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  • Updated

"Vaccine hesitancy among rural health facilities remains rampant even as providers faced a major surge of Covid-19 due to the more transmissible delta variant, a new study finds," Robert King reports for Fierce Healthcare. The study, released last week by the Chartis Group, "also found that nurse staffing shortages are contributing to suspensions in care in vulnerable communities." About 30 percent of respondents said the nursing shortage had caused their facility to suspend medical services, primarily surgeries, and another 22% said they were considering such a move.

Over 98% of the facilities surveyed reported staff shortages, mostly nurses. Burnout, retirement, and going for a better-paying job at another hospital are the main causes of the shortages, not mandates; in fact, about 75% of respondents said their facility doesn't have a mandate, King reports. The lack of mandates may have contributed to lower vaccination rates, the study noted.

However, vaccination rates are rising: "Chartis spoke with rural hospitals across the country from Sept. 21 to Oct. 15 and found that 44% of respondents said 50% to 69% of professionals in their facility were fully vaccinated," King reports. "That is an improvement on an earlier survey conducted in March and April of this year, where 37% of respondents said 50% to 69% of professionals were vaccinated."

The vaccination numbers will have to ramp up if the federal government's mandate takes effect. The rule would require all staffers to be vaccinated by Jan. 4 or risk losing federal reimbursement for Medicare and Medicaid patients. But 10 states have challenged the mandate in court, so its future is uncertain.

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A rural Connecticut woman's recent ordeal highlights a recent study noting that rural women, especially in communities of color, often have more difficulty accessing hospital childbirth services.

Shantell Jones lives in Windham, a town of 25,000, 41 percent Latino. She lives six blocks from a hospital, but when she went into early labor the ambulance had to drive to another one 30 minutes away because Windham Hospital shuttered its labor and delivery services last year, Jean Lee reports for NBC News. Ten minutes into the drive, Jones gave birth in the ambulance as it parked by the side of the highway, and though she and her son are healthy, others are not so lucky sometimes. 

Pregnant women without easy access to a hospital with obstetric services could be at an increased risk of giving birth prematurely, giving birth in an emergency room, or outside of a hospital entirely, public-health experts say. Thousands of other pregnant rural women are facing that risk as hospitals reduce or close obstetric services to cut costs. "Nationwide, 53 rural counties lost obstetrics care from 2014 through 2018, according to a 2020 study in the Journal of the American Medical Association." It also found that 1.045 of the out of 1,976 rural counties "never had hospitals with obstetrics services to begin with."

Communities of color and those with high poverty rates are especially at risk. Not only are they more likely to lose or never have local obstetric services, but they're more likely to have transportation issues or lack insurance that would cover a pricey ambulance ride to a hospital further away, Lee reports. Local ambulance services might not be able to respond as readily because they're stretched thin too.

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A chief walks through his fire station in Ringgold, Va.
(Photo by Caleb Ayers, Danville Register & Bee)

Rural fire departments

have struggled

to get adequate funding, volunteers, employees and equipment, but the pandemic has made the situation worse."Rural firefighters have been on the front lines of the pandemic, tackling wildfires and vehicle accidents even as they transport ill and injured residents to hospitals," Aallyah Wright


for Stateline. "Covid-19’s heavy toll on rural hospitals has extended to emergency responders, meaning firefighters are answering more medical calls than ever before. The increased workload, and the specter of vaccine mandates, has made recruitment even tougher."

The pandemic has traumatized rural firefighters and other health-care providers. "The mass death and suffering of the past 20 months has spawned a surge of post-traumatic stress disorder, anxiety, depression, insomnia and substance use disorder among health care professionals of all kinds," Wright reports. "Answering calls at the homes of relatives, friends and neighbors—which many rural firefighters have had to do—magnifies the pain."

That's on top of difficulties rural fire departments already face, such as poor roads and communications infrastructure, increasingly frequent and more powerful wildfires, and state laws that can require volunteer EMTs to transfer patients to paramedics for more advanced treatment—without compensation.

That's a lot to ask a volunteer to endure, even those who feel called to serve their communities as fire fighters. "Of more than 1.1 million firefighters nationwide, 67% are volunteers who are not paid or receive a minimal amount to cover gas and other expenses, according to a 2021 fact sheet by the National Volunteer Fire Council," Wright reports. "Many of them are in rural America: Nearly 40% of communities with between 5,000 and 9,999 residents had all-volunteer departments as of 2018, according to a tally released last year by the National Fire Protection Association. In communities with between 2,500 and 4,999 people, the percentage of all-volunteer departments was 72%, and 92% in towns of less than 2,500."

