Adam Willmann was born in Goodall-Witcher hospital in Clifton, a small town in central Texas. Now he's its CEO, and he's worried his hospital may have to stop delivering babies.

That's because some of the experienced nurses in the Goodall-Witcher obstetrics department aren't vaccinated for COVID-19 and don't intend to be. But under a new federal mandate, hospitals will soon have to require their staff to be vaccinated.

"They are also near retirement age and a few of them have already voiced that, 'I will just retire,' " Willmann said. "And then a couple other nurses said, 'Well, I'll just go work for my husband's construction company.' "

Willmann's situation is not unique. Rural health providers across the country are sounding alarms about the new mandate that will start as soon as next month. The Biden administration wants every person working in a health care setting — from hospitals to nursing homes to dialysis centers — to be fully vaccinated for COVID-19.

But in rural areas where vaccination rates are low and hiring is already difficult, hospital directors are worried there could be staffing shortages that force them to turn patients away.

Willmann has been pushing hard to get all of his 250 employees to take one of the COVID-19 vaccines, but staff vaccination has topped out at around 70%. That's well above the rate in the surrounding community, but still not enough.

"We're kind of at that point where everybody that's willing to get it, got it," he said.

"We did not undertake this decision lightly"

That stagnation of vaccination rates in medical facilities all over the country is what drove the Biden administration to go for a mandate, said Chiquita Brooks-LaSure, the administrator of the Centers for Medicare and Medicaid Services.

"We did not undertake this decision lightly," Brooks-LaSure said in an interview with NPR.

The agency is expected to finalize details of the new requirement over the next month. It plans to withhold Medicare and Medicaid funding from facilities unless they follow the mandate.

Brooks-LaSure said she knows some hospitals and nursing homes, especially in rural areas, are worried the vaccine mandate will cause staffing shortages. But she said health care workers who aren't vaccinated and become sick or have to quarantine also cause staffing shortages.

The government is also concerned about safety. "It's very clear from the data that staff who remain unvaccinated are affecting both the patients who are coming in to the facilities as well as their colleagues," Brooks-LaSure said.

Brooks-LaSure said staffing issues may not end up being as severe as some fear. She pointed to the experience in Maine, where Gov. Janet Mills already put a state mandate in place for health care workers.

"Even though there was a lot of noise around what these mandates mean, the actual number of health care workers who quit was very limited," Brooks-LaSure said.

Mandates mean more vaccinations. But also, hate mail

In New Hampshire's rural Coös County, Tom Mee has been working through the issues of putting a mandate in place. He's the CEO of North Country Healthcare, which decided to require vaccines for people who work at its three hospitals after the Food and Drug Administration gave its full approval to the Pfizer vaccine.

Staff have 60 days to get the shot. "Our D-Day is Oct. 23, and one way or another, our workforce will be 100% compliant with the vaccine," Mee said.

Mee said the decision was the right thing to do to protect the health of patients and employees. But it has been difficult to implement. He has received hate mail. But the mandate is working: A month ago, 78% of staff were vaccinated, but now it's up to 90%.

But, he said, it's inevitable that the mandate will mean a handful of employees will quit or are forced to leave, gaps he expects to be able to fill by shifting staff around.

"It's a scene that you're going to see repeated throughout the United States," said Mee. "I've been in health care for 34 years, and I've never seen anything like this before."

Rural hospitals want help from Biden administration

In many regions, there's not a deep bench of qualified people to fill vacant health care jobs, especially during a pandemic, said Alan Morgan, CEO of the National Rural Health Association.

Morgan is urging the Biden administration to come up with a plan to help with expected staff shortages once the mandate goes into effect, similar to the federal strike teams sent in to communities struggling to handle surges of COVID-19 cases that overwhelm local medical resources.

Morgan suggested that teams could be drawn from the U.S. Public Health Service, the National Guard or the Federal Emergency Management Agency to help rural hospitals.

Rural hospitals and clinics may be able to hire temporary relief nurses to come to their communities and use federal funding to help offset the expense, Morgan said. But city hospitals typically offer more attractive pay. Morgan also worries about a gap between the time the mandates take effect and the time a new tranche of federal funding becomes available.

Morgan has been asking administration officials, hoping for some signal that contingency planning is underway and so far hasn't gotten a reassuring response.

He is concerned that even small numbers could create outsized problems for rural hospitals. "Even if it would impact only 2% to 5% of the hospital staff, that's going to create a service disruption," Morgan said.

"Are we going to have to transfer existing patients? Are we going to have to put a halt on incoming patients?"

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