Thousands of new cases have been reported among vulnerable elderly residents in the last several months, as the virulent Delta variant fuels outbreaks.A Connecticut nursing home had planned to roll out Covid booster shots to residents at the beginning of this month.But before it could start the program, the coronavirus swept through the home, the Geer Nursing and Rehabilitation Center in North Canaan, infecting 89 people, including 67 residents. Nearly all were fully vaccinated.Eight of the residents died from Covid, according to the home, which described all as having “serious underlying health issues.”The severity of the outbreak helped spur Connecticut officials to announce recently that the state would set up booster clinics at all of its nursing homes, to cover those facilities that had yet to administer additional doses.Several states are experiencing new surges in Covid cases, especially in the Midwest and the Northeast. And fresh outbreaks have been reported this month at nursing homes in Vermont, Virginia and elsewhere despite a monthslong vaccination rate nationwide of about 86 percent among residents in skilled nursing facilities.Booster programs have taken on more urgency given that nearly 4,000 new Covid cases are reported every week in nursing homes, according to federal data, and experts say many of the case clusters are occurring in homes that have yet to administer the extra doses.“When we compare rates of Covid-19 disease between those who are vaccinated with two doses and those who received a booster dose, the rate of disease is markedly lower for those who received their booster, demonstrating our booster shots are working,” said Dr. Rochelle Walensky, the director of the Centers for Disease Control and Prevention, at a White House briefing this month.And in some places, outbreaks among residents may still be occurring because vaccination rates among nursing home staff members continue to lag behind national averages.Unlike last winter’s concerted federal push to vaccinate residents and staff in nursing homes, the booster rollout has been sluggish and piecemeal, health experts said. Public information is sparse: About 42 percent of Americans over 65 have received a booster shot, according to federal reports, but there is no data available yet on U.S. sites to track nursing home booster programs.Medics transported a man with possible Covid symptoms from a senior living center in Houston to a hospital in August.John Moore/Getty ImagesThe staggering Covid death toll at nursing homes in 2020, steep declines in cases after the successful vaccine campaign and then the steady rise again in late summer and this fall should have made boosters for older Americans a top priority, some experts say.“What’s been surprising is the lack of data and attention on nursing homes this time around,” said Dr. Ashish Jha, a physician and dean of the Brown University School of Public Health. The government should have authorized additional doses as early as July, he noted, especially since nursing home residents were among the first to receive the vaccines 10 or more months ago.“The data was clear at that point,” Dr. Jha said. “We were seeing waning immunity, particularly in the elderly.”In August, third doses of some vaccines were authorized for people with weakened immune systems. But by the time booster shots were approved for the Pfizer-BioNTech vaccine in late September, followed by approvals for the Moderna and Johnson & Johnson vaccines the next month, many nursing home residents had already lost some of their initial protection against infection, experts say. And they were more vulnerable to serious disease because of their age and declining health.“Six months for them was a lot earlier than six months for the general population,” said David Grabowski, a health policy professor at Harvard who studies nursing homes. Residents of assisted living facilities are particularly at risk because there does not appear to be a coherent strategy, he said. New outbreaks complicate matters by putting booster programs on hold until the cases subside.The effort to vaccinate residents last winter was delegated to two large drugstore chains, CVS Health and Walgreens. When the federal contracts ended earlier this year, nursing homes reverted to relying on the pharmacies typically used to help them vaccinate residents against the flu.The Biden administration said it was having success in its efforts to ensure residents receive the additional doses. “We’re seeing really, really strong progress in states across the country,” said Sonya Bernstein, a senior White House adviser on Covid. She singled out programs in West Virginia, Ohio and North Carolina as robust.Other areas have also managed to provide significant booster coverage. For example, Los Angeles County announced in mid-November that nearly all the residents in skilled nursing facilities had received booster shots.Ms. Bernstein said the federal government was also working with facilities that can’t find a pharmacy. “Any long-term care facility that needs help is being matched with one of our partners,” Ms. Bernstein said.Half of those 65 and older who became eligible for booster shots of the Pfizer vaccine in late September have received them, public health officials said in a recent announcement. That’s compared with the nearly three months it took to deliver half of the first doses to this group.The Centers for Medicare and Medicaid Services, which reports vaccination rates nationwide and for individual facilities on its website, said it planned to post data on boosters within the next two weeks and on its website allowing consumers to compare individual nursing homes “in the coming months.”“C.M.S. is working with nursing homes to increase Covid-19 booster uptake,” the agency said.Pharmacies helping nursing homes with these efforts say they have not experienced any particular problems. “From our perspective, we have not heard of any delays or concerns,” said Chad Worz, the chief executive of the American Society of Consultant Pharmacists. “The vaccine is in ample supply.”Booster shots were given to staff members at the Hebrew Home at Riverdale in the Bronx in September.Seth Wenig/Associated PressCVS Health, whose Omnicare unit provides services to nursing homes, said it could not provide any data on the number of booster shots it had delivered to nursing homes. “We’ve seen strong interest from our long-term care customers and continue to meet that demand through several distribution channels,” said T.J. Crawford, a spokesman.But other pandemic-related problems continue to plague nursing homes, some of which still had large numbers of unvaccinated workers, although the average staff vaccination rate has now reached 74 percent. Looming close is the federal mandate to immunize staff, although numerous states are suing to block the rule.The Coronavirus Pandemic: Key Things to KnowCard 1 of 4The Omicron variant.

