Nearly two years before COVID-19 was declared a national emergency in the United States, the federal government set out to add thousands of medical workers to its emergency reserve, calling it a critical need.
Those workers are supposed to serve as a backstop for the nation’s health care system and can help ensure hospitals are not overwhelmed in case of disasters like the pandemic.
Yet, by the time the pandemic hit and the government had set a hiring goal of 10,300, it had only half that many and even fewer to deploy during the tragic omicron surge that would stretch the capacity of hospitals across the country.
Amid inter-agency confusion and finger-pointing, the Trump administration had failed to hire enough federal medical workers during non-pandemic times to provide more than a meager backstop for struggling hospitals when the pandemic hit. Then, when President Joe Biden took office, his 200-page plan to combat COVID didn’t mention any efforts to expand their ranks.
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Even at full strength, the federal reserve of medical personnel was not designed to meet all of the nation’s emergency needs during a once-in-a-century pandemic, but the failure of two administrations to reach that hiring target had sweeping impacts when omicron hit. Omicron sidelined legions of medical professionals even as it swamped hospitals with patients, contributing to the loss of 44,000 staffed hospital beds nationwide – enough to treat the entire population of Huntsville, Texas.
Patients were turned away. Care was delayed. The death count soared.
And with a scarce pool of federal medical personnel, hospitals found themselves calling for help that simply wasn’t there. The shortage hampered the federal government’s ability to ensure more staff were spread to where they were most needed. And the vacuum helped trigger a staffing war that pitted hospitals and states against each other in a dog-eat-dog battle for limited health care personnel.
Faced with the crisis in early December, Biden declared help was on the way. The president announced he was sending out enough workers to help 60 hospitals. It was far from enough. At the time, more than 1,000 hospitals in 48 states reported critical staff shortages, a USA TODAY analysis of federal data shows.
Administration officials acknowledge that requests for federal help had to be prioritized and weighed against available resources. In some cases, states didn’t get as much help as they asked for, but they said every state that asked for help got something by the second week of March. In some cases, that included paramedics to help shift patients between hospitals.
The White House said the administration has made significant investments to bolster the health care workforce overall, including enticements to encourage recruiting and retention of health care workers. The federal government also provided funding to states to help them meet staffing needs, including by reimbursing the costs of activating National Guard troops and hiring temporary workers.
Dawn O’Connell, assistant secretary for preparedness and response at the U.S. Department of Health and Human Services, said federal medical teams throughout the pandemic have “served as an emergency lifeline to hospitals by providing temporary relief to staff, adding bed capacity, decreasing wait times, and improving outcomes for patients.”
Federal officials, however, would not say how many workers were available for deployment, how many were requested by the states or why expanding their ranks wasn’t included in Biden’s COVID plan when he took office or in his new plan released earlier this month.
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In an effort to assess the impact of the shortages, USA TODAY contacted nearly two dozen states and drew on members of the USA TODAY Network, including the Milwaukee Journal Sentinel and The Arizona Republic, and found evidence of lengthy delays in patient care as doctors struggled to place a growing number of patients in a shrinking number of beds.
In all, between Thanksgiving and Jan. 21 – the peak months of the omicron surge – just 1,127 federal workers were deployed to 22 states plus territories and tribal areas. In the next seven weeks as hospitalization rates dropped, 12 more states received workers for a total of 2,150.
Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said the amount of federal medical workers the government sent to America’s hospitals was miniscule compared to what’s needed.
“It’s not enough just to send out a limited number,” said Osterholm, a member of the Biden transition advisory group on COVID, calling it “almost a token-type approach.”
He said the need for a larger, more flexible pool of federal medical workers is crucial. “Now’s the time to realize we’ve got to have this,” he said.
Dr. Robert Kadlec, a key official who championed the push for more federal medical personnel, said “without a doubt” that hitting the hiring targets would have put the country in a better position when the pandemic hit.
Deployed correctly, the additional workers would have gone a long way toward eliminating the January bed shortage, at least temporarily, said the retired Air Force colonel and physician who was assistant HHS secretary of preparedness and response under Trump. “Could you do all 44,000? Maybe not. But again, there are other ways to flex and do this.”
