Close to 5,000 Providence nurses and about 150 doctors, midwives and advanced practice providers went on strike indefinitely starting Friday morning.

The strike includes nurses at all eight of Providence’s hospitals in Oregon.

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With the strike looming, Oregon Gov. Tina Kotek urged Providence to reconsider its decision to withdraw from all bargaining with its nurses last week.

“Over the last two weeks, I have continued to communicate with the Providence CEO and Oregon Nurses Association leadership,” Kotek told OPB in a statement. “I have urged both parties to stay at the bargaining table – that means all hospital staff, not just physicians. Every hospital worker deserves a fair contract.”

Here’s everything you need to understand about the strike, the state’s largest by health care workers to date.

How long will the strike last?

The Oregon Nurses Association has called the strike “indefinitely.” Providence has hired temporary nurses for two weeks. The strike could end sooner if the two sides reach an agreement.

What’s this all about?

A lot.

Providence says it has offered nurses a 20% raise over the next three years — before overtime, holiday pay or incentives.

Some of the most contentious issues in bargaining relate to working conditions in hospitals. The striking doctors, for example, have asked Providence to commit to capping hospital admissions when the number of patients surges above what doctors can reasonably handle. Providence said it offered to establish a committee to work on that issue.

The nurses, meanwhile, are sparring with Providence over whose interpretation of state law, which outlines nurse-to-patient ratios, will be written into their contract.

The unions are also seeking guarantees for their members in the event that Providence sells or spins off its practices or hospitals.

Nurses are also pushing for additional paid time off and lower out-of-pocket costs for their health plan.

And there’s also disagreement over how to account for the time taken to negotiate the new contracts — over a year, in many cases. Nurses want pay raises to be retroactive. Providence is instead offering a lump-sum signing bonus of up to $5,000.

Contract alignment is also an issue. Providence is pushing for three-year contracts in some cases, while the union wants two-year contracts. According to bargaining records posted by ONA online, the union is trying to align contracts across hospitals, a move that would increase its bargaining power, while Providence wants to limit this alignment for what seems to be similar reasons.

Providence Willamette Falls Medical Center, in Oregon City, Ore., Aug. 2, 2023. Nurses at this hospital, and seven others, are set to walkout at 6 a.m. Friday. Kristyna Wentz-Graff / OPB

Why did mediation break down?

Nurses union representatives say Providence wasn’t being responsive to their proposals, and offered very little until the union asked for federal mediators to step in. They also say Providence was, in effect, vetoing any proposals related to sick leave and health insurance.

Providence, meanwhile, has accused the union of a long-term plan to orchestrate the strike, pointing to messaging from the union over the last year. Providence says it was making progress in mediation on some of the hardest issues, like the staffing concerns raised by doctors, before the nurses union issued the strike notice.

How will the strike impact patient care?

Providence says it has hired temporary nurses at all eight affected hospitals.

The union says Providence patients shouldn’t hesitate to cross the line during the strike if they need to.

“If you need care, please get care,” said ONA’s executive director, Ann Tan Piazza.

But nurses say they are concerned about the quality of care during their absence.

“The idea of providers going on strike is pandemonium,” said Christina Malango, a nurse at the Providence Women’s Clinic who has been bargaining for the union. “It’s such a vital, sacred area of care.”

Providence says the greatest impact will be at St. Vincent Medical Center and six Providence Women’s clinics in the Portland metro area, locations where some doctors and other advanced practice providers are striking alongside nurses. Providence says it has hired some, but not enough, replacements for the striking doctors.

At St. Vincent, up to 70 unionized hospitalists are striking. They are physicians and nurse practitioners who supervise care for a majority of the patients in the hospital. The strike does not include emergency room doctors or surgeons.

Providence has said St. Vincent will need to reduce its patient count by 10-20% during the strike. Some planned surgeries have been postponed “and we anticipate longer delays in our emergency department” as well as more ambulances being diverted to other hospitals, said Raymond Moreno, M.D., chief medical officer at St. Vincent.

Providence has also been rescheduling appointments at its women’s clinics.

But records show Providence may be publicly playing up concerns about the impact of the strike. In a press release sent Jan. 6, Providence said it had alerted state leaders that the strike put health care access at “significant risk.”