Ten states filed a lawsuit on Wednesday seeking to block the Biden administration’s coronavirus vaccine mandate for health care workers, on the heels of a court decision that temporarily halted the broader U.S. requirement that workers of all large employers be vaccinated or undergo weekly testing.The new suit, filed in U.S. District Court in eastern Missouri, claims the rule issued last week by the Centers for Medicare & Medicaid Services “threatens with job loss millions of health care workers who risked their lives in the early days of the Covid-19 pandemic to care for strangers and friends in their communities.”The 10 states also argue the rule “threatens to exacerbate an alarming shortage of health care workers, particularly in rural communities, that has already reached a boiling point.” They say any further losses will only endanger patients, causing “devastating adverse effects on health care services.”But the broader point echoes a separate lawsuit brought by many of the same Republican-led states against the private-employer mandate for those with 100 workers or more, contending that OSHA does not have the authority to dictate such policy.In announcing the rule, the administration set a deadline of January for all 17 million health care workers to be fully vaccinated at health care facilities receiving government funding under the Medicare or Medicaid programs. Employees of hospitals and nursing homes, along with other medical sites, would not have the option of testing in lieu of immunization.Federal officials said they could not comment on pending litigation, but legal experts said the agency generally has the ability to establish rules governing the organizations it pays to deliver care. “C.M.S. has very broad authority to regulate Medicare-certified providers,” said Katrina A. Pagonis, a lawyer specializing in regulatory issues for Hooper, Lundy & Bookman.The rule “is essentially a condition of participation” in federally funded programs, said Erin J. McLaughlin, a health care lawyer for Buchanan, Ingersoll & Rooney. The government invoked the Supremacy Clause in the Constitution to pre-empt state and local laws when issuing the rule.President Biden’s call for mandates followed months of pandemic outbreaks as the Delta variant threatened regions of the country, some with low vaccination rates but also others with vulnerable populations like those in nursing homes that had just begun to recover from the devastating death toll of 2020.Some public health experts have argued that breakthrough infections possibly caused by waning immunity six months or more after vaccination, especially among the elderly, was a factor in urging mandates for health care workers.After a steady decline in infections earlier this year among nursing home staffs and residents, spikes in cases this past summer alarmed officials. Many nursing homes had large numbers of workers who remained unvaccinated even after Mr. Biden announced the plan to mandate immunizations..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-1kpebx{margin:0 auto;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-1kpebx{font-size:1.25rem;line-height:1.4375rem;}}.css-1gtxqqv{margin-bottom:0;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-1g3vlj0{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-1g3vlj0{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-1g3vlj0 strong{font-weight:600;}.css-1g3vlj0 em{font-style:italic;}.css-1g3vlj0{margin-bottom:0;margin-top:0.25rem;}.css-19zsuqr{display:block;margin-bottom:0.9375rem;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}Many medical societies came out in favor of strict mandates for health care workers, arguing these employees have a special obligation to keep their patients and colleagues safe. And many large, multistate hospital systems and large nursing home companies began requiring staff vaccination, although others lobbied against blanket requirements.The administration said about 40 percent of all hospitals already require vaccinations. About 73 percent of nursing home workers are now vaccinated, according to federal data.“It’s critical to us to make sure we’re ensuring the safety of residents living in nursing homes and other individuals in health care settings,” said Chiquita Brooks-LaSure, the administrator for Medicare, in an interview after the agency issued the new rule. Vaccinated staff members are less likely to get sick and spread Covid, she said.Ms. Brooks-LaSure acknowledged providers’ concerns over losing workers who refuse to be vaccinated, but she said mandates often ease shortages because employees don’t become infected. “What we’re seeing on the ground is that they are not going to work because they are sick,” she said.She also cited the experience in states that have issued requirements as evidence that vaccination rates will rise as a result of the government’s decision. Many large hospital systems and even city agencies that mandated the vaccine reported that only a small minority of employees were unwilling to be vaccinated.But the 10 states — Alaska, Arkansas, Iowa, Kansas, Missouri, Nebraska, New Hampshire, North Dakota, South Dakota and Wyoming — claim the federal government has overreached its authority to dictate what happens in their states. “This case illustrates why the police power over compulsory vaccination has always been the province of — and still properly belongs to — the states,” they argue in the lawsuit.While some nursing homes and hospitals have expressed disappointment over the new rules, there is little expectation that large numbers would lose their government funding.While Medicare has the authority to terminate providers that do not comply, Ms. Brooks-LaSure emphasized the agency’s approach will be to work with facilities. “Our focus is really on educating providers and getting people to be in compliance,” she said.

The latest Democratic proposal would funnel $150 billion toward subsidized home and community-based care. Experts worry that may not be enough to ease the severe shortage of workers.Spinal surgery four years ago left Alene Shaheed in a wheelchair and dependent on short daily visits from home health aides to help her get around.But her support system fell apart this year during the prolonged coronavirus pandemic, and her routine care became unpredictable. Four agencies serving her hometown, Jacksonville, Fla., failed to provide aides regularly, due to severe shortages of the low-wage workers.“If no one comes for three days, I don’t get a bath for three days,” said the 76-year-old. “I don’t have anyone to fix meals, so I’m eating ramen noodles until someone gets there.”About 800,000 people are on waiting lists to receive subsidized home care. For millions of Americans, finding reliable and affordable assistance to stay at home — instead of moving into a nursing home, where Covid-19 killed tens of thousands of people — has never seemed more urgent.Expanding home and community-based services is part of the legislative package that President Biden and Democrats have proposed. At this stage of negotiations in Congress, the amount for such programs under Medicaid — partly to increase the historically low wages of home care workers — has been reduced to $150 billion from $400 billion over eight years.“We’re going to expand services for seniors so families can get help from well-trained, well-paid professionals to help them take care of their parents at home — to cook a meal for them, to get their groceries for them, to help them get around, to help them live in their own home with the dignity they deserve to be afforded,” President Biden said on Thursday.”Will the amount in the current plan be enough? Supporters say the new health care money would shift Medicaid’s decades-long bias away from nursing home care. Many experts doubt promises that this round of funding can fix a system as broken as home care, especially as the growing retirement of the boomer generation requires more assistance to stay independent and strains health care funding.