Inadequacies in the nation’s vital safety net of federal medical personnel became painfully clear long ago, when the city of New Orleans reeled in the aftermath of Hurricane Katrina in 2005. Hundreds of residents died, including at the Louisiana Superdome, where federal medical workers sent to treat evacuees were badly managed and too few, a congressional investigation found.
Such federal medical workers are drawn from a patchwork of agencies and overseen by the Department of Health and Human Services. The U.S. Public Health Service Commissioned Corps enlists medical professionals who already work for federal agencies such as the Centers for Disease Control and Prevention, or the Food and Drug Administration. The Corps is a uniformed service branch like the Army whose members can be ordered to deploy. The National Disaster Medical System enrolls doctors, nurses and paramedics from outside the federal government who can be tapped as intermittent employees during disasters.
Teams of federal medical workers have been deployed during H1N1 in 2009, and also to help with the Ebola outbreak and opioid epidemic.
The federal government is often best positioned to step in to provide and coordinate resources when disasters are so severe or so large that responding is beyond the capabilities of individual states.
In 2017, alarms about inadequacies in the system sounded again, when a devastating hurricane season meant workers were needed across several disaster zones – in Texas, Florida, Puerto Rico, and the U.S. Virgin Islands. The pool of emergency federal medical workers proved inadequate – short some 2,000 personnel, by one count.
The shortage forced the federal government to turn to the military, whose medical personnel are needed elsewhere, to treat troops in battle and to provide medical care where they are stationed around the world.
Trump administration officials at HHS set out to expand the ranks of federal medical workers in 2018. Demand for commissioned corps workers alone had skyrocketed 44% from 2013 through 2018.
“The Corps had been neglected and there’d been a dearth of unified leadership for a long time,” said Dr. Brett Giroir, former assistant secretary for health and admiral with the U.S. Public Health Service Commissioned Corps.
HHS got special hiring authority from Congress to allow quick onboarding of recruits and set a target of 6,290 workers in the National Disaster Medical System. By 2019, Giroir sought 7,700 in the Commissioned Corps and also started work to establish a pool of 2,500 on-call workers for the Corps, called a Ready Reserve. In all, the targets would have brought the total to more than 16,000.
Excluding workers like engineers, veterinarians and morticians, roughly 10,300 of those would be clinical professionals who could provide medical care, based on information gleaned from the GAO report and interviews with officials.
But the hiring effort was delayed and bungled from the start, a review by the nonpartisan Government Accountability Office found. HHS didn’t have specific recruiting or hiring strategies to meet its targets, despite the special hiring authority granted by Congress in 2018 and again in 2019.
What’s more, HHS officials were signing people up for two-year appointments that needed to be extended and renewed, which would “further burden hiring efforts.” Neither the HHS preparedness office nor its staffing and recruitment center could explain why they didn’t make indefinite appointments – as had previously been done to the National Disaster Medical System.
“Officials from both agencies stated that the decision came from the other agency, further exemplifying a lack of strategies,” the GAO concluded.
Giroir said he spent 2018 and 2019 fighting the White House Office of Management and Budget, which wanted to cut the Commissioned Corps. He said the battle stalled hiring and made it difficult to retain officers already in the Corps.
“They were worried about their careers because everybody was trying to kill us,” Giroir said.
Kadlec, then an assistant secretary at HHS, said hiring plans ran headlong into bureaucracy at an agency unaccustomed to speedy recruitment, training and deployment.
“It was just very convoluted,” said Kadlec, who has faced criticism for his oversight of the nation’s stockpile of medical supplies but dismissed complaints as unfounded.
By late 2019, there were only 5,000 federal medical workers in the Corps and Disaster system, less than half the goal, and the Ready Reserve was still in the planning stages.
Then the pandemic struck.
As the nation reeled amid the initial onset of COVID-19, the Trump administration turned to its pool of federal medical workers.
The government deployed them to help passengers disembarking from cruise ships in California and Japan and to nursing homes whose residents and staff were dying at alarming rates.
In June 2020, GAO investigators issued a scathing report calling on the federal government to do more to ensure it had adequate numbers of medical workers to deploy. “The unprecedented scale of recent disasters highlights the need for further progress to build resilient capabilities to respond to disasters of increasing frequency and magnitude,” investigators noted.
And yet seven months later, the day after Biden was inaugurated, his team released a 200-page COVID plan that acknowledged a dire staffing situation at hospitals across the nation, but made no mention of any efforts underway to expand the ranks of federal medical personnel.
