Leighton Ku, PhD, MPH
Professor, Dept. of Health Policy and Management
Director, Center for Health Policy Research
Erin Brantley, PhD, MPH
Deputy Director, Center for Health Policy Research
December 14, 2021
On November 5th 2021, in the face of an ongoing public health emergency, the Centers for Medicare and Medicaid Services published an interim final rule mandating COVID-19 immunizations for employees of 15 separate types of providers that participate in Medicare and Medicaid.The rule aims to ensure that health care workers are immunized against the virus in order to keep health care settings safe and thereby reduce the risk of infection among the most vulnerable populations, including nursing home residents, hospital patients, patients served in physicians’ offices, rural health clinics and community health centers, and other places where people receive health care. Medicare and Medicaid providers covered by the rule must ensure that all health care workers are fully vaccinated by January 4, 2022, although it permits exemptions based on sincerely held religious beliefs or practices as well as medical conditions.
The CMS rule has been issued as part of the HHS Secretary’s duty to protect the health and safety of Medicare and Medicaid patients. The rule rests on evidence showing that vaccination of health care workers led to reduced rates of COVID-19 infections by patients and that vaccination rates increased when health care facilities required workers to be vaccinated. Analyses of data from prior vaccination requirements (e.g., those imposed by private companies or by other government jurisdictions) suggests that almost all affected workers will become vaccinated and that relatively few will lose their jobs.
By December, however, states challenging the rule had succeeded in convincing lower courts to issue a nationwide injunction against the rule. The state challengers relied heavily on anecdotal evidence suggesting that health care workers would quit in the face of a mandate and that this threat outweighed the risk to patients of COVID-19 exposure from unvaccinated workers. Others have argued that a health care worker vaccine mandate could trigger a worker shortage once health care providers become obligated to start firing unvaccinated workers.
Vaccination requirements by health care providers and other organizations, which had already begun, accelerated after President Biden announced the administration’s policy on September 9. Thus, although the CMS regulation unquestionably would expand vaccination requirements in health care, health care vaccination requirements had already been imposed earlier in the year by many health care facilities and other companies. Even health care systems serving rural areas where vaccine resistance tends to be higher have succeeded in imposing a vaccine mandates that have achieved as high as 99 percent compliance. Furthermore, 13 states or localities, including New York, California, Illinois, Washington DC, Colorado, Philadelphia, and Maine, had already adopted similar health care requirements as early as August, 2021. Indeed, on December 13th the United States Supreme Court affirmed the constitutionality of the New York COVID-19 vaccine mandate that allows no exceptions other than on medical grounds.
Anecdotes and rumors of quit threats and widespread health worker loss run contrary to actual data reported by employers--including hospitals and doctors’ offices across the country—that indicate that after dropping somewhat in April 2020 when the COVID-19 pandemic began, health care employment has largely recovered and is approaching previous record levels. Figure 1 illustrates total health care employment, as well as employment in ambulatory health care (e.g., doctors’ offices or clinics), hospitals and nursing homes from January 2020 to November 2021, as reported by the Bureau of Labor Statistics’ (Department of Labor’s) Current Employment Survey on December 3, 2021. Total health care employment, which reached 16.4 million in January 2020, fell to 14.8 million in April 2020 and has gradually climbed back to its previous high, reaching 16. 1 million in preliminary data for November. Total health employment would be even higher if all states that have not already done so were to expand their Medicaid programs using the generous expansion incentives made available under the American Rescue Plan, enacted earlier this year.
Despite earlier vaccination mandates at facility or state/local levels and the President’s September announcement, the data show that there has not been any major drop-off in health care employment in 2021. In fact, modest increases in ambulatory health care and hospital employment have occurred. While there has been a gradual reduction in nursing facility employment, this reduction began earlier in 2020, and the slight downward trend has not changed in recent months. Other data reported by the Bureau of Labor Statistics indicate that the number of job hires and separations (i.e., people quitting) in the health care field have remained relatively steady, although the number of job openings has increased in 2021. The increase in job openings advertised parallels the broader challenges of hiring across multiple sectors in a tight economy.
It is true that COVID-19 and other challenges have been stressful for many health care workers, but most have remained resilient and continue to serve the health care needs of their communities. The data shown above are national data; there could be differences in some communities. For example, there is evidence that vaccination rates are lower in many conservative areas of the country, a fact linked to higher rates of COVID-19 infections, hospitalizations and deaths. But as CMS notes in its rule, the greater difficulty of retaining health care workers in these communities could be the result, not of concern about the vaccination, but instead, of heightened concern about COVID-19 exposure in health care settings.
The evidence shows that fears that COVID-19 vaccination will create widespread health care labor shortages are a product of anecdotes and fears. A close look at the actual numbers suggests that problems have been exaggerated. There is relatively little evidence that COVID-19 vaccination requirements are creating major employment problems across the United States, but there is evidence that COVID-19 vaccination mandates increase vaccination rates without reducing employment.