But there’s no written record of Providence officials expressing any specific concerns about community health during the strike to the Oregon Health Authority.

OPB received, through a public records request, all written communications between Providence and state health officials concerning the strike.

Providence’s leadership in Medford emailed state health officials Jan. 3, noting they had hired temporary nurses and predicting little disruption to patient care. Then, on Jan. 6, the executive director of state government affairs for Providence, Kristen Downey, forwarded OHA’s chief of staff the same press release that went out to news agencies. Those are the only written communications sent between Dec. 30, 2024 and Jan. 7, 2025.

Nurse Heather Medema, at ONA headquarters Dec. 30, 2024. Medema says poor health benefits are one issue that’s led nurses to strike. “A lot of people think that if you work in healthcare you’re going to have great health insurance,” she said. “That’s rarely been the case for me.” Amelia Templeton / OPB

Has Providence broken any labor laws?

Providence executives have — during this strike and previous strikes — said they will withdraw from bargaining with the union as soon as they receive a 10-day strike notice. Providence says this is because their nursing and medical executives who participate in bargaining need the full 10 days to hire and onboard temporary workers.

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The nurses union contends that this is an unfair labor practice, essentially an effort to intimidate workers out of striking, and has filed a charge with the National Labor Relations Board.

Labor law experts say it depends on whether Providence is telling the truth about needing the time to prepare.

“It’s bad faith to say on principle, we refuse to bargain if there’s a 10-day strike notice,” said Gordon Lafer, a professor and co-director of the University of Oregon’s Labor Education & Research Center.

Lafer says a 10-day strike notice is not meant to signal that a strike is inevitable — merely that it is possible.

“There’s no legal provision to say ‘we’re not going to bargain,‘” he said.

However, private employers can withdraw from bargaining if they have a legitimate business reason to do so — for example: needing all hands on deck to prepare for the holiday rush. If Providence has truly been unable to return to the table to bargain with its nurses due to bandwidth, then withdrawing from bargaining is a legitimate choice.

“The more it shades over into: ‘our response to employees saying ‘we’re preparing to strike’ is us saying therefore we refuse to bargain with you as an intimidation tactic’ — that’s bad faith,” Lafer said, and potentially retaliation.

Two days before the strike, Providence continued to say it was unable to return to the bargaining table with its nurses.

“Our bargaining team members are in the process of orienting and onboarding 2,000 temporary replacement workers to ensure continued patient care during the strike. We look forward to returning to the bargaining tables once patient care is stabilized,” a spokesman said.

Have the unions broken any labor laws?

It’s unclear. This week, Providence asked to resume bargaining with two units: Hospitalists at St. Vincent, and the physicians and nurses at the Providence women’s clinics.

Nurses at those clinics met with Providence this week, but didn’t reach an agreement to avoid the strike. Providence and that unit are continuing to share proposals over email.

The hospitalists did not meet with them, and in a letter invited Providence to return to bargaining with “all 5,000 providers.” That could potentially raise a legal issue.

Lafer said the hospitalists can’t condition bargaining on Providence bringing the nurses back to the table.

“That’s not allowed,” Lafer said, but noted that it’s not clear that’s what happened.

The hospitalists union said that it never stopped bargaining with Providence, as issuing a strike notice is not withdrawing from bargaining. The union said it is still negotiating, but is waiting for Providence to provide it with new proposals responsive to its demands.

Two days before the strike, Providence said it had sent over new proposals.

“ONA acknowledged receipt of our proposals for the hospitalists, and we are waiting to hear whether/when they will return to the bargaining table,” a spokesman said.

Striking nurses will lose wages. What about health care benefits?

In a statement to OPB, Providence indicated it does not expect the strike to last long enough to put caregivers at risk of discontinuation of their health insurance.

“We’ve shared with our caregivers who choose to strike that health insurance benefits will continue initially. We look forward to resuming bargaining at all tables as soon as we are able. We are confident that we will be able to reach agreements. We don’t expect continuation of benefits to be an issue,” Providence said.

Can nurses who walk out Friday return to work before the strike is over?

Maybe. Providence declined to state its position on this question. Legally, striking workers’ rights hinge on how the National Labor Relations Board classifies the strike in question.

