May 9, 2023 – The federal public health emergency for COVID-19, in place in the United States for more than 3 years, ends on Thursday. The secretary of the Department of Health and Human Services first issued the emergency declaration under the Public Health Services Act, and it was renewed repeatedly – until now.
This is the latest in a line of recent pandemic declarations and announcements:
- This past Thursday, the World Health Organization declared an end to the COVID global health emergency, saying that COVID is now “an established and ongoing health issue which no longer constitutes a public health emergency of international concern.”
- President Joe Biden signed a bill ending the COVID national emergency (distinct from the public emergency) in April.
- CDC Director Rochelle Walensky, MD, said she will step down at the end of June.
- Many nongovernment sites have shuttered their pandemic tracking sites.
The end of the public health emergency, though, may be the most significant change for many Americans.
Throughout the pandemic, the emergency declaration, along with administrative actions and laws, gave the federal government flexibility in waiving certain rules affecting health care, including Medicare, Medicaid, and private health insurance. It also provided immunity to providers in areas such as Health Insurance Portability and Accountability Act (HIPAA) compliance. And, of course, it gave free access to COVID-19 vaccines, testing, and treatments.
As the declaration ends, what – and who – will be affected? While some of the changes are fixed, others are in flux, or subject to change, depending on insurance status and other things.
Among the bigger changes:
- Free, at-home COVID tests don’t have to be covered by private insurers or Medicare.
- Private insurers will no longer be required to cover vaccines for free.
- Medicare will still cover vaccines, but Medicaid no longer has to cover vaccines, tests, or treatments for uninsured people.
- Private insurers and Medicare Advantage plans may have cost-sharing for COVID lab tests ordered by a provider and for testing visits.
- Federal employees, federal contractors, and international air travelers don’t have to be vaccinated.
- State and local health departments no longer have to report COVID data to the CDC (ending community-level tracking).
- Telehealth flexibilities put in place during the pandemic to allow prescription of controlled medications will be extended.
- Title 42 – a rule that was instituted to stem the spread of COVID across the southern border by expelling some migrants seeking asylum in the U.S. – will be lifted. A humanitarian (and political) crisis is expected.
Over, but Not Done
Not everyone is happy with the transition plan, including Anne N. Sosin, a policy fellow at the Nelson A. Rockefeller Center at Dartmouth College, who co-authored an opinion piece in the journal BMJ in late April. She said that “with the end of the public health emergency on May 11, COVID-19 has simply joined the ordinary emergency that is American health.” Sosin said she fears health inequities will grow.
Less frequent reporting means less data, and that will make tracking more difficult, said Rajendram Rajnarayanan, PhD, an assistant dean of research and associate professor at the New York Institute of Technology College of Osteopathic Medicine at Arkansas State University in Jonesboro.
Much is yet to be worked out, and that is causing confusion, said William Schaffner, MD, an infectious disease specialist and professor of preventive medicine at Vanderbilt University in Nashville.
Over and over, experts echoed the fear that a reduction in services will disproportionately affect the uninsured, underinsured, and some ethnic groups.
And the virus has not gone away, experts emphasized. “I think it’s important to recognize that, even though we are certainly at a low point right now with cases and hospitalizations and deaths, that COVID is certainly not done with us yet,” said Meagan Fitzpatrick, PhD, an assistant professor of medicine at the University of Maryland School of Medicine. “We still have about 1,000 Americans dying every week from COVID-19. We still have [thousands of] Americans hospitalized right now with COVID-19. So, these numbers are not zero, and they’re certainly not negligible.”
In fact, The Washington Post reported this past Friday that infectious disease experts have warned the White House that there is about a 20% chance of another major COVID outbreak within the next 2 years.
Here is a more in-depth look at the changes coming when the public health emergency ends.
The CDC will stop tracking and reporting COVID cases at the community level. During the pandemic, it has been possible for people to enter a location in a search tool on the CDC website to find out, with a color-coded indication, whether the virus level is low, medium, or high in the location chosen.
Each category included information about how to stay safe. After May 11, the CDC will lose authorization to collect "certain public health data" and moving forward will track COVID in much the same way as the flu and other respiratory illnesses.
The agency will rely heavily on hospitalization data as its "primary surveillance indicators,” the CDC said, but that information lags, with the data usually coming in well after someone got infected.
Also going away is the COVID Data Tracker Weekly Review of the community data.
During the emergency period, the CDC had the authority to require data reporting from states. After it expires, the CDC can request but not require this data. And that’s a mistake, said Philip Huang, MD, director of the Dallas (Texas) County Department of Health and Human Services, one of the speakers at a recent media briefing hosted by the Big Cities Health Coalition, an organization of 35 member cities serving 1 in 5 Americans.
“Congress should grant CDC this authority,” he said, because not having this information is like “flying blind.”
Tests and Vaccines
Private insurers and Medicare will no longer be required to provide eight free at-home COVID-19 tests a month.
Private insurers no longer have to cover vaccines. (But many experts predict that most people with private insurance will continue to pay nothing out of pocket for COVID vaccines and boosters.)
