Throughout the COVID-19 pandemic, short-staffed rural hospitals have been stretched to their limits.
Some have cut back, delayed or eliminated services such as elective surgeries, labor and delivery, and other inpatient care. Nurses and other health care employees have worked double shifts, and many rural hospitals have had to create makeshift intensive care units.
In the broadest sense, President Joe Biden’s vaccine requirement for the more than 17 million U.S. health care workers will alleviate the strain on all health centers and clinics by boosting the country’s overall vaccination rate—and by reducing the number of health care workers who are forced to take sick leave because they contract COVID-19. Big-city hospitals have brushed aside some workers’ protests and lawsuits, implementing vaccine mandates without a significant effect on staffing or patient care. About 41% of U.S. hospitals already have a vaccine mandate, according to the American Hospital Association.
But the story may be more complicated in rural America, where resistance to the vaccine remains strongest. Some rural hospital leaders worry the vaccine mandate will exacerbate a labor shortage that was profound even before the pandemic. There are predictions that some hospitals will have to close their doors.
“I've talked with administrators of hospitals that have estimated anywhere from 3% to as much as 20% of their workforce may have to quit their jobs if they're required to have the vaccine as a condition of their employment,” said Brock Slabach, chief operations officer for the National Rural Health Association, a nonprofit that represents rural hospitals and clinics as well as doctors, nurses and administrators.
“In a rural hospital, that could be two, maybe three nurses,” Slabach said, “which could cripple their ability to meet the demands of patient care.”
As of early October, nearly 43% of the rural population was fully vaccinated, compared with 53% of the U.S. population, according to an analysis of federal Centers for Disease Control and Prevention data by the Daily Yonder.
To get more jabs in arms, the Biden administration announced last month that it will require COVID-19 vaccinations for workers in most health care settings that receive Medicare or Medicaid reimbursement, including hospitals, dialysis facilities, ambulatory surgical settings and home health agencies. The federal Centers for Medicare and Medicaid Services hasn’t yet announced a deadline for workers to meet the requirement.
Even before the federal requirement, at least 22 states plus the District of Columbia announced that state health care workers—or, in some cases, all health care workers—would need to be vaccinated or regularly tested, according to the nonprofit National Academy for State Health Policy.
But six states—Arkansas, Georgia, Indiana, Montana, Tennessee and Texas—have approved laws or have executive orders from their governors prohibiting vaccine mandates as a condition for employment.
Hospital leaders say the conflicting guidance makes it difficult to know how they should proceed, though experts assert that federal law will supersede any conflicting state law or executive order.
In Texas, for example, Republican Gov. Greg Abbott’s Oct. 11 executive order imposed fines on employers that mandate vaccinations for employees.
Jerry Jasper, the CEO of Brownfield Regional Medical Center in rural Terry County, Texas, said Abbott’s action puts hospitals such as his in a bind. On the one hand, forgoing a vaccination requirement might allow them to retain some vaccine-resistant health care workers. On the other hand, the federal government will deny federal funding to any hospitals that violate Biden’s vaccination order. Jasper currently has positions open for nurses and lab technicians, among others.
“It's kind of a scary part to be walking in, especially if you're a hospital, because President Biden's actually saying if you don't do the mandate, you're not going to get Medicare or Medicaid funding. Then, you got our governor saying the total opposite,” Jasper said.
“We have 75% of our staff vaccinated. ... I, myself, am vaccinated and believe in the vaccine, but I have employees that don't. So, what do you do?” he said. “If I had to get rid of 25% of my employees, say 40 to 50 employees, that's a huge number. It’ll be devastating.”
In some places, vaccine-related resignations and firings already are affecting patient care. For example, the Lewis County Health System in New York closed its maternity unit after staff resigned over the state's vaccine mandate.
Dr. Randy Tobler, CEO and director of women’s services at Scotland County Hospital in rural Memphis, Missouri, said his hospital will abide by Biden’s mandate, but some staff members have told him they will quit rather than get vaccinated.
“We realize it will further erode our ability to adequately provide acute care for COVID-19, motor vehicle accidents, heart attacks and other kinds of problems,” Tobler told Stateline. “While we actively encourage the staff to have a vaccine, we have to balance that against the risk of not being able to provide care to patients by not having enough staff in the hospital when patients present with acute illness.”
Tobler added that he’s talked to numerous staff members to educate them about vaccines and encourage them to get the shot. The key, he said, is showing respect and building trust.
“I've gotten a lot more people to decide to get vaccinated that way, as have most doctors … instead of being heavy handed,” Tobler said. “That's just the way rural communities are: Things are done on trust, not on denigration and insults.”
As the most recent COVID-19 surge subsides, some rural hospital leaders are less worried about the effect of the vaccine mandate.
In Washington state, Democratic Gov. Jay Inslee in August issued an executive order requiring the state’s health care workers to be vaccinated by Oct. 18. In a survey conducted by the Washington State Hospital Association shortly before the deadline, hospitals reported that 88% of staff already were vaccinated.
There was a slightly lower rate in rural areas, but not a huge gap, said Jacqueline Barton True, vice president of advocacy and rural health at the association.
“There were a lot of rural hospitals that said, ‘I'm going to close. I'm not going to be able to stay open,’” Barton True said. “[But] the number of folks who said they were concerned about service disruptions, even within a week's time, really shifted.
“On the other hand, if there's a large surge in COVID cases again, like we've seen about a month ago, that could create additional strain on the system that we may not be able to absorb.”
Barton True said her association is “cautiously optimistic” that the vaccine mandate won’t cause any of the state’s 45 rural hospitals to close.
But Slabach, of the National Rural Health Association, argues there should be alternatives to vaccine mandates, such as weekly testing. He worries mandates will push more people out of a profession that already is losing workers. Earlier this month, the federal Bureau of Labor Statistics reported that while overall employment rose by 194,000 in September, the health care sector lost 18,000 jobs.
Health care has lost 524,000 workers since last year, with nursing and residential care facilities accounting for more than half of the loss, according to the report.
Jasper, of the Brownfield Regional Medical Center in Texas, said he’s concerned about the future.
“It’s worrying about if you got enough staff to take care of the patient. It's worrying about how you're going to take care of the financial responsibility for the hospital and keep it open,” Jasper said.
“It’s just a big juggling act at this point. And it's hard to know what's the right direction and what's best.”