a time of rapid consolidation of the industry. I have learned that Sutter seems to have no plan to interfere in the new union relationship with the doctors at Allina.

Some Context and Observations

The above graphic tells us that only 8% of physicians in the U.S. belong to unions. Most are in the public sector. Even with the rising interest among doctors in attaining a collective voice, growth in unionization has been very slow. Private sector doctors who belong to unions represent a tiny percentage within the large and sprawling industry which includes both non-profit and for-profit health systems. This is where most doctors work.

The experience of the recently unionized physicians and APPs at Allina Health is illustrative of both the hope and the challenges for doctors.

The concerns that doctors express as to the reason to form unions or in some fashion attain collective voice have largely to do with the pressures that come from understaffing, administrative burden, decision-making about care made far away from the point of care, and the dynamics of burnout that create personal and professional stress on the nation’s doctors. While the Allina doctors made some progress in these subjects in their contract, the root causes of these issues remain, especially among primary care doctors.  Reimbursement rates from both commercial and public insurance remain low for primary care doctors, and as a result their salaries remain far lower than other specialists. There is a huge primary care shortage in the nation:

According to the National Center for Health Workforce Analysis: 

In 2023, there were 340,319 primary care physicians (includes MDs and DOs and excludes residents) in the U.S. In 2024, there were an estimated 374,970 NPs and 29,433 PAs in primary care.

• There is a projected shortage of 70,610 full-time equivalent (FTE) primary care physicians by 2038, which will be particularly acute in nonmetro areas.

• A substantial and increasing amount of behavioral health and obstetrics and gynecology (OB-GYN) services are being provided by PCPs.

• Primary care physicians, NPs, and PAs earn less than counterparts in other specialties.

• Burnout has increased in many health care occupations, but especially among primary care physicians. Almost half of primary care physicians reported feeling burnout in 2023.

• Primary care physicians are using telehealth more than prior to 2020. Telehealth has helped improve management, health outcomes, and cost savings for chronic diseases.

• The demographics and geographic location of the U.S population are projected to change dramatically over the course of this century. The primary care workforce will have to change with it to continue to deliver high-quality care.”

The Allina primary care providers certainly won a voice to be able to discuss issues related to staffing in their clinics, and from their comments they feel that having attained that voice is the true victory. I wholeheartedly agree.

At the same time, the bargaining took a very long time (2 years). It was an acrimonious negotiation, and according to the chief negotiator with whom I spoke, every advance required a long, sometimes bitter tug-of-war to mitigate the employer’s hold on management rights to run the health system as they see fit. Issues such as staffing in particular, as well as system decision making about care delivery, tend to be very closely held rights by management.  

We know that healthcare is highly regulated, and reimbursement systems and workforce shortages which impacts patient access are severe. As a result, tight operational budgets must pay for rising labor costs, new technologies, and other investments in all manner of infrastructure. 

These day-to-day financial realities and contradictions lead to conflict in the workplace which remains as a core overall environment in collective bargaining.

In this case, while the entire primary care provider workforce became unionized, nearly all the rest of the doctors in the acute care hospitals, except for one, remain non-union. Allina operates 12 acute care hospitals with thousands of physicians not in the union. (One of the hospitals is unionized, also by Doctors Council. It is among the smallest, and they are still a long way from achieving their first contract). This imbalance in overall power also limits the extent of change that can be achieved, especially in a first union contract.

From my perspective, the contract victory is an important one.  

The unionized primary care providers have demonstrated to all observers that unionization, even when bargaining is limited to discreet issues, even when there is a power imbalance, and even when there are so few models to build on given the tiny number of unionized doctors across the nation, that the providers are enthusiastic about their achievement.  They are more aware of the barriers to success than anyone. Yet, they persevered.

The industry will take notice, as will thousands of doctors clamoring for a voice.

Doctors and their many professional societies will take notice of this contract victory. It is the largest of its kind in the private sector and will likely inspire many to experiment with new strategies to go beyond the limitations inherent in this effort.

This is an historic achievement, not because of the contract gains alone for the providers. Rather, a first positive step is always the most challenging and inspiring.

Finally, the Scheinman Institute on Conflict Resolution is more than ready and able to assist parties achieve broad and lasting solutions to the root causes of conflict as well as managing conflict for positive mutual gain.

It seems that interest in collective voice for doctors has entered a new stage.  

Must positive change and improvement take so long and be so difficult, or can a consensus be built in time that doctors and health systems have great mutual interest?

The experience of this first contract with Allina raises these questions in real time and in real ways. 

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.