By Liz Carey for The Daily Yonder. Broadcast version by Nadia Ramlagan for North Carolina News Service, reporting for The Daily Yonder-Public News Service Collaboration.

Rural hospitals, already struggling with financial strains due to COVID-19, face an even more significant threat, experts say: the workforce shortage.

Hospitals say they are short on workers in all areas of the health-care system, not just the clinical ones. According to the American Hospital Association, about 20% of all hospitals across the country expect worker shortages to reach dire levels.

"It (the pandemic) has really stressed the workforce in ways that we're not going to recover from for decades," said Julia Harris, a senior policy analyst with the Bipartisan Policy Center. According to Haris, 2021 saw the biggest drop in the number of nurses in the workforce in history. Over 100,000 nurses disappeared from the hospitals' nursing supply, putting a lot of pressure on smaller facilities to hire nurses.

"But then, the smaller rural hospitals really can't compete dollar for dollar with other centers and so workforce is their number one expense," she said. "When we're talking about competition to keep the people needed to run a hospital, it's very scary to think about what they're going to do when the federal funds dry up."

The pandemic hasn't stopped causing workforce issues, said Dr. James Hoekstra, president of High Point Medical Center, during a webinar hosted by the North Carolina Healthcare Association.

"The stresses that were put on the health-care systems, especially the rural hospitals, during the pandemic are actually continuing," Hoekstra said during the webinar. "We have lost a lot of providers to retirement. We've lost a lot of providers to going to different areas of the country to travel and earn more money. We've lost a lot of providers and staff to burnout and what we've been left with is a situation where we've had to hire a lot of what we call travelers or contract labor."

That leaves the hospital with higher costs.

During the pandemic, thanks to federal Covid funding, rural hospitals were able to pay top dollar for travel nurses, sometimes paying as much as $200 per hour. Those salaries were subsidized with federal COVID relief funds. Now, all hospitals pay between $7,400 and $1,400 per week, according to Vivian Healthcare, a health-care labor placement company. And with COVID funding drying up, hospitals are responsible for all of those fees.

Whitfield Regional Hospital in Demopolis, Alabama, lists a travel nurse opening on Vivian for just under $1,700 a week - which includes a more than $900 a week salary, plus a nearly $700 a week tax-free stipend for a 13-week assignment. The hospital currently has 20 openings for full-time nurses.

According to a Vivian spokesperson, staff nurses traditionally make far less than travel nurses. Currently, the national average for a staff nurse is about $37 an hour, while travel nurses make on average $3,600 a week, the spokesman said in an interview.

"Rural hospitals pay more generally, especially factoring in cost of living (e.g. Houston average weekly is $2,761. Lubbock, Texas, is $2,831). During the pandemic, wages have shown the strongest correlation to COVID case counts rather than geography," the spokesman said.

At Northeastern Vermont Regional Hospital in St. Johnsbury, Vermont, nurse positions start around $30 an hour, CEO Shawn Tester told Kaiser Health News. At the height of the pandemic, the hospital paid staffing agencies around $175 per hour. Now that fee is down to over $100 an hour, he said, but the hospital is working to negotiate that rate down further.

According to the U.S. Bureau of Labor Statistics, U.S. health-care organizations will need to fill nearly 200,000 nursing positions every year from now until 2030. Some studies even project that the country will face a shortage of more than 29,000 nurse practitioners by 2025.

Vivian's research into nursing shows the outlook for clinical staffing doesn't look good. Nearly 65% of the 3,000 nurses they surveyed said they were looking to transition out of the profession in the next five years. Almost half (44%) said they felt like their unit is short-staffed "all the time."

National organizations hope Congress will step in to do something about it.

In a letter to U.S. Reps. Rosa DeLauro, D-Conn., and Tom Cole, R-Okla., chair and ranking member of the House Subcommittee on Labor, Health and Human Services, Education and Related Agencies, the AHA said that 781 hospitals across the country, or 18.9%, said they would face critical staffing shortages.

"While the nation may be rounding the corner in the battle against COVID-19, the health-care workforce continues to contend with many immediate challenges related to the pandemic, as well as a health-care landscape that has been deeply altered," the AHA wrote.

The AHA is asking Congress for $1.51 billion to fund health-care workforce development programs for the 2023 fiscal year's budget, including $374 million for rural health programs. The request represents an increase of $43 million over levels approved in 2022.

"Rural health programs... are vital to ensuring that needed services remain available in America's rural communities," the AHA said. "We also urge Congress to support funding to establish a Rural Emergency Hospital Technical Assistance Program, to support rural hospitals who are making the transition to maintain critical services for their communities."


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Massachusetts farmers said they are bracing for revenue losses due to cuts in fresh produce SNAP benefits.