Workers participating in a legal strike over unfair labor practices have the greatest rights, including the right to be reinstated before a strike is over, as long as they make an unconditional offer to return. That means a worker is agreeing not to walk out again as part of the same strike, over the same unfair practices.

It’s a one-time deal, and the right doesn’t extend to workers participating in economic strikes, or workers who engage in intimidation or illegal behavior during the strike.

According to Lafer, there are other relevant limits to the right to be reinstated. Providence could potentially invoke an exception, for operational need, to deny allowing a worker to return during the two-week period when a fill-in has been hired. But, Lafer said, this is a very tricky area of the law, and the labor relations board would likely view a blanket policy excluding all striking workers from returning before the two weeks is up as unlawful coercion or intimidation.

The nurses union has filed several unfair labor practice allegations against Providence.

Is there any potential for outside intervention?

Federal mediators can intervene if certain groups or bargaining units decline to participate, but only in rare cases where a work stoppage threatens substantial disruptions to commerce or public health.

“Additionally, the President has authority under the Taft-Hartley Act to intervene, or a Board of Inquiry can be established,” said Greg Raelson, director of public affairs for the Federal Mediation and Conciliation Service. “Though such actions are exceedingly rare.”

Lafer concurred that any outside intervention in the strike is unlikely, and there isn’t a precedent for the president intervening in a health care strike.

What economic factors are at play in the strike?

Providence, like many hospital systems, holds a multibillion-dollar investment portfolio. But it’s been losing money on its core business in Oregon: providing health care.

Between 2022 and 2024, Providence’s Oregon hospitals have operated at a loss for eight out of 10 quarters.

The organization expects another annualized loss for Providence Oregon for 2024. Through Q3, it is showing an operating loss of more than $100 million. That’s the backdrop to Providence’s reluctance to make more concessions.

The union, meanwhile, is deeply concerned about one of the strategies Providence is pursuing to get back in the black — an initiative the organization refers to as “deconstruct and diversify healthcare” in its public financial statements.

So far, it has involved spinning off parts of Providence’s operations, either through outright sales or through partnerships.

Providence sold its lab business in 2023 and will privatize its home health and hospice services this year, in a private-equity-backed deal under review by Oregon regulators. The union believes Providence has plans to split off additional service lines, potentially affecting the working conditions at stake in the negotiations.

Correction: The original version of this story misstated the number of clinics involved in the strike. Staff at six women’s clinics are participating in the walkout. OPB regrets the error.

Oregon’s Health Care Market Oversight (HCMO) program is reviewing a proposal to spin off Providence’s home health and hospice services into a joint venture supported by private equity.

Sarah Bartlemann, the cost programs manager for Oregon’s Health Authority (OHA), confirmed the review in a letter to a Washington D.C. attorney representing Compassus, Providence’s partner in the deal.

OHA’s HCMO program evaluates health care business transactions to ensure they do not negatively impact citizens or communities. The program also empowers state regulators to impose conditions on acquisitions and mergers or reject deals they find anti-competitive.

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Critics of the deal argue that the joint venture will result in cost-cutting measures, increased staff workloads and reduced patient services.

Providence is the fifth largest nonprofit health care provider in the United States, while Compassus is a private equity-backed provider of home-based care services operating in more than 30 states.

The two companies initially planned to complete the deal by Dec. 29, according to licensing records. However, the state’s review will likely delay this timeline, as the HCMO requires a minimum of 30 days and can take up to 180 days to finalize its review.

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On Dec. 10, Thomas Doyle, general counsel for the Oregon Nurses Association, a labor union, wrote to the director of OHA. In his letter, he requested the authority to intervene in the merger and acquisition process. He urged OHA to “prevent any further changes in the ownership, license or administration over Providence health care entities, including home health and hospice agency licensures, while OHA reviews whether the proposed joint venture must go through the HCMO process.”

OHA is currently accepting public comments regarding the deal on its website. Nearly all of the submitted comments are opposed to the transaction.

One comment from Paul Goldberg, a retired director of the Oregon Nurses Association, expressed concern about Providence’s motivation for pursuing the deal.

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“I am concerned that Providence is trying to structure a joint venture that avoids its obligations as a non-profit, tax-exempt hospital,” Goldberg wrote. “It should be required to ensure that its assets transferred to a for-profit entity are utilized for the public good. After all, many of its assets have accumulated over time due to its non-taxed status.”

