Updated at 9:00 a.m. ET
Michelle Sweeney could barely sleep. The nurse in Plymouth, Mass., had just learned she would be furloughed. She only had four hours the next day to call all of her patients.
"I was in a panic state. I was sick over it," Sweeney said. "Our patients are the frailest, sickest group."
Sweeney works for Atrius Health as a case manager for patients with chronic health conditions and those who have been discharged from the hospital or emergency room.
"It's very devaluing, like a slap in the face," Sweeney said. "Nursing is who you are ... I've never been unemployed my entire life."
It's an ironic twist as the coronavirus pandemic sweeps the nation: The very workers tasked with treating those afflicted with the virus are losing work in droves. Emergency room visits are down. Non-urgent surgical procedures have largely been put on hold. Health care spending fell 18% in the first three months of the year. And 1.4 million health care workers lost their jobs in April, a sharp increase from the 42,000 reported in March, according to the Labor Department. Nearly 135,000 of the April losses were in hospitals.
Fae-Marie Donathan was among those who filed for unemployment in April. A nurse for 42 years, she worked until recently as a per diem nurse in the Surgical ICU at the University of Cincinnati Medical Center. As the pandemic took hold in the U.S., Donathan, 64, expected her skills to be essential, but was recently told she would no longer be scheduled.
"I was thinking maybe I would have to worry about when I was going to get a day off," Donathan says. "I was thinking totally the opposite, never ever suspecting that I would be sitting at home not getting any hours at work."
Donathan says she normally makes around $1,100 every two weeks; she says her last paycheck was $46 in take-home pay. Asked for comment, a spokesperson for the University of Cincinnati Medical Center said in an email that the health system, "like many others, has experienced financial challenges as a result of the pandemic and has taken steps to align staffing with current needs as we seek to avoid layoffs."
The University of Cincinnati Medical Center is among many: The American Hospital Association recently predicted that U.S. hospitals and health systems would end up taking a $200 billion hit over a four-month period through June. Most of that money — $160 billion — is from lost revenue from more lucrative elective procedures.
"The only people who are coming into the hospitals are COVID-19 patients and emergencies," says American Hospital Association Executive Vice President Tom Nickels. "All of the so-called elective surgery, hips and knees and cardiac, etcetera, are no longer being done in most institutions around the country."
Nickels says hospitals are in a tight spot: "They're still having to have their institutions open. They are still caring for people who come in. They are still taking care of COVID-19. But that's an enormous amount of lost revenue."
The revenue losses will more severely affect poorer and more rural hospitals whose finances may be marginal in the best of times, Nickels says.
"That is certainly an existential threat," he says. "And I think [it] will threaten the ability of some of these hospitals to remain open."
Some nurses have traveled across the country to hot spots like New York City to find work, unsure if they'll have a job when they return home. But even there, hospitals that were once swamped are finally coming up for air and administrators are now reckoning with the financial impact of the pandemic.
Rozetta Ludwigsen, 64, works at a small hospital in Anacortes, Wash. She's gone from working a 40-hour week to only a few days a month.
"I never thought we'd be in this situation where there'd be no work for us," she said.
Before the pandemic, Ludwigsen was hoping to retire within the coming year. Now she may have to delay her plans for a year or longer.
In eastern Washington state, Shawn Reed, an ER nurse at MultiCare Valley Hospital, said she is sacrificing her own hours for people who need the money more.
"When I look at a nurse ... who's pregnant with her third child and I know she's going to need hours now, I am willing to fall on that sword," Reed said. "I can do it here and there, but I certainly can't do it long term."
The Emergency Nurses Association (ENA) has created a relief fund for its members who are struggling financially. Hundreds of their members have already applied for help.
"Looking at it from a long-term perspective, you have to worry about the profession and what's the impact on the profession," said Mike Hastings, the president of ENA.
A question of funding
The federal government has been distributing a portion of the $100 billion Provider Relief Fund to hospitals and other providers, as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act. Among the funding is a $10 billion allocation each for rural hospitals and pandemic hot spots.
Nickels, of the AHA, says it's too early to tell the effect of emergency federal funding targeted for hospitals, and whether those funds will help hospitals retain workers.
But Randi Weingarten, president of the American Federation of Teachers, which is also the nation's second-largest nurses' union, says it's clear the federal funding is far from enough. The union has identified at least 200 hospitals nationwide cutting worker hours, mostly in the form of furloughs, according to Weingarten.
Even as the pandemic tapers off in some places, hospital revenue losses will take time to correct, especially because hospitals may face a potential "payer mix" problem before Americans go back to work. Many people who lose their jobs will also lose employer-sponsored health insurance, and those private plans reimburse providers at much higher rates than publicly funded plans like Medicaid and Medicare.
The Economic Policy Institute estimates that nearly 13 million Americans have likely lost their employer-sponsored health insurance so far.
"Even if [patients] do go back to the hospital, they'll be paying a lot lower rate than they did when they had insurance through their employer," says Christopher Whaley, a policy researcher with the Rand Corporation.