Younger people are far less likely to volunteer at fire departments, several firefighters told Wright. Bob Timko, of the National Volunteer Fire Council's recruitment and retention committee, told her that volunteer departments need to work harder to recruit, possibly by partnering with local businesses: "[Young people] aren’t coming in the door ... I would challenge leadership to develop a program or use resources to educate people on what we do."

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On Jan. 1, the Biden administration will finally implement new rules that limit so-called surprise bills from out-of-network medical providers —

including air ambulances

— needed in an emergency.

"Passed as part of the omnibus legislation to fund the federal government in 2021, as well as provide Covid-19 pandemic relief funds, the No Surprises Act’s new rules and requirements would protect consumers from out-of-network bills and balance billing," Liz Carey


for The Daily Yonder. "Currently, when an insurance plan doesn’t cover out-of-network care, the insurer may deny a patient’s bill entirely, or only pay a portion of the bill. When this happens, it leaves the patient liable for the balance of the bill – the difference between the undiscounted fee charged by the provider and the amount reimbursed to the provider by the insurance plan. Balance billing can leave patients on the hook for hundreds, if not thousands of dollars."

But "under the new rules, in emergencies, out-of-network providers would only be allowed to bill what in-network providers would bill, and they would be prohibited from billing the patient for whatever insurance doesn’t cover," Carey reports. "The Centers for Medicare & Medicaid Services estimated the median cost for air ambulance transportation at between $36,000 and $40,000. While air ambulance providers are not allowed to send surprise bills to Medicaid or Medicare patients, patients with private insurance often find that their air ambulance trips are out-of-network, leaving them with surprise bills in the tens of thousands of dollars."

The 2021 law

does not apply to ground ambulances, which have the highest out-of-network billing rates of any medical specialty, according to The New York Times.

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The pandemic has thrown into sharp relief a long-standing problem: The country doesn't have enough registered nurses, especially in rural areas.

For example, a recent Southern Illinois University Medicine report found that rural Illinois is short as many as 19,100 nurses, Jakob Emerson reports for WICD in Springfield. The reasons cited in the report likely apply in other rural areas: Nurses go for better-paying urban jobs, especially since they likely have large student loans to pay off; medical education is concentrated in urban areas; and rural nurses tend to be older and aren't replaced as quickly as they're retiring. And some rural RNs are being lured away by lucrative traveling nurse jobs.

"Pre-pandemic reports from the

Bureau of Labor Statistics

show there were more than three million nurses in the nation in 2019, and an estimated 176,000 annual openings for registered nurses across the country," Morgan Matzen


for the Sioux Falls Argus Leader. A

data analysis

found that nursing shortages in many states are expected to get even worse by 2030.

Another reason for the overall shortage: Nursing schools don't have enough instructors to train more, Yuki Noguchi reports for NPR. The pandemic has worsened this shortage, too: Nursing educators need advanced degrees but typically earn half what they would as a nurse working on the floor. The pandemic increased financial strains for many nursing instructors, forcing them to quit and find more lucrative work. In 2019, colleges and universities turned away some 80,000 qualified applicants because they were short of faculty or other resources.

Colleges in South Dakota and other states, are trying to address the problem by offering more classes, Matzen reports. Community colleges, especially in rural areas, can play a vital role in boosting nursing associate's degree programs, but community-college nursing programs are notoriously competitive, Devon Haynie reports for U.S. News & World Report. Look here to see if your local community college offers an associate degree in nursing.

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The Rural Health Research Gateway will host a webinar at 1 p.m. Tuesday, Nov. 9 to discuss the critical role of family physicians in rural America, how they're trained, their rural distribution, and differences in scope of practice in rural vs. urban family doctors. The webinar will last about an hour. It's free, but registration is required. Click here for more information about the webinar and to register.

Lars Peterson and Davis Patterson will present the webinar. Peterson is a family physician and health services researcher, vice president of research of the American Board of Family Medicine, an associate professor of Family and Community Medicine at the University of Kentucky and a faculty member at its Rural & Underserved Health Research Center. His major research focuses on how continuing education can improve quality of care. 

Patterson is a sociologist and research associate professor of family medicine at the University of Washington. He is also director of the WWAMI Rural Health Research Center and the Collaborative for Rural Primary Care Research, Education, and Practice. He is also an investigator in the UW Center for Health Workforce Studies. His research focuses on improving rural areas' health-care access and examining trends in rural workforce supply.

