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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By Naoki Nitta for Civil Eats.
Broadcast version by Suzanne Potter for California News Service reporting for the Solutions Journalism Network-Public News Service Collaboration
It's no wonder that hospital food gets a bad rap, says Santana Diaz, executive chef at the University of California Davis Medical Center, a sprawling, 142-acre campus located in Sacramento, California. As a seeming compromise between nutrition and institutional efficiency, food has long been dished up as an afterthought to patient care. “That was never the focus of hospitals,” he adds.
But for Diaz, good food is key to good health. Since taking the helm of the facility’s nutrition and dining services in 2018, he has worked to revamp the cuisine, including sourcing almost half of ingredients from farms and ranches within a 250-mile radius of the Sacramento Valley. Food grown in local fields, orchards, and pastures with healthy soil management practices simply make for healthier, more nutritious, and more flavorful meals, he says—the perfect ingredients for changing the “stigma” associated with hospital fare.
Diaz is not alone in making this shift, but he may be ahead of the game. In 2022, the University of California (U.C.) system—a network of 10 campuses and five medical centers—committed to supporting regenerative farming as part of U.C. President Michael Drake’s vision to mitigate the effects of climate change and drive a more equitable food system. And as an advisor to an initiative lead by the nonprofit organization Roots of Change, Diaz is helping to steer the larger institution toward local agriculture—through the system-wide procurement of regeneratively ranched beef.
The term, a general reference to pasture management that prioritizes soil health and perennial plants by grazing livestock through rotated paddocks, encompasses a set of practices that advocates say results in healthier animals and pastures. Research also shows that beef from cattle raised strictly on grass is more nutritious than conventional beef, although it’s not yet clear how regenerative practices may impact those findings.
Cumulatively, the U.C. dining system serves more than 600,000 meals a day during the academic year. By ensuring reliable demand for regeneratively raised meat, proponents of the system’s new procurement pledge see the sizable volume giving the state’s independent ranchers and rural economy a huge boost, and bolstering the local and regional meat supply chain.
It’s a tall order, but Diaz knows the sway that comes with institutional demand. The former executive chef at the Sacramento Kings’ Golden 1 Center and the San Francisco 49ers’ Levi’s Stadium is also a founding member of Beef2Institution, a non-profit program helping K-12 schools, hospitals, and sports venues in California source beef from local, family-owned ranches.
Institutions are the perfect outlet, says Diaz, for ground, braising, and stewing meat and the other lower-value, secondary cuts that make up nearly two-thirds of every beef carcass. So featuring hamburgers, boneless short ribs, and carne asada as part of a local farm-to-fork menu offers nearby ranchers a prime bread-and-butter opportunity, he says—all the while exposing a captive audience to the value of beef raised on regenerative pasture.
“Obviously, we’re not going to change patient behavior . . . in [one] hospital stay,” Diaz notes. But because diet plays a major role in raising the risk of heart disease, diabetes, and other chronic conditions, there’s huge merit, he adds, in educating them about preventative and nutritional approaches to health management.
And with his kitchen alone churning out 6,500 meals a day—along with patients, the medical center feeds an army of clinicians, staff, and medical and nursing students—the appetite of the entire U.C. system will likely have a resounding impact on the larger beef market in the state. “That’s how institutions can flex their buying power,” Diaz says.
A Premium Product
Despite research showing that eating less beef has significant health and environmental benefits, including shrinking an individual’s carbon footprint by as much as 75 percent, America’s steak and burger consumption is on the rise.
Currently, the vast majority of U.S. beef comes from cows raised on pasture for about the first year of their lives, then moved to concentrated animal feeding operations (CAFOs)—large-scale industrial facilities that grain-finish cattle in confinement for six to eight months before slaughter. Along with concentrated levels of environmental pollution, critics deride beef feedlots as places where hundreds if not thousands of cattle are crowded together. These conditions typically require antibiotics to prevent herds from getting sick; subsequently, this “subtherapeutic” use has also been linked to antibiotic resistance.