Weingarten says this crisis is an opportunity to rethink how the American hospital system is funded.
"This particular issue about what do we do in terms of funding our hospitals is not an issue in Canada. It's not an issue in Great Britain," she says. "It's not an issue where there are better funding systems."
But short of reworking the entire finance system of American health care, Weingarten says individual hospitals could also make changes to avoid cutting hours.
"Instead of reduction of the workforce, there should be a reallocation of work," she says. "Thinking innovatively and resourcefully, health care workers should be cross-trained to work in areas of the hospital that are overloaded like ER or ICU. Displaced workers could be trained and paid to staff a robust trace-and-isolate program as society reopens."
"Where's the end?"
Without that reallocation, some nurses still in the hospitals are taking on extra tasks in their already grueling 12-hour shifts. They're mopping rooms, changing sheets, taking out the trash and arranging rides because the people who once did that are gone.
"We're kind of jack-of-all-trades at this point," said Amy Erb, a nurse at California Pacific Medical Center in the Bay Area in northern California and a California Nurses Association Board member. "We're being phlebotomists, drawing labs. We're being social workers. We're being psychologists."
Then there are the days she's had her hours cut, which makes her worry about the future. So far her hospital has worked to avoid layoffs.
One nurse in a Detroit-area hospital says all the extra hours she once worked have disappeared.
"Our job title expanded exponentially," she said. She spoke on the condition of anonymity for fear of losing her job. The one thing she thought she had was job security. "Then the layoffs started coming and I was like 'never mind.' "
She now often cleans the rooms and answers phones because the staff who did that are gone.
The financial stresses are compounded by an already stressful and terrifying time for healthcare workers.
"People were dying left and right," she said. "The way we were treating them then is different than now, maybe they would still be alive if they came in today ... it eats me up at night."
She spent the first month of the pandemic crying every night.
Her unit is a COVID-19 positive unit. Things are easing up now, but she still works with those COVID-19 patients every day. She's less afraid, she spends more time in the patient's rooms. She is their support system, their link to their families and their nurse.
Last week, Palomar Health in north San Diego County in California eliminated over 300 positions. But the workload didn't change — it just shifted to people like Sue Phillips, a critical care trauma and rapid response nurse.
"We have very limited physical therapy, speech therapy, occupational therapy and that's part of our care team, so that's now going to fall onto our end to be providing that care," she said. "It's uncharted territory. In my 25 years of nursing, I've never seen anything like this before."
When a patient came in recently with broken bones, the doctor couldn't turn to the orthopedic technicians. Those technicians had been laid off. So Phillips found herself putting traction on a hospital bed, a pulley system that slowly lifts and moves the broken body parts.
"I've never had to do that before," she said. "The operating room staff was bare-boned staff, so there weren't enough people to assist the physician in doing the surgery that day."
She said she was worried she'd make a mistake. Also gone is the lift team that used to help Phillips pick up and turn patients. All of this, she said, adds stress to her job.
Meanwhile, her family is afraid to be around her because of her work. She's staying away from her husband. On their 30th wedding anniversary Friday, they'll celebrate apart.
Phillips is tired.
"We've been doing this now for six weeks. Where's the end? When are things going to get a little bit back to normal?" she asked. "Now we've had these huge layoffs."
NOEL KING, HOST:
Here's something counterintuitive. Millions of people are being laid off - we know this. You would think that the one group that would be safe from layoffs are health care workers, but that's not the case. Across the country, many people who work in hospitals are having their hours cut or they're losing their jobs altogether. What is going on?
NPR's Leila Fadel and reporter Will Stone in Seattle have been looking into it. Hi, you guys.
LEILA FADEL, BYLINE: Hi.
WILL STONE, BYLINE: Hi.
KING: Will, let me start with you. With everything that is going on right now, why would hospitals be cutting people's hours and laying them off?
STONE: The pandemic has totally disrupted the business of health care, from big private hospitals to small community ones. You have most in-person doctor's visits canceled and many non-urgent so-called elective procedures were stopped. Add in the fact that fewer patients overall are coming into emergency rooms and you have a situation where hospitals have fewer patients and are losing some of their biggest sources of revenue. In fact, consumer health care spending fell 18% in the first three months of the year.
KING: And the knock-on effect of that is that people who work in hospitals are losing their jobs.
STONE: That's right. Many are losing work - some permanently, others temporarily. I spoke to Shawn Reed (ph) who's an ER nurse on the east side of Washington state. Her hospital has scaled back ER staffing to the bare minimum, and they're asking nurses like her to take furloughs.
SHAWN REED: Basically, if our volumes don't pick up, then we have to really look at how we're staffed. We're trying to avoid layoffs and we're trying to keep people working. And so when I look at, like, a nurse that we've only had for, you know, maybe a year or two who's pregnant with her third child and I know that she's going to need hours now, I'm willing to fall on that sword to make sure that she can get hours.
