What Does Healthcare Rationing Look Like During a COVID-19 Surge?

overwhelmed emergency room in a Texas hospital

Brandon Bell / Getty Images

Key Takeaways

  • Hospitals in some places are filled to capacity as COVID-19 cases continue to surge throughout the country.
  • When health systems face overwhelming demand for hospital beds, medications, ventilators or care providers, they may need to ration their resources.
  • Many hospitals choose to ration care based on how likely a patient is to survive, though hospitals approach this differently.

Many hospitals in the United States are facing extreme shortage as they exceed their capacity to care for all the patients who need medical attention during the COVID-19 surge.

A man died this week of a cardiac event after hospital staff in northern Alabama contacted 43 hospitals in three states to find a cardiac intensive care unit bed for him. In Idaho, public health officials announced statewide healthcare rationing, meaning ICU beds are reserved for the patients most likely to survive.

More than 93,000 hospital beds are filled with COVID-19 patients nationwide. About 80% of ICU beds are in use and 79% of all hospital beds are currently full across the country, according to the Department of Health and Human Services.

The Delta variant is driving a surge in hospitalizations, especially among unvaccinated individuals. Nearly 37% of Americans who are eligible to get the shot are not yet fully vaccinated.

As resources at healthcare centers become increasingly strained, hospitals are increasingly faced with tough decisions about which patients to prioritize for care.

What Does It Mean to Ration Health Care?

In medicine, “rationing” means access to care is restricted for certain groups. In some ways, health care in the U.S. is already rationed. For instance, health insurers may not cover certain treatments or procedures, and those who are uninsured or have high out-of-pocket costs may not be able to access care.

In times of medical crises like the COVID-19 pandemic, health care may be restricted for people with emergency medical needs out of sheer necessity.

“We have only a certain number of licensed beds or operating rooms. We keep only a certain amount of antibiotics or pain medication, and a certain number of ventilators on site,” says Lewis Kaplan, MD, past president at the Society of Critical Care Medicine and surgery professor at University of Pennsylvania.

“When you have either no more space, no more people to provide care, or no more therapeutic agents… this is the space where rationing comes in,” Kaplan tells Verywell.

Hospitals have general practices for how to handle an overflow of patients and stretch resources when they’re limited. But unlike scenarios such as natural disasters, in which the influx of demand for emergency care eventually wanes, the strain on hospitals during the pandemic has been ongoing, says Hamad Husainy, DO, FACEP, an emergency department physician in Alabama and spokesperson for the American College of Emergency Physicians.

Not only are there more patients requiring intensive care due to COVID-19, they also tend to stay in the hospital longer. The median length of stay for a COVID-19 patient who is admitted to the ICU is seven days, compared to one day for patients admitted in 2019, according to Nuffield Trust, a health think tank in the United Kingdom.

“What we're seeing now is more and more longer stretches of outbreaks of sicker people. And it's leaving a lot of us to say, ‘is this going to end? Is this the new normal?’” Husainy says.

How Hospitals Address Overflow

Expanding physical capacity is difficult and expensive, and hospitals can’t be built overnight, Husainy adds.

When hospitals reach capacity in their standard set-up, they may take steps like pausing elective surgeries, and converting cafeterias and hallways to accommodate overflow patients.

Even when hospitals can flex their physical resources, there must also be enough providers to care for those patients. The increased stress placed on medical staff during the 17-month-long pandemic has exacerbated an already embattled nursing labor market.

Some health systems have accelerated training programs for clinicians and asked others to perform duties outside of their typical practice. Hospital staff who are asked to take on more, and sicker, patients, have a greater likelihood of facing burn-out.

“You can't put patients in rooms that don't have nurses to staff them,” Husainy says. “There have been situations where patients end up in hallways and things of that nature. But you can't take an already stressed nurse and give him or her nine or 10 patients, including hallway patients, and expect that they're going to show up for work the next week.”

When a hospital is completely full, patients may be transferred to another hospital that has more capacity. But in regions where most health systems are over-burdened, it can be difficult to find open beds or specialists to perform certain procedures, and patients may be transferred hundreds of miles away.

If the situation becomes particularly dire, clinicians follow a rubric to determine who gets priority for care. Usually, people who are most likely to respond to treatment and survive are favored, though the details differ between health systems.

First-come-first-served basis and those based on age are not the most effective rationing systems, Kaplan explains.

“You probably know some 74-year-old who has one comorbidity, is pretty darn fit, lives independently, with a mind sharp as attack. You'll also know a 26-year-old who's had a liquid organ transplant, has five comorbidities and is on immune suppressive agents,” Kaplan says. “These are very different patients. How do you account for all of that?”

Kaplan says a panel of professionals decides on an objective rubric for allocating resources. Bioethicists, clinicians, and others create plans which may factor in a patient’s life expectancy, pregnancy status, and even their role in society.

“The person who's holding your hand, talking to your loved ones, looking into your eyes, is not the person that decides. You can imagine how much of a conflict that would be,” Kaplan says.

Plus, care must be rationed based on the patient’s prognosis, rather than a behavioral decision they’ve made. Under the Emergency Medical Treatment and Labor Act, no one can be refused emergency medical care, regardless of their reason for needing it or ability to pay.

What This Means For You

If the health systems in your area are particularly strained, there may be a pause on certain elective procedures, and it may be more difficult to access emergency medical care. The best way to avoid being hospitalized for COVID-19 is to become fully vaccinated.

Finding a Way Out

In a six-part COVID-19 mediation plan announced last week, President Joe Biden said that the Department of Defense will double the number of healthcare providers sent to hard-hit hospitals to support clinicians against the surge of patients.

Husainy says that this support, while appreciated, is just a “drop in the bucket.” If additional clinicians were deployed to all the hospitals that needed them, he says they would need to serve nearly all the health centers in the Southeast.

Increasing COVID-19 vaccination rates is the best way to keep people out of the hospital, Husainy says, and he has yet to see a vaccinated patient in his own practice.

“What would be better than anything—and this is the approach I've taken—is to be very kind and honest with individuals and just say, ‘We're going to do everything we can to make you feel better. I would just implore you to share with your family members and those that you love and those that you have any influence over to consider vaccination,’” Husainy says. “That's my moment to make a difference with the next patient.”

“The reality is that we all work in hometown America, wherever that is—whether it's urban or rural—and you can only change one person at a time,” he adds.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.

2 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. U.S. Department of Health and Human Services. HHS Protect Public Data Hub: Hospital Utilization.

  2. Centers for Disease Control and Prevention. COVID Data Tracker.

By Claire Bugos
Claire Bugos is a health and science reporter and writer and a 2020 National Association of Science Writers travel fellow.