Giroir called the oversight “a bit naïve and wrong.” “It’s not as if this just happened,” he said.
The Biden administration focused heavily on vaccinations. Between February and June 2021, roughly 5,100 military personnel, including medical and support troops were dispatched to 25 states. They administered roughly 5 million vaccines, according to U.S. Army North, which oversaw the effort.
In July, as the delta variant threatened widespread deadly outbreaks across the country, Biden announced his administration would send out teams of federal workers to help with hospital staffing, testing efforts, and other tasks.
But the deployments paled in comparison to the numbers of hospitals reporting critical staff shortages.
By late August, the administration had dispatched workers to just 10 hospitals in four states, whereas 835 hospitals in 46 states reported critical shortages on that day, according to figures provided by the White House and HHS data. In 10 states, a quarter or more of hospitals faced critical shortages.
Administration officials said many states did not request help, and some were dismissive of their need for federal assistance.
Then the highly contagious omicron variant accelerated the staffing collapse in the days after Thanksgiving, as staff called out sick and were quarantined.
Across the country, health care workers suffered burnout after nearly two years in crisis mode battling the pandemic. People were exhausted. Some decided to retire. Others got out of the profession.
At St. Agnes hospital in Wisconsin, President Katherine Vergos said part of what has devastated the already stretched hospital staff is witnessing death after death after death, at a rate never seen before in the small community hospital in Fond du Lac. Some are family members and friends.
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One nurse, normally a positive voice at meetings, crumpled in tears after learning at a recent meeting how many patients had died while he had been on leave the week before.
Vergos, her voice cracking as she recalled what happened, said the nurse had thought the 12-day vacation would be a balm for the burnout. Instead, it all came crashing back. “He told me, ‘Katherine, I didn’t become a nurse to see everybody die.’”
The American Hospital Association said omicron presented additional challenges because it was more contagious so more staff were out sick or in quarantine.
“Hospitals are just like any other employer where they have people who get sick,” Lisa Kidder Hrobsky, senior vice president of federal relations, said. “(But) health care is sort of the one place right now where you really don’t want to have all of these workforce shortages.”
After all, the loss of personnel equates to a loss of beds available for sick patients.
“Your hospital can have an infinite number of beds, but if you don’t have the staff, if you don’t have the nurses, the respiratory therapists, the social workers, the care managers, the environmental services workers to staff those beds, then those beds aren’t available for care,” said Dr. Samir S. Shah, the editor-in-chief of the Journal of Hospital Medicine and a pediatric hospitalist in Ohio. “And that’s a big, big problem.”
As the pandemic wore on, there was a general decline in staffed hospital beds. Although federal medical surge teams are not meant to compensate for chronic staffing shortages, each wave of pandemic created acute drop-offs in beds that went so low in some cases hospitals imposed crisis standards of care.
Across the United States and its territories and tribal areas, the number of staffed inpatient beds nationwide dropped to alarming lows as omicron peaked over the winter hitting just over 750,000 the day after Christmas — down 44,000 from one year earlier, a USA TODAY analysis of HHS data shows. That decline came as hospitalizations skyrocketed.
As the omicron variant subsided 25,000 beds came back on line by the end of February. That still hasn’t brought the nation back to early pandemic levels – which sat at 804,000 in December 2020.
In West Virginia alone, the number of staffed beds in its hospitals dropped from 5,327 in May 2020 to 4,754 in December 2021, according to data from the West Virginia Hospital Association, a decline of about 11%.
“It’s frightening,” Jim Kaufman, president and CEO of the association, said. “I’m not going to lie. It’s truly a challenging position for anybody who works in a hospital to be in.”
As omicron widened the crisis, Biden went to the National Institutes of Health and made an announcement: He would triple the number of teams of federal medical workers sent to hospitals to 60, saying they “make a gigantic difference.”
“Republican governors as well as Democratic governors contact me when I go into their states, talk about ‘thank you for these surge teams,’” the president said on December 2. “Some communities are hit so much harder than others. … They just can’t make it without (them).”
Over the next few weeks, he announced he would mobilize 1,000 military medical workers from the Department of Defense to help as well.