STONE: When we spoke, Reed had lost four out of her six shifts that week, and she says she just can't afford to do that long-term, even though she understands why it's happening. Another nurse in the Seattle area told me he's now driving four hours away to pick up extra shifts because the hospital where he usually works, a place that was busy with coronavirus, is now cutting their hours.
KING: Absolutely extraordinary. And Leila, I know that you talked to a nurse at a hospital that laid off more than 300 people last week. That's an astonishing number.
FADEL: Yeah, that was at Palomar Health in north San Diego County. And basically, when you lose hundreds of people, the workload doesn't significantly change. So that work then lands on those that are still there, people like Sue Phillips (ph), a critical care trauma and rapid response nurse. At her hospital, the orthopedic technicians were laid off, so they aren't there to set up traction on a hospital bed. That's a pulley system that slowly lifts and moves the broken body part.
SUE PHILLIPS: The operating room staff was bare-bones staffed, so there wasn't enough people to assist the physician. So that patient's care, to me, was delayed - and expecting us to set up a traction on a bed when we had never done that before.
FADEL: She says she was really worried that she'd make a mistake. So it's just added stress when it's already such a stressful time for health care workers. Phillips has also given up on seeing her grandkids and is isolating herself from her husband at home so she doesn't get them sick because she's working with COVID-19 patients every day.
KING: A lot of anxiety. Will, I remember when this pandemic started just a couple months ago and the anxiety then was that hospitals just would not have enough doctors and nurses. Is that still a concern, or has that completely changed?
STONE: Actually, in many places, that narrative has flipped. Some have said, hey, we were on the front lines, sometimes in risky situations without enough masks or protective gear and now we're worried about our jobs and paying our rent. The U.S. shed more than 40,000 health care jobs in March. Rozetta Ludwigsen (ph) is a nurse who works at a small hospital north of Seattle. She's gone from working a 40-hour week to only a few days a month. She's in her mid-60s, and actually, before this pandemic hit, she was hoping to retire in the coming year.
ROZETTA LUDWIGSEN: I don't know if that's going to happen at all. I don't know if I'm going to have to stay another year. That's not something I wanted to do. You know, the longer I work the more I fear that I'm going to end up with something and I'm not going to enjoy my retirement. So (laughter)...
STONE: She finds it ironic that not too long ago there were calls for nurses and doctors to come out of retirement. Now she's not sure she'll be able to retire as soon as she'd like.
KING: So we have two groups of people here. We have people dealing with the trauma of being laid off, and we have people who are still working. Leila, for the people who are still working, what does this mean for them?
FADEL: Well, basically less staffing means nurses in ERs, ICUs, they're taking on all kinds of extra tasks to make up for those layoffs or furloughs. In one Detroit area hospital, I spoke to Fatima Hashem (ph). She's an ER nurse. She works with COVID-19 patients every day. So she's helping treat them. She's FaceTiming their families. She's being their support system. And now, because some of the cleaning and maintenance people have been laid off...
FATIMA HASHEM: We are going in and cleaning these rooms up, you know, getting them ready for the next patient.
FADEL: So that means she's changing sheets, sweeping, taking out trash. And Hashem says the people who worked as patient advocates or in guest relations are also mostly gone, so she's arranging rides for patients through insurance, bringing people coffee and warm blankets. One nurse I spoke to in California, Amy Erb (ph), describes her and other nurses' jobs in the midst of layoffs and reduced hours like this.
AMY ERB: Kind of jack of all trades at this point. You know, we're being nurses; we're being environmental services; we're phlebotomists drawing labs; we're being, you know, social workers; we're being psychologists. We're taking all of this on. And you know, we do that to some extent every day, but it's been very much exacerbated by this crisis.
KING: You know, Leila, we've seen so much support for health care workers - people calling them heroes, people sending them food and, when they can, equipment. When you talk to these folks, are they telling you that that's helpful?
FADEL: Well, I mean, people - they love the support of handmade signs, the food deliveries, the applause. But they're also really frustrated. This is a terrifying time for health care workers. One nurse I spoke to in the Detroit area says she spent the first month of this pandemic crying every night because she was scared because of the shortage of protective gear. But she was also grieving because she's working with patients who are really sick or dying alone because of COVID-19. And now she's worried about her job. So they want more. They want protective gear and job security.
KING: So if we pull back here, Will, I guess the big question is - is there any fix?
STONE: Things are already changing in some places as hospitals ease into elective procedures again. That will bring in money and get some people back to work. Congress has also come up with some funding, but industry groups say that's still not enough. Even in New York City, where the hospitals were swamped, the situation is calming down. And one head ER doctor there says some hospitals are now looking at their finances and wondering if they can stay afloat.
KING: Sounds like a long way to go. Reporter Will Stone in Seattle and NPR's Leila Fadel in Los Angeles. Thank you both. We appreciate your reporting.
FADEL: Thank you.
STONE: Thank you.
(SOUNDBITE OF PENSEES' "LUNAMOTH") Transcript provided by NPR, Copyright NPR.