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.
Echoes 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.
In 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.
Some 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.
Understand Vaccine and Mask Mandates in the U.S.
- Vaccine rules. On Aug. 23, the Food and Drug Administration granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for an increase in mandates in both the public and private sectors. Private companies have been increasingly mandating vaccines for employees. Such mandates are legally allowed and have been upheld in court challenges.
- Mask rules. The Centers for Disease Control and Prevention in July recommended that all Americans, regardless of vaccination status, wear masks in indoor public places within areas experiencing outbreaks, a reversal of the guidance it offered in May. See where the C.D.C. guidance would apply, and where states have instituted their own mask policies. The battle over masks has become contentious in some states, with some local leaders defying state bans.
- College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
- Schools. Both California and New York City have introduced vaccine mandates for education staff. A survey released in August found that many American parents of school-age children are opposed to mandated vaccines for students, but were more supportive of mask mandates for students, teachers and staff members who do not have their shots.
- Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get a Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities, even within their work force.
- New York City. Proof of vaccination is required of workers and customers for indoor dining, gyms, performances and other indoor situations, although enforcement does not begin until Sept. 13. Teachers and other education workers in the city’s vast school system will need to have at least one vaccine dose by Sept. 27, without the option of weekly testing. City hospital workers must also get a vaccine or be subjected to weekly testing. Similar rules are in place for New York State employees.
- At the federal level. The Pentagon announced that it would seek to make coronavirus vaccinations mandatory for the country’s 1.3 million active-duty troops “no later” than the middle of September. President Biden announced that all civilian federal employees would have to be vaccinated against the coronavirus or submit to regular testing, social distancing, mask requirements and restrictions on most travel.
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