More Americans are now hospitalized with COVID-19 than at any previous point in the pandemic. The current count--147,062--has doubled since Christmas, and is set to rise even more steeply, all while Omicron takes record numbers of health-care workers off the front lines with breakthrough infections. For hospitals, the math of this surge is simple: Fewer staff and more patients mean worse care. Around the United States, people with all kinds of medical emergencies are now waiting hours, if not days, for help.
Some reporters and pundits have claimed that this picture is overly pessimistic because the hospitalization numbers include people who are simply hospitalized with COVID, rather than for COVID--"incidental" patients who just happen to test positive while being treated for something else. In some places, the proportion of such cases seems high. UC San Francisco recently said a third of its COVID patients "are admitted for other reasons," while the Jackson Health System in Florida put that proportion at half. In New York State, COVID "was not included as one of the reasons for admission" for 43 percent of the hospitalized people who have tested positive.
But the "with COVID" hospitalization numbers are more complicated than they first seem. Many people on that side of the ledger are still in the hospital because of the coronavirus, which has both caused and exacerbated chronic conditions. And more important, these nuances don't alter the real, urgent, and enormous crisis unfolding in American hospitals. Whether patients are admitted with or for COVID, they're still being admitted in record volumes that hospitals are struggling to care for. "The truth is, we're still in the emergency phase of the pandemic, and everyone who is downplaying that should probably take a tour of a hospital before they do," Jeremy Faust, an emergency physician at Brigham and Women's Hospital, in Massachusetts, told me.
Some COVID-positive patients are unquestionably hospitalized for COVID: They are mostly unvaccinated, have classic respiratory problems, and require supplemental oxygen. Omicron might be less severe than Delta, but that doesn't make it mild. "If a virus that causes less severe lung disease affects an extraordinarily large proportion of the population, you'll still get a lot of them in the hospital with severe lung disease," Sara Murray, a hospitalist at UC San Francisco, told me. The proportion of such patients varies around the country: In areas where Omicron has taken off, it's lower than in previous surges, but it remains high in communities that still have a lot of Delta infections or low vaccination rates, as The Washington Post has reported. At the University of Nebraska Medical Center, "the vast majority of our COVID-positive cases are at the hospital for reasons related to their COVID infection," James Lawler, an infectious-disease physician, told me.
At the other extreme, there are patients whose COVID infection is truly incidental. They might have gone to an emergency room with a broken limb or a ruptured appendix, only to realize when they got tested that they also have asymptomatic COVID. Many health-care workers told me that they've treated such patients--but rarely. "It happens, but it's not a big proportion," Craig Spencer, an emergency physician at Columbia University Medical Center, told me.
The problem with splitting people into these two rough categories is that a lot of patients, including those with chronic illnesses, don't fit neatly into either. COVID isn't just a respiratory disease; it also affects other organ systems. It can make a weak heart beat erratically, turn a manageable case of diabetes into a severe one, or weaken a frail person to the point where they fall and break something. "If you're on the margin of coming into the hospital, COVID tips you over," Vineet Arora, a hospitalist at the University of Chicago Medicine, told me. In such cases, COVID might not be listed as a reason for admission, but the patient wouldn't have been admitted were it not for COVID. (Some people might have chronic conditions only because of an earlier COVID infection, which can increase the risk of diabetes, heart problems, and other long-term complications.) "These incidental infections are not so incidental for people with chronic conditions," Faust said. "Whether they live to see the age of 60 or 90 depends on things just like this."
Colds and other viral infections can also land people in the hospital by pushing their chronic diseases over the edge. "But we don't generally see such infections happening to such massive swaths of the population at once," Murray said. Omicron (helped along by Delta) is doing what other respiratory viruses do, but with enough speed and ferocity to overwhelm the health-care system. As Arora put it to me recently, "We have a lot of chronically ill people in the U.S., and it's like all of those people are now coming into the hospital at the same time."
These patients whose problems were exacerbated by COVID are often misleadingly bundled together with the smaller group whose medical problems are truly unrelated to COVID. In fairness, there's no easy way to tell, for example, whether a COVID-positive person's heart attack was triggered by their infection or whether it would have happened anyway. But health problems don't line up to afflict patients one at a time. They intersect, overlap, and feed off one another. The entire for-COVID-or-with-COVID debate hinges on a false binary. "The health-care system is in crisis and on the verge of collapse," Spencer said. "It doesn't matter whether it's with or for. It's a pure deluge of numbers."
Even the truly incidental cases increase the strain. COVID-positive people must be kept apart from other patients, which complicates hospitals' ability to use the beds they have. These patients need to be monitored in case their infection progresses into something more severe. If they start dying for unrelated reasons, their family won't be allowed into their room. The health-care workers who treat them need to wear full personal protective equipment. If they need follow-up care, they can't be discharged to a nursing home or similar facility. They're taking up space and attention when hospitals are short on both. "If you're 90 percent full and you suddenly have 10 percent more patients, I don't care if it's half COVID, all COVID, incidental COVID--it just matters that you're full," Faust said.
In the short time since Omicron was discovered, the popular narrative about the variant has calcified around the idea that it is milder. That is true for individuals, and in comparison with Delta, but the variant certainly isn't mild for unvaccinated people, for those who could develop long COVID from a supposedly "mild" infection, and especially not for the health-care system as a whole. The hospitalization debate illustrates how wishful thinking about the new variant, and America's continued failure to consider the pandemic at both the personal and societal scales, is obscuring the danger of the current surge.
Instead of overselling our plight, official hospitalization data might actually be underestimating it. The number of staffed hospital beds, as tracked by the Department of Health and Human Services, is subject to the whims of individual hospitals, which can choose how to count the number of beds that their staff could reasonably oversee. Many health-care workers have told me that over the course of the pandemic, they have been pushed to care for more patients than they can safely handle, and that the pressure is getting worse as more of them are falling sick with COVID themselves.
Capacity data also tend to be out-of-date by at least a week. Take Maryland as an example: As Faust recently wrote, HHS currently estimates that only 87 percent of the state's hospital beds are occupied. But a model that he co-created, which projects that number forward based on the previous week's cases, suggests that's not right--and that every county in the state is now above capacity. The experiences of Maryland's health-care workers support Faust's conclusions. Last week, a Maryland nurse told me that her emergency department regularly has 10 patients on ventilators waiting for a bed in the overcrowded ICU. A critical-care physician said that patients with heart attacks and other emergencies might wait 24 to 36 hours before seeing a doctor. It is difficult to reconcile these firsthand accounts with the notion that 13 percent of the state's beds are still free.
COVID data have always been mushy, lagging, and incomplete. No single metric can account for the number of patients, how sick they are, what their care demands, how many health-care workers are around to help them, or how close those workers are to their breaking point. We have no straightforward way to measure exactly how stressed the health-care system is.
But we can ask health-care workers what they're experiencing. I've asked dozens over the past three months, and heard from hundreds more. And what they've said, almost unanimously, is that they're exhausted, demoralized, overwhelmed, and working in a system that cannot handle the strain it is being asked to shoulder. Debating how many patients are in the hospital with COVID or for COVID distracts from the most important question of the moment: As Anne Sosin, a public-health practitioner at Dartmouth College, wrote to me on Twitter, "What is or will be too much for our health systems and workforce to bear?" The U.S. is about to learn the answer the hard way.