Millions could lose health insurance when Covid emergency ends

The Biden administration is telling health-care providers to begin preparing for an end to the public health emergency declared in response to the Covid-19 pandemic nearly three years ago.

The change will have broad implications for Medicaid health insurance recipients and could significantly impact how hospitals and pharmacies operate.

How the U.S. manages Covid this fall and winter will provide crucial data on whether the emergency needs to remain in place, Health Secretary Xavier Becerra told reporters on a call earlier this month.

The Health and Human Services Department will give the public 60 days notice before lifting the public health emergency, Becerra said. His comments come after President Joe Biden claimed in September that the pandemic is over, though he said Covid still presents a health challenge.

Becerra renewed the emergency declaration until Jan. 11 last week as the U.S. presses ahead with a fall booster campaign, but the Centers for Medicare and Medicaid Services told health-care providers in August to start preparing for a return to pre-pandemic rules as soon as possible.

The public health emergency, first declared by the Trump administration in January 2020, has been renewed every 90 days since Covid arrived in the U.S. and ravaged the country.

HHS has used its emergency powers to transform how healthcare is delivered in the U.S., support beleaguered hospitals, simplify access to vaccines at pharmacies and keep millions of Americans enrolled in public health insurance. The health emergency also allowed millions of people to receive increased food benefits through the federal government’s nutrition program.

When the public health emergency does end, HHS estimates up to 15 million people will be disenrolled from Medicare and the Children’s Health Insurance Program. Nutrition experts fear millions of families will face a hunger cliff. Hospitals are concerned the end of pandemic flexibilities will compound a serious healthcare worker shortage. And pharmacies are warning that it could become more difficult for people to access vaccines.

“We’re in the third year of the pandemic. We’ve gone through hell. We’ve sacrificed. We’ve used all kinds of emergency powers,” said Lawrence Gostin, an expert on health law at Georgetown University in Washington, D.C.

“So if you’re going to end all that, you have to end it in a transparent way honestly with the American public about what they gain and what they lose,” Gostin said.

The most dramatic impact from ending the public health emergency will fall on people enrolled in Medicaid and the Children’s Health Insurance Program. Medicaid provides inexpensive and often free health insurance to lower-income adults while CHIP does the same for children whose families are struggling to make ends meet.

Medicaid and CHIP enrollment increased 26% during the pandemic to a record of more than 89 million people as of June, according to the federal government. Enrollment surged because Congress basically prohibited states, which administer the programs, from kicking people out for the duration of the public health emergency.

States received extra federal money through the Families First Coronavirus Response Act for Medicaid and CHIP on the condition that they kept all current and new recipients enrolled during the public health crisis.

“That basically means states can’t disenroll anyone from the program except under unique circumstances,” said Jennifer Tolbert, a Medicaid expert at the Kaiser Family Foundation. States could only disenroll people if they were no longer a state resident or if the recipient voluntarily left the program.

Before the pandemic, people had to renew their Medicaid coverage every year by confirming to state officials that they still met income and other eligibility requirements. While many people were disenrolled for a change in income, others were kicked off simply because they did not respond to state requests for information or because they couldn’t be contacted, Tolbert said.

Medicaid and CHIP will return to business as usual when the public health emergency ends. States will have 14 months to verify who is eligible and who is not. An estimated 15 million will have to leave the programs, according to HHS. About 7 million will lose Medicaid coverage due to bureaucratic obstacles despite still being eligible for the program, according to HHS.

While some of these people may be eligible for subsidized coverage through the Affordable Care Act, they have to apply through the health insurance marketplace. Molly Smith with the American Hospital Association said some people will likely fall through the cracks and end up uninsured.

“We don’t have a good track record in this country of transitioning between different types of coverage,” Smith said.

In 12 states that haven’t expanded Medicaid, with Florida and Texas the biggest, as many as 383,000 people are expected to fall into a gap in which their incomes are too high to meet their state’s eligibility for Medicaid, which guarantees coverage for the poor, but too low to qualify for discounted insurance under the Affordable Care Act, according to HHS. The ACA, know as Obamacare, was designed to help low- and moderate-income Americans.

HHS, in an August report, said it’s crucial for states that haven’t expanded Medicaid under the ACA to do so in order to prevent these people from becoming uninsured after the public health emergency ends.