“You have to be very realistic about the amount of need you have in the system right now,” said David Grabowski, a professor of health care policy at Harvard Medical School. The $150 billion does represent a significant influx of funds, but there are limits, he said: “Once you start to do the math, the dollars don’t go as far as you’d like.”States are required to use Medicaid funds to cover nursing home care, but states have considerable leeway under federal regulations to decide how much should be allocated to provide home and community-based services.People who need help with tasks like feeding themselves, getting dressed or taking medication must often qualify for a Medicaid waiver to get home care. Medicaid, a federal-state program that is the primary source of coverage for long-term care, spends about $114 billion a year on these home and community-based services, representing well over half of the overall spending on long-term care. About 2.5 million people received waivers in 2018, according to the latest data available in a report by the Kaiser Family Foundation.Medicare, the federal insurance program for older and disabled adults, does not cover long-term care and it limits the kind of home care people can receive.It’s well known that demand far outstrips supply for home care for those who want to live independently. Some people may have private insurance or pay for the care themselves.Under Medicaid, the waiting lists for older and disabled Americans wanting home care keep growing because states cap enrollment. Most people on the lists live in states that did not expand Medicaid, according to a Kaiser analysis.Benefits for home care also vary widely from state to state. For example, someone in Pennsylvania is eligible for about $50,000 a year under Medicaid for home or community services, while someone in Iowa may get only $21,000.The lack of funding “really forces older adults into institutions,” said Amber Christ, an attorney with Justice in Aging, a nonprofit group. The new congressional package, she said, means that “we have an opportunity to flip the script.”She and other advocates plan to push for additional money. “We’re going to keep working to increase funding because more is needed to ensure all aging adults and people with disabilities have the option to receive the care they need at home,” she said in an email.Expanding home and community-based services is part of the legislative package that President Biden and Democrats have proposed.Stefani Reynolds for The New York TimesIncreasing wages for home health workers has been a contentious provision for Republicans, who see it as a giveaway to unions and would limit states’ flexibility in spending new funds.Calculating how the proposed $150 billion in the Democrats’ proposal is still guesswork, without detailed legislative language.Jonathan Gruber, a health economist at M.I.T., said the lower figure would provide home services for perhaps one million more people and create about 400,000 new jobs. That could include jobs for caretakers like family members who are unpaid but unable to go to work.But if the amount gets cut further — and negotiations on the bill are far from over — supporters warn that states may be less willing to expand services.“We need a big investment,” said Nicole T. Jorwic, senior director of public policy at The Arc, an advocacy group for people with physical and developmental disabilities. The bill has to provide at least $150 billion so “states will see the value and worth of taking it up,” she said.Even that level of funding might not eliminate the waiting lists, but “it will help take people off,” she said.Under the American Rescue Plan Act passed by Congress this year, all states made use of temporary funds allocated to shore up home and community-based services, Ms. Jorwic said.Still, the issue of wages in a pandemic economy where people are shunning lower-rung jobs bodes ill for the home health industry, whose workers have long been paid far less than others in service industries. Some businesses now pay $15 an hour or more, luring away those in underpaying jobs and leaving the vulnerable without reliable help.About 70 percent of long-term care workers earn less than $30,000 a year, according to Kaiser, and they are more likely to live in poverty. “It’s the same person who is aging into poverty and who is going to get pushed into a nursing home,” said Ms. Christ of Justice in Aging.While details are sparse, the proposed legislation would require states to prove that the funds were funneled toward higher wages. “This would be the first time that there was a large federal investment to increase wages,” Ms. Jorwic said.Higher wages are critical to finding more aides for those like Ms. Shaheed in Florida. “They’re no longer able to find anyone willing to come in for the low wages they are paying,” she said. “Nobody is going to come and help me for $10 an hour.”For those who have had to wait to qualify for financial aid for home care, the difference is palpable.People like Stephen Grammer, who has cerebral palsy, were warned since childhood that they faced institutionalization if home care could not be routinely provided.In his 20s, Mr. Grammer spent nearly a decade in a nursing home after his mother became ill. He chafed at the restrictions imposed on him while he was living with older adults with Alzheimer’s. If he left the premises, he had to be back by midnight or it would count against the 18 nights a year he was allowed to be outside.“When I had to use the restroom, I would press the call button, and many times the workers would come and turn off my call light and would walk away even though I had to go to the bathroom,” he said by email.Mr. Grammer, who uses an electric wheelchair and advocates for disabled individuals these days, eventually qualified for a Medicaid waiver and another state program that provides housing. Now at 41, he lives on his own in Roanoke, Va., and someone comes in 16 hours a day from 6 a.m. to 2 p.m. and from 4 p.m. to midnight.“I have the freedom to come and go as I please,” Mr. Grammer said.

A new analysis underscores concerns about how federal aid was allocated to health care institutions under the Provider Relief Fund, a $175-billion program that has drawn sharp criticism for giving so much money to the wealthiest U.S. hospitals.The study, published Friday in JAMA Health Forum, shows that more money flowed to hospitals that were in a strong financial position before the pandemic than went to hospitals with weaker balance sheets and smaller endowments.Small rural hospitals, called critical access hospitals, received lower levels of funding, according to the study, by researchers at the RAND Corporation, a nonprofit group. Those rural facilities often operate under extremely tight budget constraints, and some have closed or been acquired over the course of the pandemic.More aid also flowed to those hospitals caring for the greatest number of Covid patients, many of which were large academic medical centers and big hospitals.“There were large differences in how much each hospital got in funding,” Christopher M. Whaley, one of the study’s authors, said in an interview.The analysis of 952 hospitals found that 24 percent received less than $5 million, while 8 percent got more than $50 million. Overall, the small rural hospitals received 40 percent less funding than their larger and more prosperous counterparts.The researchers did not take into account $24 billion that was specifically targeted to rural and safety-net hospitals in underserved areas, which may have helped these organizations.Congress authorized the aid to cushion losses sustained by hospitals during the pandemic, as patients stayed away and facilities could not perform lucrative surgeries and procedures.But some of the hospitals that received hundreds of millions of dollars in federal funds went on buying sprees during the Covid crisis, gobbling up weaker hospitals and physician groups. A few large chains, including HCA Healthcare and the Mayo Clinic, chose to return at least some of the money.The havoc caused by the Delta variant has further strained many hospitals, overwhelming intensive care units and forcing some to renew delays in elective treatments.A September report commissioned by the American Hospital Association predicted a third of will have operating losses in 2021. Hospitals say they are treating sicker patients, many of whom delayed care earlier in the pandemic, and are paying more for staff, supplies and drugs.Dr. Whaley said the larger flow of money to hospitals in strong financial shape calls into question “the purpose of having these financial resources,” noting some institutions have massive endowments and sizable assets. In contrast, rural hospitals receiving the least aid were already under financial strain when the pandemic hit.“Policymakers should continue to ensure that these types of hospitals are sufficiently funded, potentially with additional rounds of funding,” the researchers wrote.