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"At a time when the surgeon general says misinformation has become an urgent threat to public health, an investigation by The Associated Press found a vocal and influential group of chiropractors has been capitalizing on the pandemic by sowing fear and mistrust of vaccines," The AP reports. "They have touted their supplements as alternatives to vaccines, written doctor’s notes to allow patients to get out of mask and immunization mandates, donated large sums of money to anti-vaccine organizations and sold anti-vaccine ads on Facebook and Instagram, the AP discovered."

In many rural communities a chiropractor is one of the few specialists, and they may appeal to people who are wary of traditional doctors. It should be noted that many of the nation's 70,000 chiropractors endorse vaccination, but "the pandemic gave a new platform to a faction of chiropractors who had been stirring up anti-vaccine misinformation long before Covid-19 arrived," The AP reports. Since 2019, "chiropractors and chiropractor-backed groups have worked to influence vaccine-related legislation and policy in at least 24 states."

It's unclear how many chiropractors are anti-vaccine, but a recent survey pegs it around 20%. And though there are no nationwide numbers on vaccination rates among chiropractors, Oregon tracks vaccination rates among all health-care providers. As of September 5, only 58% of chiropractors in the state were vaccinated, compared to 92% of medical doctors and 75% of the general public, AP reports.

Anti-vaccine chiropractors commonly say their care can help patients weather viral infection or even keep them from being infected, and at least one allegedly said the pricey supplements he sold would do the trick. "Public-health advocates are alarmed by the number of chiropractors who have hitched themselves to the anti-vaccine movement and used their public prominence and sheen of medical expertise to undermine the nation's response to a Covid-19 pandemic that has killed more than 700,000 Americans," AP reports.

"People trust them. They trust their authority, but they also feel like they’re a nice alternative to traditional medicine," Erica DeWald of Vaccinate Your Family, which tracks figures in the anti-vaccine movement, told AP. "Mainstream medicine will refer people out to a chiropractor not knowing that they could be exposed to misinformation. You go because your back hurts, and then suddenly you don’t want to vaccinate your kids."

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Here's a roundup of recent news stories about the pandemic and vaccination efforts:

Major health insurers are billions of dollars behind on reimbursements, particularly hurting rural hospitals and doctors when they can afford it least. Read more here.

Vaccines are linked to preventing more than a quarter of a million coronavirus cases and 39,000 deaths among American seniors, according to a new Department of Health and Human Services report.

Hospitals overwhelmed with Covid-19 patients have had to delay treatments and surgeries for people with other conditions such as cancer or heart disease. Many of those patients say they don't feel optimistic about being able to access treatment in time. Also, the glut of Covid patients means rural hospitals are having a much harder time transferring critical patients to larger hospitals. A Florida woman had to call 169 hospitals to find one to provide the intensive, last-ditch Covid-19 treatment her husband needed to live. Telehealth can help rural intensive care units care for critical patients instead of having to transfer them, though, as one rural Alabama hospital has found.

Sen. Lindsey Graham was booed over the weekend when he encouraged a crowd of Republicans in Summerville, S.C., to get the coronavirus vaccine. Read more here.

An appeals court has ruled that New York health-care workers must temporarily be allowed to claim a religious exemption from the coronavirus vaccine while the three-judge panel considers whether the mandate as a whole is legal. Read more here.

Eastern Kentucky has some of the highest infection rates in the country, but its hospitals—like those in many other rural areas—face a severe employment shortage. So to sweeten the pot for potential workers, insurer Anthem Blue Cross and Blue Shield has launched an endowment-funded scholarship program at two Eastern Kentucky colleges. In return for the scholarship, nursing students must work in rural communities for at least three years after graduation. Read more here.

For employers that mandate vaccines, it can be difficult to judge whether an exemption request is based on "sincerely held" religious beliefs. Read more here.

Few who spread misinformation have faced real consequences (though Alex Jones was found responsible for damages related to his false claims on the Sandy Hook shooting), but an Oregon doctor has had his medical license revoked after he falsely said mask-wearing could trigger carbon dioxide poisoning. The rise of an Ohio attorney who spread misinformation shows how vaccine misinformation can be a lucrative path to right-wing celebrity.

A psychologist offers tips for helping children cope with pandemic anxiety. Read more here.

A Colorado-based health system says it will almost always deny organ transplants to patients who haven't been vaccinated against the coronavirus, because those patients will have suppressed immune systems and will be much more likely to die if they get Covid-19. Read more here.

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New York Times map; click the image to enlarge it.

Here's a roundup of recent news about the pandemic and immunization efforts:

Covid-19 hospitalizations are hitting crisis levels in the South, making it more difficult to maintain care or even find beds for the sickest patients. One in four hospitals now has more than 95% of its intensive-care beds occupied, up from one in five last month. In June, when cases were at their lowest level, fewer than one in 10 hospitals had dangerously high occupancy rates. Read more here.