Nevertheless, CAFOs are also the basis of a “hyper-efficient” commodity system, says Renee Cheung, managing partner at Bonterra Partners, an impact investment advisory firm for regenerative agriculture and co-author of a market analysis of grass-fed beef. These operations pump out a consistent, year-round supply of beef for the meatpacking industry, a sector dominated by a handful of multinational giants that control more than 80 percent of the country’s beef market.
Grazing cattle on pasture for the entirety of their lives, on the other hand, is far less productive. As such, strictly grass-fed or grass-finished operations tend to be modest in scale, says Cheung, with the majority of ranches in the U.S. herding around 50 heads. The smaller volumes and seasonality of pastures create more variability in slaughter weight and harvest windows, running counter to the conventional year-round commodity model.
As a result, non-CAFO operations don’t benefit from the economy of scale built into the heavily consolidated processing and marketing infrastructure, Cheung says. With limited access to centralized meatpacking facilities, these producers are often saddled with high overhead for transport, cold storage, and market delivery—all of which add to premium prices at the meat counter.
The cost, however, also reflects a more superior product. Compared to conventionally raised beef, studies show that strictly pasture-fed beef contain higher nutrients with less fat, often with lower levels of antibiotics, hormones, and risk of food contamination. And grass-fed cuts simply taste better, according to Chef Dan Barber, sustainable and ethical farming advocate and author of The Third Plate, who extols its rich, complex, and “undeniably beefy” flavor.
Not all pasture-based ranchers have adopted paddock-based regenerative practices, but the number appears to be growing. That’s in part because the holistic principles of regenerative ranching go hand in hand with land stewardship and animal welfare, says Michael Dimock, executive director of Roots of Change. By “mimicking nature,” the grazing patterns of ruminants benefit from natural forage and room to roam, all the while “maximizing soil health and biodiversity” of plants, insects, and other animals.
Regardless, recent research shows that 100 percent grass-fed cattle have a larger carbon footprint than those finished on grain because they fatten at a slower rate, yet also weigh as much as 20 percent less at maturity. And while regeneratively managed pastures have been shown to sequester carbon, the science behind the potential for “carbon-neutral beef” has been overblown. Still, Dimock adds that well-managed, rotational grazing enhances pasture productivity, helps restore spent cropland, and prevents wildfires by keeping invasive grasses and dry brush in check.
It’s also a highly efficient use of marginal land, notes Dimock—a classification of the 70 percent of the world’s arable regions unsuited for crop production due to poor soil, aridity, or steepness. As he sees it, regenerative ranching is also accessible and practical for smaller operations because it’s scalable, and lowers the financial risks associated with compliance-centered practices like organic farming.
The Power of Procurement
Making regenerative beef a more attainable business model requires developing a resilient supply chain, says Dimock, one that caters primarily to smaller producers. The COVID-19 pandemic exposed the vulnerabilities of a heavily consolidated industry, including bottlenecks in meat processing due to labor shortages and transportation breakdowns. Along with the USDA’s recent $1 billion investment in expanding the nation’s meat and poultry processing capacity, he sees California’s $600 million Community Economic Resilience Fund (CERF) giving a major boost to the state’s meat supply infrastructure.
The targeted funding includes shoring up the network of smaller, regional harvest, processing, and storage facilities, he adds, and will help rural communities develop stronger economic hubs that decentralize the current top-heavy model. But those new and expanded facilities won’t succeed if there isn’t a consistent market for the kind of meat they process.
“If we want to give small-scale ranchers a fair shot,” Dimock says, “we have to break up [the current corporate stronghold].”
Going up against the commodity system, however, comes with additional challenges. While grass-fed beef accounts for roughly $4 billion, or 4 percent of the overall U.S. market, an estimated 80 percent of the supply consists of imports, largely from Australia, Uruguay and Brazil—countries where raising livestock on pasture is far more economical. Passed through a USDA-inspected plant, these products can be labeled “domestic,” leaving true domestic producers at an economic disadvantage.