Less than half of workers are still not immunized at facilities in several states. “I just feel like a sitting duck,” one resident said.When Jim Lewis was told earlier this month that his 90-year-old mother, who lives in a nursing home outside of Boise, Idaho, tested positive for Covid-19, he wondered if she had gotten the virus from an unvaccinated employee.And he had reason to worry. A little more than half of the workers in the home, Creekside Transitional Care and Rehabilitation, were not vaccinated at the time, federal data show.“It was obvious that the facility had staff members who were vaccine hesitant,” said Mr. Lewis, whose mother and immediate family are all immunized.Idaho was hard hit by the Delta surge this summer and early fall, and nursing homes were not impervious to the highly contagious variant that swept through many states with lower vaccination rates. Ten states, including Florida, Michigan and Ohio, still report vaccination rates for nursing home staff under 60 percent.Others, like New York and California, and some large nursing home chains have imposed their own mandates. But many nursing home administrators are waiting for the federal government to issue new rules that will govern a mandatory vaccination program for all their staff members that President Biden first announced two months ago. And some facilities and labor groups are still pushing for a testing option in lieu of a shot.But months of delays and vaccine resistance have had wrenching consequences for families like Mr. Lewis’s, who once again are barred from visiting because of outbreaks. Creekside did not return repeated calls and emails seeking comment.After steep declines earlier this year, Covid cases and deaths in nursing homes climbed in August and September, resulting in about 4,000 deaths — even though nearly 90 percent of the nation’s nursing home residents were fully vaccinated. Residents are particularly vulnerable to breakthrough infections because so many are older and suffer from serious medical conditions, like the multiple myeloma the former secretary of state Colin Powell was being treated for when he died from complications of Covid on Monday.“It is medically wrong and borders on unethical to have unvaccinated nursing home staff caring for residents,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “The vaccine works. It has made a profound difference.”The Biden administration has said that nursing homes could face a loss of government funding — the industry heavily relies on Medicaid and Medicare funds — if they do not comply, but the regulations for enforcement of a mandate have yet to be disclosed.Federal officials say they expect to issue the regulations sometime later this month. The rules were delayed from last month after the mandate was broadened to include all health care workers.Officials from the Centers for Medicare and Medicaid Services, which will be issuing the rules, would not comment on the forthcoming regulations and did not make anyone available for an interview. It is unclear whether they are considering a testing option for nursing homes, according to people who have worked closely with the administration.Residents and their families say they are frustrated with the monthslong delays in securing that extra layer of protection, given that so many of the unvaccinated are aides and nurses who provide the most direct, daily care.Elizabeth, a nursing home resident in Minnesota, said she caught Covid earlier this year from an unvaccinated worker before she got her second dose of the Moderna vaccine. When she asked when the staff might be vaccinated under the president’s order, she was told the nursing home may focus on testing workers rather than requiring them to be vaccinated.“Nothing has happened,” said the resident, who asked that only her middle name be used and that her nursing home not be identified in fear of retaliation, a concern shared by others interviewed for this article.Her state’s Covid surge prompted the governor to call in the National Guard last week to help ease its severe shortage of health care workers.“I just feel like a sitting duck,” she said. While she continues to wear a mask, some of the staff are no longer taking the same precautions to control the spread of the virus. “It just feels horribly unsafe,” she said.While 14 percent of Americans 65 and over, including nursing home residents, have already gotten boosters, many nursing home employees have yet to get a first shot.Alisha Jucevic for The New York TimesWaning effectiveness of the vaccines that were first given to many nursing home residents has also raised concerns in the last few months.“People are dying, residents are dying,” said Susan Reinhard, the director of the AARP Public Policy Institute, which has pushed for more transparency about vaccination rates in nursing homes. “They should be afraid.”Lower vaccination rates translate into more infections, and mandates are a way to increase those rates, said Dr. Ezekiel J. Emanuel, a bioethicist at the University of Pennsylvania who advised Mr. Biden during his transition. “We should be clear that mandates have been working and have been working in every industry that has tried them,” he said.Vaccination rates among nursing home staff increased to 69 percent by early October from 62 percent in early August, when Mr. Biden announced the mandate, but some facilities still report a staff rate of half or fewer, according to the latest federal data.While some nursing homes have moved ahead with their own mandates, many are taking a wait-and-see approach, said Mark Neuberger, a lawyer with Foley & Lardner who advises health care organizations on employment issues.“Will there be an alternative?” asked Zach Shamberg, the chief executive of the Pennsylvania Health Care Association, a state trade group representing nursing homes that is pushing to be able to test employees in lieu of the vaccine. “That is preferable to simply losing those workers, especially as providers are combating work force shortages.”Many nursing homes “remain very concerned that we are not going to see vaccination acceptance rates increase,” he said.“Our hope is that the small print allows us to do a test-out option,” said Mary Susan Tack-Yurek, the chief quality officer and a partner at Quality Life Services. The family-owned nursing home chain in western Pennsylvania reports that a little more than half of the staff is vaccinated. “Are we pleased with our staff vaccination rate? No, we are not pleased with it,” she said..css-1kpebx{margin:0 auto;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-1kpebx{font-size:1.25rem;line-height:1.4375rem;}}.css-1gtxqqv{margin-bottom:0;}.css-k59gj9{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;width:100%;}.css-1e2usoh{font-family:inherit;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;border-top:1px solid #ccc;padding:10px 0px 10px 0px;background-color:#fff;}.css-1jz6h6z{font-family:inherit;font-weight:bold;font-size:1rem;line-height:1.5rem;text-align:left;}.css-1t412wb{box-sizing:border-box;margin:8px 15px 0px 15px;cursor:pointer;}.css-hhzar2{-webkit-transition:-webkit-transform ease 0.5s;-webkit-transition:transform ease 0.5s;transition:transform ease 0.5s;}.css-t54hv4{-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-1r2j9qz{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-e1ipqs{font-size:1rem;line-height:1.5rem;padding:0px 30px 0px 0px;}.css-e1ipqs a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;}.css-e1ipqs a:hover{-webkit-text-decoration:none;text-decoration:none;}.css-1o76pdf{visibility:show;height:100%;padding-bottom:20px;}.css-1sw9s96{visibility:hidden;height:0px;}.css-1in8jot{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;font-family:’nyt-franklin’,arial,helvetica,sans-serif;text-align:left;}@media (min-width:740px){.css-1in8jot{padding:20px;width:100%;}}.css-1in8jot:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-1in8jot{border:none;padding:10px 0 0;border-top:2px solid #121212;}What to Know About Covid-19 Booster ShotsThe F.D.A. authorized booster shots for a select group of people who received their second doses of the Pfizer-BioNTech vaccine at least six months before. That group includes: vaccine recipients who are 65 or older or who live