The effects of the mandates on staffing will likely be especially severe in rural areas, where the covid death rate is twice that of urban centers. “We need to move away from this debate about whether mandates are good or bad,” Alan Morgan, the C.E.O. of the National Rural Health Association, an organization that counts more than ninety per cent of rural hospitals and clinics among its members, told me. “All rural health-care workers need to be vaccinated now, period. But we also know that, whatever we do, some will choose not to get vaccinated. There are going to be care disruptions in rural settings. That’s not a hypothetical—it’s an inevitability.” In a rural hospital, Morgan said, “even two- or five-per-cent staff loss has a major, major impact.” Morgan thinks that leaders need to incorporate predictable staffing problems into their mandate planning. He would like to see money released from the federal Provider Relief Fund to help hospitals hire travelling nurses, and he thinks that fema and the Public Health Service Commissioned Corps should deploy teams to rural hospitals. Mandates, in his view, must come with mobilizations. So far, rural hospitals are on their own.

In nursing homes, the staffing challenges created by hard mandates are even more profound. “Nursing homes have very different staff compared to hospitals,” David Grabowski, a leading nursing-home researcher at Harvard, told me. “In hospitals, it’s mostly physicians and nurses, with relatively few care aides. In nursing homes, that’s completely flipped. The vast majority of the staff are certified nurse aides. They have the lowest vaccination rates.”

For decades, nursing homes have struggled to recruit and keep staff, because of low pay, paltry benefits, and hazardous working conditions. Since the start of the pandemic, the nursing-home sector has lost nearly four hundred thousand workers. Grabowski believes that vaccine requirements could make the situation worse. “People often say, ‘Hey, just mandate the vaccine. If they don’t want to work there, we’ll find somebody else,’ ” he said. “If it were that simple, we wouldn’t have this problem in the first place.” He went on, “Doctors don’t change professions, but nursing aides can move out of health care altogether. That presents a major workforce challenge. Aides do really hard work. They’re underpaid, they’re undervalued. And they can make just as much money at the restaurant down the street.” Grabowski’s research has found that annual staff-turnover rates at many nursing homes already exceed one hundred per cent. Staffing shortages in nursing homes are likely to exacerbate problems in hospitals: if a hospital can’t discharge patients, it can’t admit new ones. Parrinello, of Strong Memorial, told me that her hospital is currently housing three times as many patients awaiting spots in nursing homes as it was this summer.