In another comment, Kirsten Halson, an occupational therapist employed at Providence, expressed her concern that Compassus may cut programs that are seen as unprofitable, which would harm patients and caregivers.

“For-profit home health and hospice agencies often employ fewer registered nurses, social workers and full-time clinicians compared to non-profit agencies. This leads to each staff member seeing more patients, which limits the amount of time each visit can take. Such practices negatively impact the quality of care that patients report experiencing,” Halson wrote. “Since Compassus is a for-profit, private-equity-owned entity that aims to generate capital for its shareholders, I am very concerned about the sustainability of a career in health care and the constraints on my ability to provide the care that my patients need.”

Another comment raises concerns about the future of home care in Oregon’s rural communities.

“I am deeply concerned that the proposed joint venture will have a disproportionate impact on rural communities,” Elizabeth Marshall wrote. “Providence Home Health & Hospice serves many underserved areas. Rural regions already face significant challenges in accessing health care services. For-profit home health agencies, which prioritize profit over patient care, often scale back services in these areas, where travel can be costly and time-consuming. As a result, many rural patients may find themselves without access to home health and hospice care, leading to higher rates of hospitalization and poorer health outcomes.”

In October, Providence announced that it signed an agreement to form a joint venture with Compassus, focusing on management operations in Alaska, California, Oregon and Washington. This partnership encompasses a range of services, including home health care, hospice care, community-based palliative care and home care services.

Providence at Home with Compassus will be the name of the new venture. Providence’s Covenant Health hospice program will be rebranded in Lubbock, Texas as Covenant Health at Home with Compassus.

“We respect the regulatory processes in all the communities we seek to enter, and the state of Oregon has a clear process for review of proposed health care transactions,” a Compassus spokesperson said in an email to Home Health Care News. “In November, Compassus notified the OHA, to seek guidance on its review process for this transaction. From the outset, we understood regulatory reviews could add time to our anticipated transition timeline. We are prepared and committed to ensuring any questions or concerns are addressed. Ensuring the well-being of patients and their families, as well as the smooth transition of Providence caregivers to our team, are our top priorities.”

Since the launch of the HCMO program in 2022, the state has reviewed or begun reviewing 43 health care transactions. While regulators have not blocked any of these transactions, they have imposed conditions on some of the deals.

The state of Oregon will take a closer look at the deal, which is likely to delay the timeline for it to be completed if it receives approval.

The proposed joint venture between Providence and home health provider Compassus is now under scrutiny in Oregon.

The Oregon Health Authority notified attorneys representing Compassus in a letter that the transaction requires review by the Health Care Market Oversight (HCMO) program, potentially putting the deal in jeopardy and likely delaying its completion if it passes.

Under the HCMO program, state regulators can approve or deny mergers and acquisitions if they are considered anti-competitive or detrimental to Oregon’s health outcomes.

The Oregon Nurses Association called on the Oregon Health Authority to review the transaction in a letter earlier this month. Thomas Doyle, general counsel for the Oregon Nurses Association, highlighted that the joint venture could reduce essential services, such as pediatric home health.

“There is a compelling case that the proposed transaction requires HCMO approval and that Providence is seeking to sidestep that approval process or to create a sense of urgency by filing at the last minute for approval,” Doyle wrote.

As part of the proposed deal, which was announced in October, the joint venture would be called Providence at Home with Compassus and provide home health, hospice, community-based palliative care, and private duty caregiving. Compassus would mange operations for 24 home health locations in Alaska, California, Oregon, and Washington, and 17 hospice and palliative care locations in Alaska, California, Oregon, Texas, and Washington.

Providence and Compassus were aiming to close the transaction by the end of the year, according to licensing records obtained by the Oregon Nurses Association and published on the HCMO website. The HCMO review, however, could take anywhere from 30 to 180 days.

Providence spokesman Gary Walker told Oregon Public Broadcasting that the health system had filed the necessary paperwork.

“We fully intend to work closely with OHA and comply with all requirements in the review process,” Walker said.

A spokesperson from Compassus said the organization had reached out to the Oregon Health Authority in November to seek guidance on its review process for the deal.