in long-term care facilities; adults who are at high risk of severe Covid-19 because of an underlying medical condition; health care workers and others whose jobs put them at risk. People with weakened immune systems are eligible for a third dose of either Pfizer or Moderna four weeks after the second shot.Regulators have not authorized booster shots for recipients of Moderna and Johnson & Johnson vaccines yet. A key advisory committee to the F.D.A. voted unanimously on Oct. 14 to recommend a third dose of the Moderna vaccine for many of its recipients. The same panel voted unanimously on Oct. 15 to recommend booster shots of Johnson & Johnson’s one-dose vaccine for all adult recipients. The F.D.A. typically follows the panel’s advice, and should rule within days.The C.D.C. has said the conditions that qualify a person for a booster shot include: hypertension and heart disease; diabetes or obesity; cancer or blood disorders; weakened immune system; chronic lung, kidney or liver disease; dementia and certain disabilities. Pregnant women and current and former smokers are also eligible.The F.D.A. authorized boosters for workers whose jobs put them at high risk of exposure to potentially infectious people. The C.D.C. says that group includes: emergency medical workers; education workers; food and agriculture workers; manufacturing workers; corrections workers; U.S. Postal Service workers; public transit workers; grocery store workers.For now, it is not recommended. Pfizer vaccine recipients are advised to get a Pfizer booster shot, and Moderna and Johnson & Johnson recipients should wait until booster doses from those manufacturers are approved. ​​The F.D.A. is planning to allow Americans to receive a different vaccine as a booster from the one they initially received. The “mix and match” approach could be approved once boosters for Moderna and Johnson & Johnson recipients are authorized.Yes. The C.D.C. says the Covid vaccine may be administered without regard to the timing of other vaccines, and many pharmacy sites are allowing people to schedule a flu shot at the same time as a booster dose.But if those workers left rather than be forced to get the shots, “we just couldn’t function,” Ms. Tack-Yurek said. “There aren’t enough resources in agency staffing, in the National Guard, to pull from other states, to make it up.”Mary Susan Tack-Yurek, chief quality officer at Quality Life Services in New Castle, Pa. “Are we pleased with our staff vaccination rate? No, we are not pleased with it,” she said.Angelo Merendino for The New York TimesThe nursing home chain, which employs about 1,100 people, has been unable to persuade workers to get immunized, despite holding raffles offering rewards like a chance to go to Disneyworld or $5,000 in cash. “The response was minimal,” Ms. Tack-Yurek said.Other nursing home officials dismiss the option of testing as an alternative. “We already have testing,” said Brendan Williams, the chief executive of the New Hampshire Health Care Association, whose members have been more successful in vaccinating their employees. “That is just preserving the status quo.”Much depends on the communities where nursing homes draw their workers. If an area’s opposition to vaccination is strong, it becomes more difficult to sway recruits to get shots, and vice versa.At Chaparral House in Berkeley, Calif., where vaccination rates are high, the vast majority of employees presented with paperwork to get immunized were willing, said the nursing home’s chief financial officer, Chuck Cole. “Most people didn’t read beyond the first paragraph,” he said, because they were already persuaded they should get the shot. “That was very important.”By talking one-on-one with the small number of workers who were concerned about the vaccine, the nursing director and administrator were able to persuade the holdouts, he said. Only one employee of roughly 150 still refuses to get vaccinated.Covid cases in the United States have dropped significantly in the last month, as more people are vaccinated and the Delta surge seems to be subsiding in most regions of the country.The state mandates are helping to increase levels of protection for all age groups, and about 14 percent of the nation’s nursing home residents have already received a booster dose.And some nursing homes that successfully imposed their own requirements are contributing to a higher success rate, said Brian McGarry, a health researcher at the University of Rochester who is studying levels in nursing homes. Genesis HealthCare, a large chain in Pennsylvania, said while there were some departures, all of its staff is now vaccinated.“We are seeing the benefits of our policy in resident safety, as our Covid rates (and particularly the severity of any infections) have declined considerably since we instituted our policy, despite overall community infection rates remaining very high,” said Lori Mayer, a company spokeswoman, in a statement.“The mandates are starting to help,” Dr. McGarry said. The actual enactment of a requirement by a state or facility “is a heavy lever and signal to this group that it’s not going to be optional any more.”

Although nursing home deaths from Covid-19 remain dramatically down from their peak at the end of last year, a Kaiser Family Foundation analysis shows a significant uptick in August as the Delta variant swept through the country.After declining for months, largely because of the federal effort to vaccinate residents, the number of deaths rose sharply from July to August. Nursing homes reported nearly 1,800 deaths among their residents and staff in August, which represented the highest monthly toll since February.The findings underscore the ongoing vulnerability of nursing home residents, who are old and in poor health, and highlights the importance of getting booster shots to people in this population. The rising number of infections could fuel more calls to vaccinate nursing home workers ahead of the federal requirement announced in August by President Biden.“While the vast majority of Covid-19 deaths happened outside of nursing homes in July and August, the high rate of increase within nursing homes indicates that residents and staff in these settings are at risk of death during the Delta surge,” the researchers said. The study, published Friday, did not break out how many of the dead were unvaccinated.August saw a much steeper increase in deaths in nursing homes than in the community at large, said Priya Chidambaram, a senior policy analyst for the foundation and one of the study’s authors. “Vaccinations are very strongly protecting people in these facilities, but the Delta variant did have an impact,” she said.Preliminary data from September may indicate deaths are falling again, she said.Nursing homes were especially hard hit early on in the pandemic, accounting for nearly a third of the country’s overall deaths through the end of June, according to the Kaiser analysis. But the vaccination of residents brought the monthly number of deaths down from a high of around 22,000 in December and January to around 300 for June and July.Although cases did increase, “we’re still nowhere near our peak in December 2020, nor at any point last year, thanks to safe and effective vaccines as well as providers’ ongoing vaccination efforts and infection control measures,” the American Health Care Association, a major nursing home trade group, said in a statement.The association said infections were largely the result of a high number of cases in the surrounding community. The very small number of cases occurring “are largely happening in communities where there is high spread and low vaccination rates among the general population,” the group said.But the group added that it was encouraged by the recent rollout of booster shots for the Pfizer vaccine and said it was eager to follow any developments regarding the other vaccines.While the vaccination rate among residents is now approaching 85 percent, according to the latest data from the federal Centers for Medicare & Medicaid Services, only about 65 percent of nursing home employees are vaccinated, roughly the same percentage as American adults overall.“The rate of increase among staff is slower than among residents,” Ms. Chidambaram said.

