The US has started unwinding its Covid-19 crisis measures that have expanded access to health care for millions of people since the beginning of the outbreak in the country in 2020. President Joe Biden is imminently expected to sign a bill passed by Congress that will conclude the country’s national emergency. The White House on May 11 plans to end a separate, more consequential public health emergency and disband its Covid response team. A policy that increased health coverage for low-income people has already been discontinued. So has the federal government’s purchase of Covid vaccines and treatments. While some rules around telehealth will remain relaxed, others are being tightened up again. Undoing Covid emergency rules also has implications for US immigration policy.
1. What’s Covid’s toll in the US now?
Covid has killed more than 1.1 million people in the US altogether. About 230 people were dying each day as of late March, according to the Centers for Disease Control and Prevention, compared with about 3,400 at the peak in January 2021.
2. What were the emergency declarations?
- In January 2020, then-Health Secretary Alex Azar declared a public health emergency. That allowed his department to ease or waive certain requirements and put in place flexibilities to address the Covid outbreak.
- Azar the next month issued a separate emergency declaration that allowed the Food and Drug Administration to grant emergency use authorizations for Covid products. No plans have been announced for terminating this declaration, which has made Covid vaccines, treatments and diagnostics — which otherwise might have taken years to bring to market — available more quickly. Should the declaration be revoked, so will the emergency clearances for those products. With that in mind, many companies, like Pfizer, Moderna and Gilead, have sought to get their products approved through formal, more permanent pathways.
- Then-President Donald Trump issued a national emergency declaration in March 2020 that allowed the federal government to mobilize resources and provide support for activities beyond the confines of public health. For example, the declaration enabled the extension of deadlines for workers to sign up to keep health insurance after leaving a job. The Biden Administration had intended to keep the national emergency in effect until May 11, but the president has vowed not to veto a Republican-backed bill that ends it earlier.
3. Why did health coverage for the poor increase in the pandemic?
Typically, states regularly assess whether those enrolled in Medicaid, the government health program for the poor, remain eligible. In the pandemic, Congress substantially increased federal funding to state Medicaid programs, and in return, states suspended the enrollment review process for the duration of the public health emergency. Relaxing eligibility requirements this way increased Medicaid enrollment in every state. Overall, enrollment in Medicaid and the related Children’s Health Insurance Program grew by 28% since the start of the pandemic to more than 91 million people, according to data from the Kaiser Family Foundation.
4. What’s changed with Medicaid rules?
In its year-end spending bill, Congress decoupled this new flexibility from the public health emergency and tightened Medicaid enrollment provisions as of March 31. States are no longer required to keep people enrolled — and some will now begin the long process of re-determining Medicaid eligibility for millions. (Arkansas, Arizona, New Hampshire, South Dakota and Idaho will begin terminations in April, while most other states will launch the process in the summer). Enrollees will be required to verify information ranging from income to household size.
5. How many people will be affected by the Medicaid change?
The Kaiser Family Foundation estimates between 5 million and 14 million people could lose Medicaid coverage. The Department of Health and Human Services has estimated that as many as 15 million people could be removed from the program. The Georgetown University Health Policy Institute estimates almost 7 million children and teens are at risk of losing coverage. Some people leaving Medicaid may qualify for other coverage, including through employers or Affordable Care Act markets.
6. How will payment for Covid vaccines and treatments change?
Throughout the pandemic, the US government has purchased supplies of Covid vaccines and treatments, which, for the most part, have been offered to people without out-of-pocket costs. That’s about to change. In the absence of new funding for these products from Congress, the Biden administration will stop procuring them, leaving their purchase and distribution to the market. For now, there’s sufficient supply of government-purchased Covid vaccines and treatments such that access “will generally not be affected,” the health department said in February.
7. What happens once government-purchased supplies run out?
When that happens, most Americans will get their Covid vaccines and treatments through private health insurance plans or federal health programs — such as Medicaid and Medicare, the program for the elderly — as they already do with annual flu immunizations. Covid vaccines will continue to be provided to older Americans via Medicare Part B without cost sharing, and Medicaid will cover all vaccines and treatments without cost sharing through Sept. 30, 2024. Thereafter, cost may vary by state. For those with private insurance, out-of-pocket expenses for treatments could vary depending on their plan.
8. What about those with no health coverage?
Those without health insurance may face high out-of-pocket costs. The Centers for Disease Control and Prevention’s “Vaccines For Children” program will continue to offer free immunizations for kids. The Biden administration has proposed a similar program for US adults. CDC Director Rochelle Walensky has raised concerns about access challenges for adults who are inadequately insured. However, Pfizer Inc. and Moderna Inc. have said they will provide their Covid vaccines for free to uninsured people in the US via their patient assistance programs.
9. Who will pay for Covid tests?
The public health emergency allowed Medicare and Medicaid beneficiaries to receive free, rapid over-the-counter Covid tests, and the Biden administration later required private insurance companies to cover the tests without out-of-pocket costs. After the emergency ends, Medicare beneficiaries won’t be able to get free tests, unless they are ordered by a health provider. (There may be cost associated with the doctor’s visit, though). Medicaid, meanwhile, will continue to cover at-home and PCR tests until September 2024, after which coverage will vary from state to state. For those with private insurance, costs will depend on their plans.
10. What’s happening with the rules about telehealth?
Throughout the pandemic, Medicare beneficiaries were able to receive telehealth care from their homes, with new laws expanding the types of facilities that could provide such services as well as the list of services that would be covered. Congress has ensured in its year-end spending plan that most Medicare telehealth flexibilities will remain in place until December 2024. Meanwhile, most states made Medicaid telehealth flexibilities permanent. With private health insurance, coverage continues to vary by plan. Some rules about telehealth prescriptions may be changing.
11. What prescription practices are being reconsidered?
The public health emergency allowed telehealth providers to prescribe certain controlled substances virtually or over the phone without conducting an in-person medical exam. The Drug Enforcement Administration in February proposed new rules that would no longer allow providers to prescribe Adderall, Vicodin or OxyContin for example, if the patient never had an in-person visit. For another drug class — which includes testosterone and buprenorphine, a treatment for opioid use disorder that can prevent withdrawal symptoms — a clinician could order an initial 30-day supply of the medication via telemedicine, but would need an in-person visit to provide a refill. The DEA is reviewing public comments on the proposed rules.
12. How is immigration policy impacted?
The end of the public health emergency will also mean the end of Title 42, a obscure public health order dusted off under Trump at the start of the pandemic that made it easier for authorities to expel undocumented migrants. In about half of the apprehensions of migrants in fiscal 2022, in which the US border patrol encountered a record 2.2 million people entering the country without authorization, authorities used the rule to quickly send the individuals back to their homeland or to the country from which they entered the US. The alternative is to process apprehended migrants under regular immigration law. That gives them a chance to remain in the US at least temporarily in order to make long-shot bids at gaining asylum, available to people who can show they have a legitimate fear of persecution at home.
The Reference Shelf
- Related QuickTakes on endemic Covid, telehealth and the US immigration debate.
- A road map to the unwinding of emergency measures from the Department of Health and Human Services.
- The Food and Drug Administration’s page explaining emergency use authorizations.