White House officials said the federal government deployed 1,127 of the workers between Thanksgiving and January 21. But 495 of those were from the military, meaning just 632 workers from the other federal sources were deployed during those peak months, despite the hiring target years earlier of 10,300.
Explaining the deployment, administration officials said that some pools of federal medical workers have built-in limitations, and in general, the system was set up to respond to more limited, short-term disasters.
While 4,000 workers are enrolled in the National Disaster Medical System, administration officials said, only 10 teams – which range in size from less than 10 to more than 45 – are available for deployment at any given time. They are on call for a month at a time, their deployments typically last two weeks, and their schedule is set a year in advance.
In addition, because that particular pool of workers is drawn from the health care workforce, federal officials have to weigh the cost of pulling them from their regular jobs at facilities that might also have critical staff needs.
Hence, the administration turned to the military, where large numbers can be deployed quickly and for longer – 30 to 40 days instead of two weeks.
The White House said states are in regular contact with regional representatives from HHS and FEMA to assess and anticipate needs and to identify what federal resources may be available to help.
The White House also pointed out it sent no medical workers to states that didn’t formally request them. During the peak months of the omicron surge 28 states received no federal medical workers to staff hospitals. And federal officials would not say how many, if any, of those had applied for help.
More than once during the pandemic, however, federal officials issued statements citing the scarcity of federal aid workers, and encouraging states to apply for help only after their backs were against the wall and they had taken a number of other steps – from canceling all but the most urgent surgeries, to recalling retirees, activating the National Guard and asking other states for help.
Administration officials say federal efforts are supposed to complement what states are already doing and it’s important that states do all they can.
But such warnings may have discouraged some states from applying for help. In South Carolina, the state hospital association said facilities were caring for more patients than ever but they thought federal medical workers were out of reach.
“What we had heard, too, in all the previous surges when we had made the request is that they were very limited in number and availability,” said Lara Hewitt, vice president of workforce and member engagement at the association.
“Unfortunately, we’ve never been able to access any of those resources thus far,” she said in late January. The state had not received workers as of March 14, according to HHS.
State and hospital officials around the country told USA TODAY they are grateful to have federal assistance – be it money or coordination help or staff, however limited. Some noted that the widespread impact of the pandemic has stressed resources for everyone.
But the federal government’s failure to meet its hiring goal also had a cost.
Interviews, documents and data gleaned from hospital and government officials in 19 states suggest the need for workers far outweighed the government’s ability to respond.
Requests for help ranged from dozens to hundreds of medical staff, including doctors, nurses, respiratory therapists and other aides. A few states received all that they requested, and some received just a fraction.
In New Mexico, where state officials said they filed their paperwork early “just like ordering masks early,” they got five of the six teams they asked for.
“Our federal partners have been just great,” said Dr. David Scrase, cabinet secretary for health and human services in New Mexico.
Some states received federal reinforcements, but not for long enough. In Vermont, officials tried to extend the deployments of 30 federal medical workers, but federal officials said no.
“FEMA told us Vermont was in a better position with hospitalization rates than other states, so some resources would be reallocated elsewhere,” said Mark Bosma, spokesman for the state’s emergency management agency.
Others got a much smaller portion of what they requested. Michigan asked for teams at nine hospitals and got them at six. Pennsylvania said they requested teams at four hospitals and got them at two. Arizona applied for more than 1,000 staff at 21 hospitals, but received 60 workers as of early February, state officials said. By March 14, the state got 123. Wisconsin filed for more than 200 and received only 23.
“It’s better than nothing,” said Dr. Megan Ranney, an emergency room physician and academic dean at Brown University’s School of Public Health of the federal response. “But it feels like too little, too late.”
Amid the staffing crisis, states were forced to come up with their own solutions. In some cases, trying to train National Guard troops to work as nursing assistants; in others, drawing workers away from other hospitals, other states – or other countries – in a red-hot hospital staffing market akin to the Wild West.
In Wisconsin, the competition for staffing grew so fierce that one health system went to court to temporarily stop seven employees from leaving to work at another hospital. They specialized in procedures ensuring proper blood flow, including in cases of injury or stroke. A hospital in a neighboring city offered jobs with what one worker called, “life-changing money.” A judge declined to halt the move.