Starting Dec. 1, families who utilize the state's Healthy Incentives Program to buy food directly from farmers will see their benefits cut to just $20 a month, regardless of household size.

Rebecca Miller, policy director for the Massachusetts Food System Collaborative, said many farmers have structured their operations around SNAP customers.

"A lot of them are worried that they might have to do layoffs," Miller pointed out. "Especially for folks that they've hired that are multilingual that serve folks with SNAP benefits."

Miller stressed less money being spent at farmers' markets will have a ripple effect across the state's agricultural industry. Nearly 300 farmers participate in the SNAP program but state officials said the cuts are needed due to budget constraints.

The Healthy Incentives Program provides a dollar-for-dollar reimbursement when SNAP users buy healthy, local food directly from Massachusetts farmers. A state survey found that each dollar spent in the program results in an additional $2 in local economic impact, when farmers spend the money on local goods and services. Miller emphasized she is concerned about families getting through the winter.

"We expect to see increased food insecurity," Miller explained. "Folks needing to visit food pantries more, folks having to take more medicine to address chronic diet-related health needs."

Miller noted a study found each program participant increased their fresh fruit and vegetable intake by one serving per day, which leads to lower public health care costs over time. She added supporters are asking the legislature for an additional $10 million to maintain current funding levels through June. State officials say they are restructuring the program to ensure long-term viability.


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Kentucky farmers are using biosolids or "biosludge" from city sewage as cheap fertilizer but the price tag is high in terms of health, from toxic industrial chemicals known as PFAS and heavy metals contaminating produce, groundwater and soil.

Kentucky lawmakers have passed regulations experts said weaken protections for biosludge application on farmland.

Tom FitzGerald, attorney and former director of the Kentucky Resources Council, warned farmers in the Commonwealth trying to save money on fertilizer by using biosludge could end up with a significant headache down the road.

"Unless the cities are properly managing the waste that come into the system, and are sampling and clearing them for release for public use, I would simply tell the farmers not to take these biosludges, because the risks are so high," FitzGerald asserted.

According to open records request data from the Kentucky Energy and Environment Cabinet, lab samples from around a dozen wastewater treatment plants statewide revealed most contained detectable levels of PFAS.

Adam Nordell said his small family-owned vegetable farm dream in Maine became a nightmare when he discovered sewage sludge applied decades prior had irreparably contaminated his land and groundwater with high levels of PFAS. He stressed he wants to raise awareness among farmers in other states about the risks, and the importance of testing.

"We had been living on contaminated land," Nordell explained. "We've been drinking contaminated water. We've been irrigating our crops and supporting our livestock with contaminated groundwater."

FitzGerald said Kentucky's regulations reduce accountability and do not require cities to test the biosludge before it's applied to farmland.

"The cabinet should have used its authority to broaden out the list of contaminants, to broaden out the sampling and testing requirements and to broaden out the notice requirements to farmers," FitzGerald contended.

According to the Environmental Working Group, at least 5% of all crop fields nationwide could be using biosludge likely contaminated with PFAS. And since 2016, more than 19 billion pounds of biosludge have been applied to farm fields.


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Some Iowa farmers are putting a new spin on an age-old animal behavior.

They're using goats to remove weeds, overgrown brush, and non-native grasses - while helping some landowners restore native habitat to their acres at the same time.

Goats are pretty well known for producing milk and cheese. They're even used to help practice yoga these days.

Matt Vermeersch is a member of Practical Farmers of Iowa who farms about 170 acres near Red Oak - near the Nebraska state line - and operates Goats-On-The-Go, a side business stocked with herds of goats hungry for woody vegetation.

"A lot of really what we refer to as weeds, or pain-in-the-butt plants," said Vermeersch. "Things that they love are things like poison ivy, nettles, wild berry species with their thorns - then more woody species like Honeysuckle or buckthorn."

Vermeersch estimated his three Goats-On-The-Go herds cleared about 120 acres of various vegetation this year, and could have done more had it not been for Iowa's severe spring and summer weather.

There are ecological benefits to the practice, too. People hire Vermeersch's goats to clear land where native species once grew, and where farmers want it to return.

Vermeersch said while Iowa landowners are often trying to clear overgrown brush and reintroduce native species, sometimes they just need stands of troublesome weeds and brambles removed.

At which, Vermeersch said, the goats have no equal.

"It almost looks like a wildfire went through there the day after you take the goats off," said Vermeersch. "We refer to it as a grazing line - and pretty much anything under 6 feet tall all that will be left are sticks and stems. All of the leafy material underneath that is usually consumed."

Vermeersch said the goats are used for different reasons across the country.

In western states, for example, they are dispatched to clear brush that can serve as wildfire fuel, reducing the chances that a fire can become catastrophic by keeping the underbrush down.