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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The chair of the Federal Trade Commission will be in rural Iowa this weekend to hear from farmers and other residents about the proposed sale of Iowa Fertilizer to Koch Industries.

The sale is pending FTC approval. Iowa spent $500 million to build an Iowa Fertilizer factory in Weverly to create competition in an already consolidated industry.

Aaron Lehman, president of the Iowa Farmers Union, said he plans to tell FTC Chair Linda Khan a sale to Koch Industries would backtrack on any competitive progress the state has made.

"Our concern is that an industry that already lacks competition and has all sorts of monopoly problems would only get worse if this sale is allowed to go through," Lehman explained.

Koch and other corporate ag conglomerates have said consolidating allows them to provide better products to farmers more efficiently. The hearing is set for Saturday on Main Street in Nevada.

In addition to reducing competition for fertilizer, Lehman argued the sale would increase prices for farmers, and ultimately mean higher food prices for Iowans. He wants Khan to hear stories firsthand, from the people on the ground in Nevada.

"We know that we might not be able to have a dialogue with the people who are investigating this situation, because they need to be impartial," Lehman acknowledged. "But our farmers need to tell their story about how the industry is already in a monopoly state."

Some 18 other ag organizations have joined the Iowa Farmers Union calling on the FTC and the Justice Department to investigate the proposed sale.

A farm group is helping Iowa agriculture producers find ways to reduce the amount of nitrogen they use on their crops.

Excess nitrates can wind up in ground and surface water, and cause health problems.

Practical Farmers of Iowa is encouraging farmers to find just the right amount of nitrogen they need for their crops - while avoiding applying too much, which the group says is common.

PFI's Field Crops Viability Coordinator - Chelsea Ferrie - said thanks to federal grants and private funding, the group will pay farmers up to $35 for every acre that has a lower than normal yield if they didn't apply enough nitrogen.

"No cost to the farmer, either," said Ferrie. "We're trying to help incentivize them. This is something that farmers want to do - I mean, they want to be good stewards of the land - but also, that they need to have a profitable farm."

The application period for the program is open through the end of April.

To help them reach the right nitrogen balance, Ferrie said PFI will help farmers on the front end of the process, too - so they aren't left guessing how much to apply.

"Talk through what your typical fertilizer plan is, and what your reduction plan would be," said Ferrie. "Then you would implement this year, going into the spring and into the season."

Farmers have relied on nitrogen-based fertilizers for generations - but when applied in excess, nitrates run off into ground and surface water, posing health concerns for animals and people.




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Pesticides are still common in agriculture. Organic producers who avoid them have seen ups and downs in pushing for stronger regulations, and they point to a South Dakota example of the harm associated with widespread use among neighboring farms.

At the heart of the regulatory fight is the application of the weed-killing pesticide dicamba, and how it can drift from one farm to another. Last month, a federal court blocked "over the top" spraying of dicamba products, but the EPA followed with an order to allow the spraying of existing supplies.

Glenn Pulse, co-owner of an organic farm in Vermillion, said a 2017 drift incident had a big impact on his operation.

"Our entire farm was covered. We lost a lot of livestock, and thousands of bees were killed," he explained.

It also resulted in health concerns for his family, having to regain his organic farmer certification, and a legal battle over restitution. Groups such as the National Family Farm Coalition have been fighting what they call the deregulation of these chemicals, arguing the drift and runoff effect has damaged millions of crops.

Dicamba-manufacturing companies deny responsibility, instead blaming farmers who apply it for not following guidelines.

The EPA has said there were already millions of gallons of dicamba in circulation prior to the court's ruling, prompting the agency's order. Pulse feels there are farmers who are careful in spraying chemicals, but he wants stronger enforcement against those he describes as "loose cannons."

"The guys that are not following the labels and they're spraying in weather conditions that are not favorable, that is where, I would say, 90% of the problems are happening with drift incidents," Pulse said.

His calls for better responses to these incidents coincide with policy demands to heavily restrict dicamba products. Meanwhile, Rep. Dusty Johnson, D-South Dakota, is the main sponsor of a bill supporters say would assure uniformity in national pesticide labeling under federal law. But opponents argue it would limit longstanding state and local pesticide safety rules.