“From the outset, we understood regulatory reviews could add time to our anticipated transition timeline. We are prepared and committed to ensuring any questions or concerns are addressed. Ensuring the well-being of patients and their families, as well as the smooth transition of Providence caregivers to our team, are our top priorities,” the spokesperson stated.

Editor’s note: This story has been updated on Dec. 20 to include comment from Compassus.

A deal that would spin off Providence’s home health and hospice services into a joint venture backed by private equity is being reviewed by state officials under Oregon’s mergers and acquisitions law.

An official with the Oregon Health Authority confirmed that the transaction requires review by the Health Care Market Oversight (HCMO) program in a letter to a Washington D.C. attorney representing Compassus, Providence’s partner in the deal.

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Providence St. Vincent Medical Center, in Portland, Ore., Aug. 2, 2023. Kristyna Wentz-Graff / OPB

The program gives state regulators the power to impose conditions on mergers and acquisitions. They can also decline to approve deals they determine are anti-competitive, or that are harmful to consumers or health outcomes for the state.

Providence is the 5th largest nonprofit health care provider in the country. Compassus is a private equity-backed provider of home-care services in more than 30 states.

The state review of the deal is a win for opponents, including the Oregon Nurses’ Association and some staff and patients of Providence’s current program, who argue the joint venture will lead to cost-cutting, higher workloads for staff, and service cuts for patients.

Providence and Compassus had originally intended to close the deal before the end of the year, according to licensing records obtained by the Oregon Nurses’ Association and posted on the HCMO website.

The state’s review will likely disrupt that timeline. HCMO requires at least 30 days and up to 180 days to complete its review.

Earlier this month, the general counsel for the nurses’ union Thomas Doyle wrote to state regulators to complain that Providence had yet to submit a required notice of the joint venture to the HCMO program, even though Providence had started an internal reorganization and written in a Nov. 8 letter to licensing officials that the deal would close Dec. 29.

“There is a compelling case that the proposed transaction requires HCMO approval and that

Providence is seeking to sidestep that approval process or to create a sense of urgency by filing at the last minute for approval,” Doyle wrote.

Providence spokesman Gary Walker said the nonprofit had filed the required paperwork. According to state regulators, attorneys representing Compasses requested an evaluation of whether the transaction required review on Nov. 21.

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“We fully intend to work closely with OHA and comply with all requirements in the review process,” Walker said.

Officials in the oversight program are posting public comments received on the proposed joint venture online.

The dozens of comments submitted to date all oppose the transaction. Many of them are written by employees of Providence’s home health and hospice teams.

In one such comment, Nurse Gina Nelson wrote that she works with older adults and children who need home care in rural communities, as part of the Providence Benedictine Home Health team, based in Mt. Angel.

She voiced concerns that the joint venture will lay off staff, particularly experienced nurses like herself who command higher wages, and will limit the time home care workers can spend with their patients.

“Say no to this,” wrote Nelson. “Oregon is unique, we care for our people and big money needs to stay out of healthcare.”

Responding to the public comments to date, Walker said Compassus shares Providence’s values and commitment to patients.

“While it is accurate that Compassus is partially supported by private equity funding, it’s important to note that it is primarily owned by other faith-based health systems and has developed similar joint ventures with Ascension Health and Bon Secours Mercy Health, to name a few,” Walker wrote.

The licensing records Providence has filed show that Compassus has a complex ownership structure. Its two largest stakeholders are St. Louis-based Ascension Health Alliance and investors in a private equity fund, Towerbrook V.

In a 2018 press release , Towerbrook Capital Partners, the firm managing the fund, said investors in Towerbrook V include “public pension funds, sovereign wealth funds, financial institutions, endowments and family offices across the US, Europe and Asia.”

Providence announced in October it planned to hand over management of its home health and hospice operations to Compassus, while retaining a 50% stake in the new joint venture, called Providence at Home with Compassus.

The deal includes locations in Oregon, Washington, California, Alaska, and Texas.

In the two years since the HCMO program launched, the state has reviewed or started reviewing 43 health care transactions. Regulators have yet to attempt to block any of them, though they have imposed conditions on some deals. A controversial proposed merger between Medicare provider Care Oregon and California SCAN group was voluntarily withdrawn following public opposition last year.