As the nation’s death toll climbed above 700,000 in October, Dr. Anthony S. Fauci, an adviser on the pandemic to President Biden, emphasized the need for the 70 million Americans who are eligible for a vaccine to get immunized during interviews on Sunday morning talk shows.“Many of those deaths were unavoidable but many, many are avoidable, were avoidable and will in the future be avoidable,” Dr. Fauci, who is also director of the National Institute of Allergy and Infectious Diseases, said on CNN’s State the Union.Dr. Fauci was enthusiastic about the development of the new Merck anti-viral pill, describing it as “extremely important.” In announcing the results of its clinical trial last Friday, Merck said the pill was able to cut the risk of hospitalization and death from the virus by half.But he also warned that Americans should not wait to be vaccinated because they believe they can take the pill. While the new medicine may decrease a person’s risk, the best way to be protected is avoiding infection, he said.Merck said it would seek emergency authorization from the Food and Drug Administration for its drug, known as molnupiravir, as soon as possible. The pills could be available by late this year.Dr. Fauci pointed to the stark difference in how many people died during Merck’s clinical trial for the treatment, with eight among the placebo group and none among those taking the drug. “That’s very impressive, so we really look forward to the implementation of this and to its effect on people who are infected,” he said.The federal government has placed advanced orders for 1.7 million doses of the new medication. But Dr. Scott Gottlieb, the former F.D.A. commissioner under President Trump and a board member for Pfizer, said that amount was “not enough” on CBS’ Face the Nation, covering only one month’s worth of infections in Southern states since the Delta variant emerged. He also contrasted that quantity with the national stockpile of medication to treat a flu pandemic, which he said numbers in the tens of millions.Earlier, Dr. Fauci dismissed the notion that federal officials had not procured enough of the medicine, saying they had placed “a good bet” on the treatment.“We have options for millions more,” he said on the program, predicting the company would ramp up production to meet demand in the United States and across the world.Dr. Fauci also expressed optimism that the country was now seeing a slow down in cases, signaling a potential respite from the pandemic. “We certainly are turning a corner on this particular surge,” he said during an interview on “This Week” on ABC News.But he also refused to predict whether people would be able to freely gather this coming Christmas, saying on CBS News that “it’s just too soon to tell.”

Hundreds of sought-after nurses are leaving some U.S. hospitals that have established vaccine requirements for all employees, involving some protests and legal opposition. But most workers, especially at large hospital chains, appear to be complying with the policies.New York hospitals and nursing homes are grappling with the state’s Monday deadline for workers to have received at least one coronavirus vaccine dose, with thousands of workers remaining unvaccinated and at risk of being fired. Several other states and cities have also imposed mandates for health care workers, with deadlines approaching.All are also facing a looming federal vaccine mandate for hospital and nursing home staff that President Biden ordered, though its exact scope and timing has yet to be announced.The departures, especially of nurses, have compounded major staffing shortages over the course of the pandemic. The situation has become acutely difficult these past few months, particularly in regions where the Delta variant has overwhelmed hospitals and caused new spikes in Covid cases among nursing home staffs and residents. In one instance, a hospital in upstate New York said it briefly had to stop delivering babies after six of its employees left rather than get vaccinated.At Novant Health, a large hospital group based in North Carolina, 375 workers were suspended after not meeting the system’s vaccination deadline this month. Another 200 agreed to comply, increasing the vaccination rate to over 99 percent of its more than 35,000 employees, according to Novant.Yet the loss of some employees “is going to be the cost of doing business in a pandemic,” said Dr. Saad B. Omer, the director of the Yale Institute for Global Health, who has studied vaccine mandates. “I’m not seeing any widespread disruptive effect,” he said.Dr. David H. Priest, an infectious-disease specialist and senior executive at Novant, said he believed that the hospital would persuade most of its workers by addressing their concerns. The hospital has “been working on this for weeks on end,” he said, by holding webinars and sending emails to help educate employees about the benefits of being immunized.How the nation’s hospitals are handling the holdouts varies widely, and many facilities are waiting for federal guidelines. Others have set deadlines later this year.Many hospitals are not establishing sharp cutoffs for when they might eventually fire someone.UNC Health, another North Carolina group, said that it was confirming the status of about 900 employees. About 70 employees have left as a result of the system’s mandate, and the group has granted about 1,250 exemptions for medical or religious reasons. About 97 percent of its work force have complied. Those who still need to be vaccinated or qualify for an exemption have until Nov. 2, providing what UNC described as “a last chance to remain employed.”At Trinity Health, one of the first major hospital chains to announce a vaccine mandate, the percentage of its vaccinated staff has increased from 75 percent to 94 percent, said the group, which operates in 22 states..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-1kpebx{margin:0 auto;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-1kpebx{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-1kpebx{font-size:1.25rem;line-height:1.4375rem;}}.css-1gtxqqv{margin-bottom:0;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-19zsuqr{display:block;margin-bottom:0.9375rem;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}SSM Health, a Catholic hospital group based in St. Louis, also adopted a mandate but said that few of its workers had left because of its requirement.Hospitals and nursing homes have raised concerns about their ability to find workers if they impose strict requirements. The situation may be worse in rural areas, where limited numbers of workers are available. But healthy vaccinated workers may also ease staffing shortages.At Houston Methodist, where 150 employees left from a work force of about 26,000 people, the hospital said that there had been little lasting effect on its ability to hire people. And when Texas was hit with rising numbers of Covid cases over the summer, the hospital found that fewer of its workers were out sick.“The mandate has not only protected our employees, but kept more of them at work during the pandemic,” a hospital spokeswoman said in an email.ChristianaCare, a hospital group based in Wilmington, Del., said on Monday that it had fired 150 employees for not complying with its vaccine mandate. But the group emphasized that over the last month it had hired more than 200 employees, many of whom are more comfortable working where they knew their colleagues were vaccinated.

