Updated: October 5, 2021 3:47 PM EDT | Originally published: October 4, 2021 3:38 PM EDT

By almost any measure, New York State’s requirement that health care workers get vaccinated against COVID-19, which was announced on Aug. 16 and went into effect Sept. 27, has been a success. Thousands of reticent health care workers across the Empire State have been vaccinated over the last month. Among hospital staff specifically, 87% were fully vaccinated as of Sept. 28, up from 77% as of Sept. 24. (A similar mandate governing education workers in New York City, which went into effect today, has also resulted in a surge in vaccinations.)

However, even health care leaders who support vaccination and vaccine mandates say that the requirement exacerbated the New York health care sector’s pre-existing condition: staffing shortages, which existed before the pandemic but have become a full-blown crisis amid the outbreak. Given that the Biden Administration is planning to issue a federal mandate that could cover 17 million health care facility workers across the United States, the problems plaguing New York could soon spread elsewhere, too.

The vaccine mandate has taken thousands of employees out of New York’s health care workforce, according to the Iroquois Healthcare Association (IHA), which represents 50 hospitals across 32 New York counties, as well as reports from other hospitals in the state. An IHA survey of 33 New York hospitals conducted on Sept. 13, before the mandate went into effect, found a job vacancy rate of 13.2%, nearly double the June nationwide average for the health care and social assistance industry. After the mandate went into effect, about 1,300 of 25,000 total employees at the respondent hospitals have been terminated or placed on leave as a result. More may follow: another 1,200 workers at those hospitals have received religious exemptions, which are only permitted under a temporary restraining order from a New York judge. The injunction is set to expire on Oct. 12, at which point hospital leaders fear many more workers will quit.

The situation risks becoming particularly dire at New York’s rural hospitals. Not only do they have a smaller talent pool upon which to draw, but rural areas tend to be less vaccinated—a September KFF poll found that only 62% of rural U.S. residents over 18 years old have received at least one dose, compared to 77% of those in cities. That increases the chances of local outbreaks that could strain hospitals like Oneida Health, which sits just east of Syracuse in Madison County, and where only 67.8% of residents have received at least one vaccine dose.

While Oneida Health has managed to vaccinate 92% of its 900 employees, hospital president and CEO Gene Morreale fears that the laggards could have a major impact across the hospital, where 18% of positions are already vacant. About 20 staff members have left the company as a result of the vaccine mandate, while another 46 are working under religious exemptions. Morreale fears that most of them will quit if those exemptions are eliminated. If that happens, “we’re going to be in tough times,” he says. “We’ll have to stop elective surgery.”

Two weeks ago, Oneida Health reduced its inpatient capacity by 25% in part to enable surgeons to treat patients from the emergency room. But the ER has become overwhelmed anyway—it has sometimes been placed on “diversion,” which means ambulances are warned to avoid bringing in patients. When that happens, ambulances must drive people further away for specialized care, sometimes delaying their next pickup, leaving those in need of emergency help waiting even longer. “The whole patient flow process is hampered right now,” says Morreale.

Understaffing can cause systemic problems in other ways, too—for example, when nursing homes are also understaffed, that creates a bottleneck in the hospital-to-care center pipeline. “A patient is ready to be discharged to a nursing home, but because of staff, the nursing home can’t accept them,” says IHA president and CEO Gary Fitzgerald. “That fills up a [hospital] bed that would be used for someone who needs it.”

There’s another wrinkle in New York’s staffing dilemma. Dr. Dennis McKenna, president and CEO of Albany Medical Center, a teaching facility with 11,000 employees, says that his hospital and others across upstate New York are seeing a larger volume of patients than usual, and those patients are sicker than on average, but in many cases with illnesses other than COVID-19. Experts theorize this surge may be due to delayed testing and medical visits during early in the pandemic; to avoid COVID-19, some patients may have missed opportunities to prevent or detect other diseases.

Moreover, because Albany Medical Center offers specialized care, including for trauma patients, patients from elsewhere in the region are often transferred there for treatment, says McKenna. In recent weeks, however, the Center has been getting calls from further and further away, from places like Buffalo and Connecticut. “The only interpretation, I think, one can have, is that the hospitals that they normally use to send patients to can’t take their patients, either,” says McKenna. As a result, even though 98% of his 11,000 workers are vaccinated, McKenna says his hospital has had to “meter” the number of elective procedures it can provide on any given day, because other local hospitals count on Albany Medical for specialty care.

“We are the only level one trauma center within 25 counties. We are the only children’s hospital within that region,” says McKenna. “The first thing we have to try to do is be sure that we preserve all of those resources because we know that they are uniquely served in this region.”

Read more: COVID-19 surge hits New England despite high vaccination rates

In the short term, both New York State and hospitals there are rushing to find ways to relieve shortages. New York Governor Kathy Hochul declared a statewide disaster emergency on Sept. 27 to address staffing shortages, which, among other things, enabled health care workers licensed in other states to work in New York. Hochul has also floated more drastic measures, like activating the National Guard to help staff hospitals if needed.

However, while COVID-19 and the vaccine mandate may have deepened the staffing crisis, the problem existed beforehand, and any solution must address the systemic issues both in New York and beyond. Part of the problem, experts say, is a lack of people willing to work in hospitals and similar facilities. “Not enough people want to work in health care, quite frankly, and all these issues in the last 18 months have just exacerbated that,” Fitzgerald says. For now, the system is still counting on many of the same health care workers who have carried the weight of the public health crisis since the start of the pandemic. Morreale fears that the shortages will lead some of them to give up on health care entirely. “I think if you look at the faces of our staff, our providers, they’re burned out,” says Morreale. “They don’t want to do it anymore. They’re tired. So the one thing we’re going to see, perhaps, is more retirements; people just saying, ‘I’ve had enough.'”

Still, experts say New York’s vaccine mandate is worthwhile because it may help get the pandemic under control, which would then open the door for the necessary deeper structural changes. “We have a broken healthcare system,” says Robin Moon, an adjunct associate professor of health policy and management at the City University of New York. “A vaccine is not a panacea, but that’s probably the best solution for now. And this needs to really work for us to be able to move forward and prepare for the next pandemic.”

Correction Oct. 5

The original version of this story misstated the name of the hospital association and the counties it serves. Iroquois Healthcare Association serves 32 New York counties, not 16.

More Must-Read Stories From TIME

Contact us at letters@time.com.

Read More From TIME
You May Also Like
EDIT POST