One in 500 Americans have died from Covid-19. See how different states, ages, and ethnicities compare. Read more here.

A truck driver from rural Tennessee, now on last-resort life-support for Covid-19, urges others who are hesitant about getting vaccinated: "Before you say no, seek a second opinion." He says a daily diet of conservative talk radio that downplayed the pandemic and emphasized personal freedom helped convince him not to get vaccinated. But, he says, people should also consider personal responsibility, and how they don't want to infect loved ones. Read more here.

Bob Enyart, a conservative radio host who bashed the coronavirus vaccine, has died from Covid-19. He also had successfully sued the state of Colorado over mask mandates and capacity limits in churches last year. "Enyart is at least the fifth conservative radio talk-show host to have died of Covid-19 in the last six weeks after speaking out against vaccinations and masking," Timothy Bella reports for The Washington Post. "The Denver host’s comments are another example of talk radio being an often overlooked space for coronavirus misinformation. In the weeks and months leading up to their deaths, all five men had publicly shared their opposition to science-based health efforts when coronavirus infections were spiking." Read more here.

Related: "Politically motivated denial of Covid-19 vaccine effectiveness tracks with a dramatic politicization of trust in science itself," Wake Forest University philosophy professor Adrian Bardon writes for The Conversation. "In a survey conducted in June and July, Gallup found that the percentage of Republicans expressing a 'great deal' or 'quite a lot of' trust in science is down, shockingly, from 72% in 1975 to only 45% today. Over the same period, confidence in science among Democrats is up from 67% to 79%." Read more here.

A recent Harris poll found that one-third of vaccinated Americans surveyed reported cutting ties in some way with friends or family who remain unvaccinated. Only 12% of Republican respondents said they had done so, compared to 28% of Democrats. And 59% of Republican respondents said they had not done so because vaccination is a personal choice, compared with 25% of Democrats. A communications scientist who studies the effects of media and health campaigns suggests more effective ways to persuade the unvaccinated.

A Tulsa pastor is offering to write religious exemptions for cash. In just two days, more than 30,000 people have downloaded the form from his church's website. Meanwhile, an expert says religious exemptions for the coronavirus vaccine could be on shaky legal ground. Read more here and here.

Hospitals nationwide are struggling to hire more nurses, especially in rural areas. A study found that state laws mandating nurse-to-patient staffing ratios helps significantly, but two other popular approaches (mandating public reporting of nurse staffing levels and including frontline nurses on hospital staffing committees) have little or no impact on nurse staffing levels. Read more here.

Rural residents should get their flu shots to avoid stressing the local health-care infrastructure even more than it already is, writes Betsy Huber, president of the National Grange, the nation's oldest agricultural and rural advocacy organization. Read more here.

The coronavirus vaccines have been linked to myocarditis, an inflammation of the heart muscle. But, a cardiovascular specialist says it's an extremely rare and often mild side effect associated with pretty much all vaccines, and that it's far more likely to happen when someone is infected with a virus of any kind (like influenza). Bottom line: unvaccinated people face a higher risk of myocarditis, as well as getting seriously ill or dying from Covid-19. Read more here.

Some have complained that wearing face masks and other personal protective equipment causes people to breathe in too much carbon dioxide and not enough oxygen. A newly published study found that, while PPE usage does increase your carbon dioxide intake, it's still well under federal safety limits. Read more here.

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Some rural health-care stakeholders worry that President Biden's vaccine mandate will exacerbate staffing shortages in rural hospitals and other health-care facilities.

Tillamook County, Oregon
(Wikipedia map)

They include David Yamamoto, a commissioner in Tillamook County, Oregon, pop. 27,688. In an op-ed for The Washington Post, he notes that vaccine resistance is high in Tillamook and other rural areas, and that many health-care workers would rather quit than get vaccinated.

On a recent conference call, the Oregon Health Authority urged county officials to simply hire more people if that happens, but didn't seem to understand how much harder it is to find trained personnel in rural areas, Yamamoto writes.

Alan Morgan, chief executive officer of the National Rural Health Association, echoes Yamamoto's concerns, Adrianna Rodriguez reports for USA Today. When a large number of workers quit, "in a large health system or urban provider, you have that workforce ability to adjust," Morgan told Rodriguez. "You don’t have that flexibility in a rural context."

Some health-care leaders hope the mandate won't spark a mass exodus, and note that vaccination rates among nursing home employees have increased three percentage points since the Aug. 18 announcement that nursing homes would need fully vaccinated staff to continue getting federal funding, Rodriguez reports.