Texas spent some $7 billion to hire temporary workers, and the governor told his health department to make sure they came from out of state. Chris Van Deusen, spokesman for the Texas Department of State Health Services, said hiring in-state workers away from their jobs “obviously that’s just going to create the hole that you’re trying to fill.”
Next door in Louisiana, State Health Officer Dr. Joseph Kanter said many hospital staff left to take more lucrative jobs as traveling nurses and contract-based temporary respiratory technicians. He said in January the state was contracting directly with staffing agencies and deploying the workers to about 60 different hospitals.
Amid the heated staffing wars, some have ramped up international recruiting. Sinead Carbery, president of International Nurse Staffing Solutions for AMN Healthcare, told the Associated Press in February the demand for foreign nurses has tripled since the pandemic began.
The American Hospital Association wants the federal government to step in. The organization fired off a letter to the White House on Jan. 27, pushing for an investigation of staffing agency pricing. The association is also asking for expedited visas for foreign health care workers.
Administration officials said they tripled the number of visas issued for health care workers in the past year. Their investments to help states hire workers worked in some cases and were less effective in others, they said
National Nurses United, the largest nurses union in the country, wants Congress to pass legislation requiring hospitals to hire minimum numbers of nursing staff per patient going forward, so they don’t need federal emergency help if at all possible.
Colorado Gov. Jared Polis also is advocating for the establishment of a national standard of hospital and health care system readiness.
“The simple truth is that states alone cannot spearhead these efforts indefinitely,” he said during a congressional hearing on COVID response in January.
With the omicron variant subsiding and no new variant threatening massive hospitalizations and widespread infections and death at the moment, it’s unclear if the Biden administration will make it a priority once again to shore up the shallow pool of federal medical personnel.
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“We are committed to further strengthening the NDMS program,” O’Connell, the HHS assistant secretary, said in a statement. She called that particular program’s deployment of 2,100 workers since Biden took office an “impressive track record.” HHS will continue to “invest in tools and training,” she said, “recruiting top talent, and strengthening relationships with state and territorial partners so that we’re able to respond effectively to the pandemic as well as natural disasters and other health emergencies.”
Earlier this month, a group of former Biden advisors and outside experts released a strategic plan that called on the administration to do more in its COVID response, including by increasing funding for existing pools of federal medical workers and establishing a larger, more flexible reserve of deployable medical personnel. The plan, called a “Roadmap for Living with COVID,” also suggests paying retired doctors and nurses to go back to work during emergencies and creating a list of volunteer medical personnel willing to be called up.
“What we’re calling for is really a much different approach, meaning that you have to be able to call on major reserves that will help buffer regional differences,” said Osterholm, the Minnesota epidemiologist and former Biden adviser, who worked on the plan.
Dr. Ezekiel Emanuel, a University of Pennsylvania vice provost who led the work on the plan, said he hoped the pandemic will help bring an end to a problem that has persisted through multiple administrations.
“We go through fits and starts, and we never seem to be able to do it, because hiring people, keeping programs with people going between episodes, is hard. I mean, ask the military,” said Emanuel, who advised Biden’s transition team and the Obama White House on health policy. “And I think it just reflects the fact that we tend to move on before we’ve actually prepared for the next thing. Now, hopefully, at this moment, we will not move on.”
Another expert who worked on the plan likened the reserve of federal medical workers to police officers.
“This is a critical need for taking care of our citizens,” said Vivian Riefberg, a professor at the Darden School of Business at the University of Virginia. “We don’t stop hiring police or personnel or stop maintaining a military defense system after a problem passes. We have it so it is ready in times of need. We need to do the same thing here.”
Kadlec, the assistant HHS secretary for preparedness and response under Trump, said the ideal number of federal medical workers would be 12,000.
“We’ve had attrition and will likely have more attrition over time,” he said. “So it’s just going to mean in the interim, until we can recruit more doctors, nurses, whatever, we actually might be more dependent on (federal medical) capabilities to respond.”
Given a large enough force, the federal government is in a unique position to respond efficiently, because it can pull resources from areas where the number of cases is declining, and distribute them to places where the disease is on the rise, said Craig Fugate, former FEMA administrator during the Obama administration.
He is advocating for a bipartisan commission to study all aspects of the federal response to the pandemic. FEMA’s role, HHS coordination, how people are distributed, all of it has to be examined, Fugate said.
“We need to go: ‘Is this really the best way to do this?’”
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