The Medicaid option to cover the uninsured for COVID-19 vaccines, tests, and treatments also ends. Those enrolled in Medicaid will still get vaccines, at-home tests, provider-ordered tests, and treatments until Sept. 30, 2024.
For those with private insurance and Medicare Advantage, the requirement of no cost-sharing for PCR/provider-ordered tests and the testing visits end.
The requirement that private plans and insurance cover vaccines without cost-sharing at out-of-network locations ends.
Medicare will continue to cover COVID vaccines without cost-sharing; COVID diagnostic tests may require some cost-sharing.
But at the Big Cities briefing, speakers said the COVID vaccines and testing will still be available in various settings, often at no charge, through public health departments and local clinics, as vaccines remain in the federal stockpile.
And the Inflation Reduction Act requires Medicaid and the Children's Health Insurance Program (CHIP) to cover recommended vaccines.
“We have a stock,” agreed Rajnarayanan. “Vaccines and therapeutics may still be available. It’s almost like a store closing, like ‘everything has to go.‘ ” What’s not known is what will happen when the stock is depleted and the vaccine costs too much for the under-insured, he said.
The emergency use authorizations for vaccines and other COVID products are not going away, since they were granted under a separate emergency declaration. As more vaccines and treatments gain full FDA approval, the point will be moot, experts at the Big Cities briefing said.
While the COVID vaccine requirement for federal employees, federal contractors, and international air travelers will end, “on the private side, there will be individual employers that could continue to require the vaccine,” Schaffner said.
For instance, he said, “here at Vanderbilt, we are obliged to be COVID vaccinated, just as we are obliged to get the influenza vaccine. And I would anticipate that would continue.”
Telehealth boomed during the pandemic, during lockdowns and after. Many of the telehealth flexibilities for Medicare and Medicaid, allowing people to do online visits, will not change. Congress has allowed these flexibilities to stay in place until at least the end of 2024.
This flexibility was not intended to continue to apply to controlled substances prescribed via telehealth after May 11, at first. A proposed Drug Enforcement Administration rule would have stopped health care providers from prescribing medication for opioid use disorder without the patient being seen in person..
After a public outcry, the DEA reversed course. On May 9, DEA Administrator Anne Milgram announced a 6-month extension to the pandemic flexibilities, through Nov. 11, while the agency considers comments from the public.
For provider-patient relationships that have been or will be established by Nov. 11, the prescribing flexibilities will be extended for another year.
The DEA rule covers a range of medicines, from ADHD drugs to buprenorphine, an opioid use disorder medication.
Health care providers will still need to transition again to a HIPAA-compliant telehealth platform when the emergency expires. During the pandemic, when the emergency was in effect, the Office for Civil Rights did not impose penalties if a practice provided telehealth services in a non-public-facing platform (such as Facetime).
After May 11, the platforms, including audio-only ones, will need to be HIPAA-compliant. Providers have a 90-day transition period to do that, with that deadline set for 11:59 p.m. Aug. 9.
The end of the PHE will be the beginning of the end for emergency waivers that mandated completely free coverage for COVID vaccines, tests, and treatments for Medicaid and CHIP enrollees. Because of the American Rescue Plan Act of 2021 (ARPA) that coverage will not officially end until Sept. 30, 2024.
According to a CMS spokesperson, "after that [September] date, many Medicaid and CHIP enrollees will continue to have coverage for COVID-19 vaccinations. After the ARPA coverage requirements expire, Medicaid and CHIP coverage of COVID-19 treatments and testing may vary by state."
The same does not apply to the uninsured. The spokesperson said "18 states and US territories (California, Colorado, Connecticut, Iowa, Illinois, Louisiana, Maine, Minnesota, North Carolina, New Hampshire, New Mexico, Nevada, South Carolina, Utah, West Virginia, the Commonwealth of the Northern Mariana Islands, Puerto Rico, and the United States Virgin Islands) opted to use an option to give Medicaid coverage to uninsured people" for COVID vaccines, tests, and treatments.
That option (including federal matching funds) expires on May 11.
‘Priority’ Instead of Emergency
Rajnarayanan is not as concerned about the community-level reporting going away as some other measures. The community-level reporting, he said, provided a guide for institutions and businesses to decide on masking and other precautions. “Most of those [measures] have gone away anyway.”
The disparities will continue, Schaffner said, the same that have existed for years in what he calls a “non-system” of medicine. “It is way past time that the U.S. acknowledge that medical care is a right, and we provide it to everyone in our population. We are the last developed country in the world not to do that.”
Rajnarayanan understands that much of the country has long ago moved on from COVID, even though “COVID is still not through.”
He acknowledges that the emergency can’t continue indefinitely. “We need to step away from calling it an emergency, but calling it a priority (which HHS is claiming to do) would continue a level of seriousness, as a bridge.”
But we're not out of the woods yet, Sosin said. “A lot of people think ‘endemic’ means end,” but it actually means that it’s transitioned to become a permanent threat, she explained. While the public health emergency allowed the U.S. to bring forth many resources to fight COVID, “now we are seeing just a sense of resignation.”