  • Updated

"President Biden announced sweeping new coronavirus vaccine mandates Thursday designed to affect tens of millions of Americans, ordering all businesses with more than 100 employees to require their workers to be immunized or face weekly testing," The Washington Post


. "Biden also said that he would require most health-care facilities that accept Medicare or Medicaid funding to vaccinate their employees, which the White House believes will cover 50,000 locations." That includes outpatient facilities like dialysis clinics and home health agencies.

Biden will also require vaccinations—with no exceptions for regular testing among the unvaccinated—for employees of Head Start programs, Defense Department contractors, and federally operated Native American schools. "The White House estimates that the policy will affect about 80 million workers, or two-thirds of the country’s workforce. Businesses that ignore the mandate could face up to $14,000 per violation," the Post reports.

The new mandates will likely have a large impact in rural America, especially among large rural employers such as manufacturers, meatpackers, and Walmart, and hospitals. Rural health-care facilities are more likely to rely on Medicare and Medicaid for reimbursement, and many are already on the brink of bankruptcy. The new mandate will affect about one in three workers in Maine, the most rural state by population.

The announcement drew immediate criticism from many, including some Republican governors, The Associated Press reports. Wyoming Gov. Mark Gordon has asked his attorney general to fight the mandate when it is put into effect, and Missouri Gov. Mike Parson is considering a special legislative session to challenge the mandate. Biden called such governors "cavalier" with the health of children and of their communities for resisting the mandates.

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Health-care worker vaccination rate by residence typeCovid States Project graph; click on the image to enlarge it.

Rural health-care workers are less opposed to the coronavirus vaccine than they were a few months ago, but they're still less likely than their suburban and urban peers to be fully vaccinated, according to a new study from The Covid States Project.

Health-care workers across the board are more likely to be vaccinated than the general public, but rural workers are less likely than their suburban and urban peers. Only 63 percent of rural health-care workers are vaccinated, compared to 74% of suburban and 75% of urban health-care workers, the study found.

Vaccine resistance among rural health-care workers is at 25%, down from 32% in March. Health-care workers in all of the most vaccine-resistant demographics became more receptive to the vaccine between March and June, including rural, Republican, female, non-college-educated, White, Black, and those that make under $25,000 in a year.
Health-care worker vaccine preferences by rurality. Covid States Project graph; click the image to enlarge it.

But, though vaccine resistance has decreased in recent months, it's still a significant issue among health-care workers. "These numbers showing that healthcare workers are 27% unvaccinated and 15% vaccine resistant suggest that, absent mandates, most of the currently unvaccinated healthcare workers will remain unvaccinated, potentially fueling outbreaks in healthcare facilities," the researchers write. "Given the current surge of cases due to the Delta variant, this will continue to put pressure on health care providers to mandate vaccination for their staff."

The Covid States Project is a joint effort of Harvard, Northeastern, Northwestern, and Rutgers universities. It receives support from the National Science Foundation, the Knight Foundation, the Russell Sage Foundation, the Peter G. Peterson Foundation, and Amazon.

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Nursing homes will lose their federal Medicare and Medicaid funding unless all employees are fully vaccinated against the coronavirus, President Biden announced Wednesday. 

"The new mandate, in the form of a forthcoming regulation to be issued by the Centers for Medicare & Medicaid Services, could take effect as soon as next month," Zeke Miller reports for The Associated Press. "Hundreds of thousands of nursing-home workers are not vaccinated, according to federal data, despite those facilities bearing the brunt of the early Covid-19 outbreak and their workers being among the first in the country to be eligible for shots."

The new rule will likely have an outsized effect on nursing homes in rural areas, where overall vaccination rates are lower and where seniors are more likely to rely on Medicaid to pay for nursing home stays. "Nationally, about 60 percent of nursing home staff are vaccinated – much lower than the 82.4% of residents who have gotten the shots," Berkeley Lovelace Jr. reports for CNBC. "In some states, the percentage of nursing home staff who are vaccinated is even lower." Without Medicaid or Medicare reimbursement, many would not be able to afford a nursing home. The nationwide median annual cost of a private room in a nursing home was $102,200 in 2019.

Some nursing homes have been reluctant to mandate vaccinations, fearing it would cause employees to quit when there are already widespread staffing shortages.

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Self-employed people like farmers are finding health insurance very expensive to purchase and maintain. Sometimes it’s even hard to find adequate health care, let alone pay the bill, in rural America. It’s been this way for decades, but some farm organizations are working to change that.

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