In areas inundated with coronavirus patients, hospitals have postponed treatments and surgeries for people with other serious conditions.In chronic pain, Mary O’Donnell can’t get around much. At most, she manages to walk for a short time in her kitchen or garden before she has to sit down. “It’s just frustrating at this point,” said Ms. O’Donnell, 80, who lives in Aloha, Ore. “I’m really depressed.”She had been preparing for back surgery scheduled for Aug. 31, hoping the five-hour procedure would allow her to be more active. But a day before the operation, at OHSU Health Hillsboro Medical Center, she learned it had been canceled.“Nope, you can’t come, our hospital is filling up,” she said she was told.Faced with a surge of Covid-19 hospitalizations in Oregon, the hospital has not yet rescheduled her surgery. “I don’t know what is going to happen,” Ms. O’Donnell said, worrying that her ability to walk might be permanently impaired if she is forced to wait too long.Recent spikes in Covid cases forced the OHSU hospital in Portland, Ore., to reschedule elective surgeries.Alisha Jucevic for The New York TimesEchoes of the pandemic’s early months are resounding through the halls of hospitals, with an average of more than 90,000 patients in the United States being treated daily for Covid. Once again, many hospitals have been slammed in the last two months, this time by the Delta variant, and have been reporting that intensive care units are overflowing, that patients have to be turned away and even that some patients have died while awaiting a spot in an acute or I.C.U. ward.In this latest wave, hospital administrators and doctors were desperate to avoid the earlier pandemic phases of blanket shutdowns of surgeries and other procedures that are not true emergencies. But in the hardest-hit areas, especially in regions of the country with low vaccination rates, they are now making difficult choices about which patients can still be treated. And patients are waiting several weeks, if not longer, to undergo non-Covid surgeries.“We are facing a dire situation,” said Dr. Marc Harrison. the chief executive of Intermountain Healthcare, the large Utah-based hospital group, which announced a pause of nearly all non-urgent surgeries on Sept. 10.“We do not have the capacity at this point in time to take care of people with very urgent conditions yet are not immediately life threatening,” he said at a news conference.In some of the hardest-hit areas, like Alaska and Idaho, doctors are taking even more extreme steps and rationing care.When they can, some hospitals and doctors are trying to seek a balance between curtailing or shuttering elective procedures and screenings — often lucrative sources of revenue — and maintaining those services to ensure that delays in care don’t endanger patients.The industry was largely insulated last year from the revenues they lost during the pandemic after Congress authorized $178 billion in relief funding for providers. Some large hospital groups were even more profitable in 2020 than before the virus took its financial toll, with some going on spending sprees and buying up doctors’ practices and expanding. Many had starting seeing operations return to normal levels.A few large hospital chains did not meet the criteria for aid they had received, and returned some of it. It’s unclear how much more hospitals can expect, even if they shutter some of their operations during this latest wave. The Biden administration said earlier this month that it planned to release $26 billion in remaining Covid relief funds.Officials have also had to weigh the risk of admitting patients who could infect others.But doctors have also been monitoring some of the long-term effects of long waiting times for non-Covid patients during the pandemic, wary of the specter of unchecked cancers or ignored ulcerative conditions if screenings are postponed.And the waiting is still extremely stressful, troubling both doctors and patients with pressing illnesses who do not view their conditions as non-urgent.Robin Strong at her home in Columbus, Ga. Her doctor told her that because of rising Covid cases, a procedure to repair her paralyzed vocal cord would be delayed.Audra Melton for The New York TimesIn Columbus, Ga., Robin Strong’s doctor told her a few weeks ago that the rising Covid caseloads there would delay a procedure to repair a vocal cord that was paralyzed in a previous surgery.Because of her condition, she chokes easily and has a hard time breathing. “I just cry all the time because of my situation,” she said.Compounding the physical discomfort is her frustration that so many people in her state won’t get vaccinated against Covid, and they are getting sick and taking up hospital beds.Only 66 percent of adults in Georgia have received at least one vaccine dose, compared with 77 percent of all adults in the United States who have received at least one dose of the vaccine, according to the latest data from federal and state health officials.“They are punishing people like me,” Ms. Strong said.In some areas, doctors are explicitly rationing care. On Thursday, Idaho state officials expanded “crisis standards of care” across the state, a standard that had been limited to the northern part of the state earlier in the month. “We don’t have enough resources to adequately treat the patients in our hospitals, whether you are there for Covid-19 or a heart attack or because of a car accident,” Dave Jeppesen, the director of the Idaho Department of Health and Welfare, said in a statement.With precious few available intensive-care beds, Idaho hospitals had largely stopped providing hernia surgeries or hip replacements before the new order. Now they are postponing cancer and heart surgeries, too, said Brian Whitlock, the chief executive of the Idaho Hospital Association. The hospitals there “have been doing their level best,” he said.In Alaska, the state’s largest hospital, Providence Alaska Medical Center in Anchorage, has also begun rationing care as patients wait for hours to get to the emergency room and doctors scramble to find beds. “While we are doing our utmost, we are no longer able to provide the standard of care to each and every patient who needs our help,” said the hospital’s medical staff in a letter to the community in mid-September.When the pandemic first slammed hospitals last year, many institutions found no alternative to postponing nonessential procedures. “We weren’t sure what we were really going to face,” said Dr. Matthias Merkel, senior associate chief medical officer for capacity management and patient flow at Oregon Health & Science University, the state’s academic medical center in Portland. “We pre-emptively stopped elective surgeries and emptied out the hospitals.”In this latest round, hospitals and doctors have been more willing to continue doing procedures like colonoscopies for some patients if they can. “We want to continue to do as much as we can in all areas,” Dr. Merkel said.His hospital, he added, hadn’t “yet recovered from the backlog we created” from delaying treatments earlier in the pandemic.Even so, some patients with serious conditions are living in a precarious limbo. Paul McAlvain, 41, had waited months to get a surgery opening at OHSU to repair a leaking heart valve.“They kept saying how bad I was and how they needed to get me in right away,” said Mr. McAlvain, a helicopter pilot for Life Flight Network, which ferries critically ill patients to medical centers. He had developed an irregular heart beat from his condition, and was finally scheduled for surgery Sept. 1.But the spike in cases this summer further postponed his operation. “I had made work arrangements, life arrangements, got mentally ready,” Mr. McAlvain said. The surgery took place on Sept. 8.Dr. Merkel acknowledged the toll that uncertainty can take on patients. “It might medically make no difference, but emotionally it could have a huge impact,” he said.Paul McAlvain recovering in the cardiovascular intensive care unit after his surgery, which was moved from Sept. 1 to Sept. 8 because of Covid cases.Alisha Jucevic for The New York TimesSome hospital officials say they have been assessing the effects of delayed care caused by the shutting down of elective procedures earlier in the pandemic. “It was very clear that many of these folks had decompensated or were more acutely ill than they would have otherwise been,” said Dr. Bryan Alsip, the chief medical officer at University Health in San Antonio, Texas..