In fact, the general lack of standards and regulations for the grass-fed sector has created a Wild West landscape of labels, says Bonterra’s Cheung. For its part, the USDA has recently announced stepping up its labeling guidelines, which distinguish true grass-fed beef from confusing claims such as “pasture-raised,” “50 percent grass-fed,” and “grass-fed and grain-finished.” These are highly misleading terms, she notes, given that most cattle are pastured for the first year of their lives. And “there has been a lot of outright cheating in the industry,” she adds—for instance, grass-fed labels can still apply to confined cattle raised on grass pellets.
The fundamental practices of regenerative ranching align with California’s efforts to promote farming “in a manner that restores and maintains natural systems,” says California Department of Food and Agriculture (CDFA) Secretary Karen Ross. The approach also complements the state’s climate smart initiatives and efforts to advance social equity through the support of small-scale farms and ranches.
Still, Ross acknowledges that the term’s inherent flexibility can make it a fuzzy concept. That’s especially true in California, where regional variations in microclimates, precipitation levels, and soil structure reflect a wide practice spectrum—some ranches in the state’s mountainous reaches, for example, may winter their herds on dried silage when fields are bare, while others may have the means to transport them to greener pastures.
“If you talk to 12 people about regenerative [practices], you’ll get 12 different definitions,” Ross says.
Currently, several certifications such as the American Grassfed Association (AGA), Regenerative Organic Certified, and Land to Market provide a range of overlapping criteria that ensure the regenerative provenance of meat. By outlining transparent measures, these voluntary labels are intended to legitimize and safeguard the premium nature of regeneratively produced beef.
Last month, the CDFA began work on officially defining regenerative ranching and agriculture. Rather than developing standards for state certification, and the goal is “to make sure that when we use the term, we have a shared understanding of what the practices are,” says Ross. The “inclusive” set of parameters will help inform state policy around regenerative food production, she adds—including public procurement initiatives.
Public institutions are “a ready-made way” to spur and ensure market demand for healthy food from sustainable sources, adds Ross, who has been involved in discussions about the UC initiative. “We’re investing in better outcomes for farmers, the community, and the environment,” she says. “That’s the power of procurement.”
Building the Supply Pipeline
Balancing supply and demand is nonetheless a delicate endeavor, says Tom Richards, co-owner of Richards Grassfed Beef in Yuba County, California. The fifth-generation rancher has been a key voice in both the UC initiative and Beef2Institution.
Most of California’s pasture-grazing operations focus on a premium, direct-to-consumer market. Between online sales, farmers markets, restaurants, and specialty retailers, year-to-year demand tends to be stable—and manageable.
The supply of better beef “isn’t something you can just dial up,” says Richards. Increasing herds is a risky investment—“it takes three years to raise one of these animals,” he notes—so clear market forecasts are imperative. “The biggest thing that we need from the industry is for somebody like a Santana [Diaz] or UC to say, ‘we’re committed to [helping you] map out a three- to five-year plan to grow your supply,’” he says.
“Right now, the market’s operating on a push,” Richards adds. “But what the industry needs is the pull”—with heavy strings attached.
For smaller-scale operations in particular, committed relationships all along the supply chain are essential to staying afloat. Yet that business model runs counter to industry approach, says Clifford Pollard, the founder of Cream Co. Meats. The Oakland, California-based meat processor “bridges the gap” between regenerative ranches and broadline product distribution on the West Coast, and has played a central role in promoting Beef2Institution’s efforts.
Conventional meat processors “trade in commodities,” Pollard says, sourcing raw material at the lowest price possible. Cream Co., on the other hand, cultivates its supply pipeline “over many years of sustained [purchasing] commitments” to individual operations, he says.
Ultimately, with demand driving supply, the large-scale procurement will undoubtedly influence the equation. Nevertheless, even incremental steps by institutions can pave the way for meaningful change, Pollard notes. “There’s often a hesitation that it has to be all or nothing, but shifting even a small portion of your spend towards [regeneratively minded sourcing] is impactful,” he says, and U.C.’s commitment really gives regenerative producers “a seat at the table.”
“We don’t need the whole table,” Pollard adds. “Just a seat.”
Naoki Nitta wrote this article for Civil Eats.
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