Vaccines and adequate supplies have definitely made the delta round of the COVID-19 pandemic less horrific for the doctors and nurses trying to save lives. The jeopardy for them and their families is at least reduced by the fact that the vaccine has been available to them, and they don’t have to rely on personal protective equipment that’s days old. But the fact that there is a vaccine and that many of the people who are filling up ICUs are there by choice adds a whole level of demoralization that didn’t exist in the first round.

“It feels very different to me because it is preventable now. So, it’s a very different feel in terms of the age of the patients coming in. They are getting really sick, there are a lot of people on ventilators and they are not vaccinated,” Dr. Meghan McInerney, the ICU medical director at Saint Alphonsus Regional Medical Center in Boise, Idaho, said in a recent interview. “It didn’t have to be this way and so with that, the air in the ICU is a little bit defeated. You know, the nurses, the doctors, the respiratory therapists, nurse practitioners, physician assistants, all the members of our team are feeling a little more deflated with this round of a COVID surge because it is a preventable illness at this point.”

Nancy Roberts, a respiratory therapist with St. Luke’s Hospital in Boise, concurred. “It’s rough. You leave here having worked a very hard shift and trying to take care of people, and not everybody makes it. So it does, absolutely, wear you down. Just knowing that we are having a hard time keeping staff and having new people hire on those are realities, so we are doing what we can do,” Roberts said. It’s bad in Idaho. But magnify that several thousands of times in Florida, and you can understand why this is happening: Doctors are walking out.

Nitesh N. Paryani, a radiation oncologist in Tampa, tries to shed light on what’s happening in his hospital and to send a dire warning to all those people refusing vaccines: “The unvaccinated are killing people in ways they probably never imagined.”

“On Aug. 3, I received a call from a hospital that does not have a cancer program,” he wrote. “Such calls are routine at the regional referral center where I work. A doctor at the outlying hospital had a patient with metastatic brain cancer. She was unable to walk, and without urgent radiation treatments there was no hope for any meaningful recovery.” He couldn’t respond to that call for help. “We had no beds available. We had paused elective surgeries the previous week and have been trying to control the influx of patients. Our emergency department had a 12-hour wait that day … But I had no choice. For the first time in my career, I had to say no.”

In plenty of hospitals all over the nation those walk-outs have been permanent, and this time around it’s staff that’s in short supply rather than equipment. Mississippi is now using paramedics and emergency medical technicians to take care of patients in emergency rooms. Tennessee has deployed the National Guard to hospitals and are allowing some health care workers to provide care they are not licensed to give.

Oregon’s Gov. Kate Brown has appealed to FEMA to build and staff a field hospital. She’s also warned her residents that in some parts of the state “there may not be a staffed bed for you if you have a medical emergency.” That’s not a scare tactic to get people to get vaccinated. It’s reality. It isn’t just the medical staff who’ve left, either. “Sometimes we don’t have anyone to answer the phones,” said Marsha Martin, a trauma nurse at University of Florida Shands Hospital in Gainesville. “We’re constantly interrupting the care we are giving to go fetch stuff,” Martin said. “There are delays in patients getting medicine they need.”

Then there’s the Gulf Coast: “The average per person hospitalization rate for Panama City, Fla.; Mobile, Ala.; and Gulfport, Miss.; is considerably higher than that of their states as a whole, even though they are three of the four states with the highest rates in the country, according to data compiled by The New York Times.”

The vaccination rate in all three of those counties is well below 40%, and the per person case rate in each is more than twice the national average. The hospitalizations and deaths are from the delta variant, and they’re overwhelmingly from vaccine-refusers. “We’ve had 44 year olds, 45, 35, that have died,” said Tiffany Murdock, a hospital administrator for Singing River Health System in coastal Mississippi. “I’ve been a nurse for 15 years, and I’ve never seen anything like it.” She talked about a husband and wife in their 40s who died last week, both unvaccinated. “We had five people die, like room after room after room after room,” just last Friday, she said.

It’s enough to start a serious discussion among public health and public policy experts: What are the consequences for the unvaccinated for what they’re doing to the nation’s health care system? It cost $2 billion in June and July of this year. $2 billion in 2 months, a Kaiser Family Fund (KFF) analysis finds.

Using Centers for Disease Control and Prevention data, KFF estimates that KFF there were around 37,000 preventable COVID-19 hospitalizations among vaccine-refusing adults in June and another 76,000 in July. That doesn’t count the children who aren’t eligible for the vaccines, a record high of 1,900 recorded just a few weeks ago.

That has to be paid for, and we’re all having to shoulder the costs through either taxes paid for public insurers or higher premiums for our private insurers. “People who don’t vaccinate are imposing costs on the community that they’re not paying for,” Dorit Rubinstein Reiss, an expert in vaccine policy at UC Hastings College of the Law, told Los Angeles Times columnist Michael Hiltzik. She proposes they be treated like environmental polluters who are fined and forced to pay for the damage they’ve caused. “‘This is not a new idea or a new question,’ Reiss told me. She identifies three rationales for making the unvaccinated pay—to internalize the cost of their behavior, extract retribution for creating costs to their neighbors, and deterrence, i.e., to prompt them to get vaccinated.”

In the meantime, plenty are pinning their hopes on the Food and Drug Administration’s approval of the Pfizer vaccine to bring the remaining unvaccinated around. But that’s not going to undo the damage already done.