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media 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a:hover{-webkit-text-decoration:none;text-decoration:none;}Though his hospital is confronting yet another wave of Covid cases, Dr. Alsip said, it is still scheduling surgeries that do not require an overnight hospital stay.In North Carolina, the pent-up demand for care has added a new layer of strain now that Delta has pushed some hospitals to their limits.“From an overall community perspective, this time, compared to March and April, our E.D. volumes are at all-time highs,” referring to the hospital emergency department, said Dr. John Mann, a surgeon who oversees surgical and specialty care services for Novant Health, a large hospital group based in North Carolina. “It’s every illness imaginable. They’re all coming in for care.”This year, unlike last, Novant is not making any universal decisions about how to handle cases that have been deemed non-urgent. While rising Covid cases forced it to stop elective procedures at its Rowan Medical Center for weeks, orthopedic and colorectal surgeries are continuing at Novant Health Clemmons Medical Center, a much smaller hospital. “We’re doing it facility by facility,” Dr. Mann said.While hospitals have generally been better able to predict what resources they will need as the pandemic ebbs and flows, making them less likely to halt elective procedures, more have started to do so recently, said David Jarrard, a hospital consultant.Hospitals are also still struggling with a severe shortage of nurses, but are less worried about running out of critical equipment like N95 masks.“We all learned a tremendous amount over the last year and a half,” said Dr. David Hoyt, the executive director for the American College of Surgeons, which released guidelines to help surgeons adjust their caseloads rather than cancel non-urgent procedures.Government officials have also been much less likely to call for an absolute stop, which occurred frequently in the early months of the pandemic. Amber McGraw Walsh, a lawyer with McGuireWoods who has closely monitored Covid restrictions, said state, local and even federal agencies do not have the appetite this time around to prohibit elective surgeries.Now, hospitals are much more likely to work with public health officials and their competitors to better manage the higher demands for care, making decisions as a group rather than individually. “You do see a lot of local hospital associations coming together, making their own rules of the road,” she said.Hospital administrators have sought a balance between curtailing elective procedures and maintaining them to ensure that delays in care don’t endanger patients.Alisha Jucevic for The New York TimesStill, the last few weeks have tested nurses and hospital staffs like no other period of the pandemic.As an anesthesiologist and intensivist working in critical care, Dr. Merkel described the last two weeks as the most difficult of his career.Despite widespread vaccine availability, Dr. Merkel and his colleagues are now caring for younger patients, those under 50, who are dying of complications from Covid, including organ failure and acute respiratory distress syndrome. Many were transferred from other hospitals because they were so ill.“It is hard to see a patient’s life ending from something where we could have had a preventive intervention,” Dr. Merkel said.

Nursing home aides — the staff members who provide the most direct care to residents — were the least likely to be fully vaccinated against the coronavirus by mid-July, according to a new analysis of U.S. facilities.The study underscores the influence that President Biden’s new federal mandate for all health care workers may have on populations like the elderly in nursing homes who are vulnerable to coronavirus infections, experts say.The findings are “alarming and reason for pause,” said Brian McGarry, a health researcher at the University of Rochester and one of the authors of the analysis, which appeared in a research letter in JAMA Internal Medicine on Thursday.Low vaccination rates among nursing home workers in some areas have fueled concern about fresh outbreaks among staff and residents in these facilities, even with high numbers of vaccinated residents. Covid deaths among nursing home staff and residents accounted for nearly one third of the nation’s pandemic fatalities as of June 1, and vaccination rates among staff average around 63 percent, according to the latest federal data.But slightly under half of the certified nursing assistants were fully vaccinated, according to the analysis, which looked at federal vaccination data through July 18. That was before many nursing homes, states and cities began imposing mandates.According to the study, in nursing homes overall, 61 percent of nurses, both registered nurses and licensed practical nurses, were vaccinated, compared with 71 percent of therapists and 77 percent of doctors and independent practitioners like physician assistants or nurse practitioners. Some large nursing homes were starting to mandate vaccinations as the Delta variant began tearing through their communities and coming into nursing homes.Nationally, about two-thirds of adults are now fully vaccinated, according to federal data.David Grabowski, a professor of health care policy at Harvard Medical School and one of the study’s authors, said few nursing homes have mandates in place so far. While homes’ vaccination rates have ticked up slightly, the overall rate for nursing homes has hovered at just a little above 60 percent in the last couple of months even as the Delta variant took hold and drove up new cases among staff and residents.The nursing home industry, which had been opposed to a mandate aimed specifically at its workers, favors the broader U.S. mandate. “We applaud President Biden for expanding Covid-19 vaccination requirements to all Medicare and Medicaid-certified health care settings as well as larger businesses,” said Mark Parkinson, the chief executive of the American Health Care Association, a major nursing home trade group, in a statement. The researchers also looked at characteristics of the nation’s 15,000 nursing homes to determine which facilities had the most success in vaccinating their workers. While the vaccination rates of the county where they were located played a significant role, the researchers also found that traits like higher quality ratings from the Medicare program, the nonprofit status of the facility and a long-tenured staff also seemed to lead to higher rates.“That gives us some suggestion that facility culture and leadership may play a role,” Dr. McGarry said, and management at these nursing homes may be better able to work with their staff to increase vaccine acceptance..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}But none of those factors alone appeared to be critical in a nursing home’s success. “A lot of things seemed to matter a little bit,” he said.Most influential may be the president’s decision earlier this month to impose a new federal mandate requiring all health care workers to be vaccinated. Nursing home workers may no longer be able to “job shop” as easily to find employment where vaccines are not mandated.“The mandate takes all those things off the board and says everyone has to do it,” he said.