Most Virginia hospitals and nursing homes aren’t mandating COVID-19 vaccines for their employees

For the third time in just over a year, Ballad Health is suspending many of its elective surgeries, citing a new surge of coronavirus cases that have left its hospitals overwhelmed.

As serious infections have risen across the region, driven by low immunization rates and the aggressive Delta variant, the system’s administrators have begged more residents to get vaccinated. But so far, Ballad — which serves much of southwestern Virginia and northeastern Tennessee — has avoided requiring the shots for its own workers.

“Of course we have encouraged it from the beginning in December when they became available,” said Lisa Smithgall, the health system’s chief nursing executive. “And we continue to foster communication on an ongoing basis. But as of today, we don’t have a vaccine mandate for our team members.”

Ballad is far from alone. While some major hospital systems in Virginia have introduced employee vaccine requirements — including Inova in Northern Virginia, VCU Health in Richmond and Valley Health in the northwestern corner of the state — the majority of Virginia’s roughly 27 health systems are not currently mandating vaccinations for their employees. Those include major players such as Sentara, HCA and Bon Secours, which together operate more than two dozen hospitals across the state.

Bon Secours St. Mary’s Hospital, Richmond, Va. (Parker Michels-Boyce/ For The Virginia Mercury)

The same is true for many of Virginia’s long-term care facilities, which account for nearly 30 percent of outbreaks and roughly 36 percent of all COVID-19 deaths, according to data from the state Department of Health. Neither LeadingAge Virginia nor the Virginia Health Care Association-Virginia Center for Assisted Living, which represent hundreds of nursing homes and assisted living facilities across the state, could say how many of their members have adopted the policies. 

But Dr. Jim Wright, the medical director for Westminster Canterbury and Our Lady of Hope in Richmond, said employee vaccine requirements are still rare throughout much of the industry

“In conversations with other medical directors, vaccine mandates are definitely in the minority in nursing homes in Virginia,” he said. “Westminster Canterbury, for example, is one of the only facilities I’ve heard of recently that has put that requirement in place.”

The holdout among health care providers has become a point of puzzlement and sometimes frustration as mandates become more common across the state, spurred by lingering resistance and grim warnings of future surges. Nationwide, at least 30 percent of hospitals have required vaccinations as a condition of employment, according to the industry publication Becker’s Hospital Review

So far, Gov. Ralph Northam has stopped short of a statewide mandate for health care workers —  policies that have been enacted in California, New York, Maine, Pennsylvania and New Jersey. But he did encourage private businesses to follow his lead earlier this month when he announced vaccination and testing requirements for roughly 122,000 state employees. 

Last week, Democratic gubernatorial candidate Terry McAuliffe also called on health systems to mandate the shots, describing it as a vital step to ending the pandemic.

“The only way we’re going to end this pandemic and keep our economy strong is by getting every eligible Virginian vaccinated as quickly as possible,” he said during a campaign stop at Inova. “Leadership on this issue is critical.”

On Wednesday, President Joe Biden announced that nursing homes will be required to ensure their staffers are vaccinated against COVID-19, or risk losing federal Medicare and Medicaid dollars. The U.S. Department of Health and Human Services will develop regulations to require vaccinations of nursing home staffers as a condition of participating in Medicare and Medicaid programs.

“I’m using the power of the federal government as a payer of health care costs to ensure we reduce those risks for our most vulnerable seniors,” Biden said during a news conference detailing new federal actions. “If you visit, live or work in a nursing home, you should not be at a high risk of contracting COVID from unvaccinated employees.”

The nursing home vaccination requirement will apply to staffers in 15,000 facilities, which employ approximately 1.3 million workers and serve approximately 1.6 million residents, according to the White House.

‘How it’s going to affect staffing’

Encouraging vaccinations has become a familiar refrain for officials and professional associations across the state, virtually all of which — including LeadingAge, VHCA-VCAL, and the Virginia Hospital and Healthcare Association — have at least “voiced support” for employers that implement the policies. But without a mandate or increased political pressure, some experts say health systems will remain reluctant to implement what they view as a risky policy decision.

Much of that risk can be traced to long-running concerns over the availability of qualified workers. Even before the COVID-19 pandemic, Virginia was projecting shortages of doctors, nurses and other health care professionals. Nursing staff have been a concern for hospitals in particular, which are anticipating growing numbers of high-needs patients as the general population grows older. At the same time, more and more nurses are nearing retirement age. 

(Getty Images)

“COVID has accelerated those types of things because we’ve seen all that happen in a short period of time,” Baker said. The ongoing pandemic has led to increased burnout among nurses and other health care providers, leading some to leave the field or reduce their hours in frontline care. At the same time, there’s never been more competition for qualified workers, according to Smithgall.

“Hospitals are no longer the primary employment area,” she said. “There are lots of different avenues — in outpatient surgery, in physician practices, in freestanding centers — and a lot of those positions are Monday through Friday and day shifts.” Worker shortages can vary by region, but Ballad currently has more than 500 open nursing positions across its 21 hospitals. Many of those slots are currently backfilled by more costly contract workers.

At the same time, roughly 37 percent of the system’s total workforce remains unvaccinated (though rates are closer to 100 percent for what Smithgall described as “advanced practice providers,” including doctors, nurse practitioners, and physician assistants). Ballad has been forthcoming that its hesitation to adopt a vaccine requirement is largely based on its fear of losing employees. The same is true in the long-term care industry, though many administrators have said they’re waiting on full approval of the vaccines by the U.S. Food and Drug Administration, according to Wright.

“I have to say that the underlying reluctance is more likely due to how it’s going to affect staffing,” he said. A little more than 68 percent of nursing home employees are vaccinated across Virginia, according to data from the U.S. Centers for Medicare and Medicaid Services. But Wright said nursing homes are also seeing disparities between more advanced providers — such as doctors and registered nurses — and those with fewer credentials, including non-clinical staff and certified nurse aides.

Those positions, though, are also low-paid, even though CNAs often provide the bulk of daily patient care. That means nursing homes are often facing competition from other industries, including retail and food service.

“The challenges we’ve had before with staffing are compounded by how complex and risky it is to work in nursing homes,” Wright said. “And if you can make about the same or even a little bit more working at Target, it’s going to be very tempting.”

As cases continue to rise across Virginia, though, there’s growing skepticism that fears among health care employers are grounded in reality. While some workers have protested vaccine mandates — including nurses at Valley Health, one of the state’s earliest adopters of immunization and testing requirements —  courts across the country have upheld the mandates. The U.S. Equal Employment Opportunity Commission also updated its guidelines in May to specify that companies can require vaccines for employees physically coming into work, Becker’s reported. 

And so far, the mandates that have been implemented haven’t led to a mass exodus of staff. As of last week, 76 percent of Valley employees were vaccinated, and attendance has been dwindling at protests after an initial event in July, said Dr. Jeffrey Feit, the system’s community health officer. Melissa Andrews, the CEO of LeadingAge Virginia, said she’s heard of facilities that have lost anywhere from one to eight employees out of hundreds after implementing a vaccine requirement.

The risk could be higher for systems in regions with overall low vaccination rates, said Paul Ginsburg, the director of public policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics. 


“They’re the ones whose capacity is under stress, so they’re least in a position to afford the loss of employees,” he said. “And they’re also in areas where they might get higher rates of workers leaving, so I think it’s a real issue.” While vaccination rates at Ballad, for example, are still hovering around 63 percent, uptake is far higher at other facilities that have also hesitated to adopt the requirements. That includes the more urban Virginia Hospital Center in Arlington, where about 85 percent of employees are fully vaccinated, according to spokeswoman Maryanne Boster.

For hospitals that have implemented mandates, though, those concerns are far outweighed by other risks. There’s growing evidence that even fully immunized individuals can catch and transmit COVID-19 (though the risk is far greater among the unvaccinated). Nationally, there are reports that unvaccinated employees are driving new outbreaks at nursing homes.

There’s currently little data on whether vaccination rates among Virginia health care providers have contributed to new outbreaks or infections. The Virginia Department of Health stopped reporting facility-specific outbreaks on July 1, citing the end of the governor’s state of emergency. The agency plans to resume that reporting “in the coming days,” according to spokesman Logan Anderson. 

But the state also hasn’t been collecting or publicizing data on vaccine uptake in health care settings. When the Mercury requested more information, a VDH spokeswoman referred back to the Virginia Hospital and Healthcare Association, a lobbying group for the industry. Immunize Virginia, a nonprofit coalition of medical and public health stakeholders, surveyed health care workers in December on their attitudes toward vaccination. But the [resulting data] only included 515 respondents and skewed heavily toward doctors and White providers. It hasn’t been updated since then, according to the coalition.

Some states are publicly reporting similar data, including Maryland, which recently ranked its nursing homes by staff vaccination rates. Dr. Christian Bergman, a geriatrician at VCU Health’s Center for Advanced Health Management, said public pressure is likely one of the only ways to drive wide-scale mandates.

VCU Emergency hospital entrance in Richmond, Va. (Parker Michels-Boyce/ For The Virginia Mercury)

“There’s a sense of burnout on the ground about vaccine education,” he said. “We’ve thrown the kitchen sink at this issue only to not move the needle very much in the last three months.” 

Stagnating vaccination rates across VCU Health contributed to its decision to launch its own employee requirements earlier this month. Just a few months earlier, in mid-December, more than 130 employees had tested positive for COVID-19 in the same week. The system’s CEO, Dr. Art Kellermann, said many of those were linked to unvaccinated employees interacting outside patient care settings — in break rooms and other communal spaces.

“Frankly, we had to make the decision: if we have another wave of infections, are we comfortable losing many of our team members to illness?” he said. “And I’m concerned if we get there — and it’s almost more likely to be ‘when’ than ‘if’ — there aren’t going to be a lot of options to bring people in from elsewhere. Everywhere is going to be challenged.”

This post has been updated to include President Joe Biden’s announcement that his administration would require nursing home staff to be vaccinated. 

States Newsroom Washington Bureau Reporter Laura Olson contributed to this report.