Medicaid’s expanded role during the pandemic helped reduce barriers to health care and also helped alleviate some of the financial pressure hospitals faced as patients surged, Smith said.

The federal government dramatically expanded the role that pharmacies play in U.S. health care, positioning them at the center of the national vaccination campaign against Covid. Two out of every 3 Covid shots have been administered by pharmacies and more than 40% of people vaccinated by them come from minority groups, according to the National Association of Chain Drug Stores.

Prior to the pandemic, some states restricted what vaccines pharmacies could administer and to which age groups, particularly for people under age 18. HHS smoothed out this patchwork, authorizing pharmacies across the U.S. to administer all vaccines recommended by the Centers for Disease Control and Prevention for people ages 3 through 18.

“They basically took away those inconsistencies that could have impeded pharmacies from delivering those services. That’s one of the biggest advances we’ve had throughout the pandemic,” said Sara Roszak, head of health policy at the National Association of Chain Drug Stores.

It’s unclear whether the nationalization of rules for vaccinations at pharmacies will end when the public health emergency has lifted. The rules were simplified under a separate emergency power called the Public Readiness and Emergency Preparedness Act.

When HHS activated this power, it was able to preempt state laws and provide liability protections for health-care personnel administering vaccines and treatments to combat Covid.

Whenever HHS decides to lift the PREP Act declaration, states will regulate how pharmacies administer vaccines again, which could bring back the inconsistences that existed before the pandemic and make it more difficult for some people to get vaccinated.

HHS has provided the National Association of Chain Drug Stores with a rough timeline of when this might happen, according to Roszak with the drug store association. The PREP Act declaration will lift either when the public health emergency ends, the vaccines have moved to a commercial market which is expected sometime in 2023, or in October 2024 — whichever date comes first.

Steve Anderson, president of the chain drug store association, asked Biden and the White House Covid task force in a September letter to keep the PREP Act declaration in place until October 2024. Roszak said this later date will give states time to make pharmacies’ expanded role in vaccinations permanent at the local level.

The Food and Drug Administration has also relied on emergency powers to shortcut its normal approval process and rapidly authorize four different Covid vaccines, numerous antiviral and antibody treatments as well as tests. 

The FDA’s ability to issue emergency authorizations for vaccines, drugs and medical devices would not necessarily end when the Covid public health emergency is lifted. These authorizations rely on a separate determination made by the U.S. health secretary under the law that governs the FDA.

But it could become increasingly difficult for HHS and FDA to justify clearing vaccines and treatments through an expedited process that shortcuts the normal system of approval when the emergency declaration is no longer in place. 

Trump administration Health Secretary Alex Azar activated the FDA’s emergency authorization powers in March 2020, about two months after first declaring the public health emergency.

“It could affect emergency use authorization, where you couldn’t give these EUAs and so the FDA would have to fully approve the drug,” Gostin said. “It could have enormous knock-on effects that need to be very carefully thought through,” he said of ending the public health emergency.

But James Hodge, an expert on public health law at Arizona State University, said the PREP Act declaration that supports Covid vaccinations at pharmacies and the FDA’s power to grant emergency use authorizations will probably remain in place for years to come.

The U.S. hospital system has in many ways born the brunt of the pandemic. Every fall and winter since 2020, emergency rooms have faced a surge of patients who have fallen ill with the virus.

The public health emergency helped ease some of this stress by vastly expanding telehealth services for Medicare patients, allowing more people to receive care without having to visit the hospital or doctor’s office. In March, Congress passed a law that temporarily locks in place expanded telehealth for five months after the public health emergency ends, but it’s unclear whether this popular service will eventually be made permanent.

The emergency has also given hospitals greater flexibility in how they can deploy staff, where they can add beds and how they care for patients. More patients who are acutely ill can now receive treatment from nurses at home rather than in the hospital.

These flexibilities would expire when the public health emergency ends. Nancy Foster with American Hospital Association said hospitals are facing a major staffing shortage right now, and the loss of pandemic-era flexibilities could compound the problem as Covid continues to circulate and public health officials expect a serious flu season for the first time since the pandemic began.

The AHA has called for the Biden administration to renew the public health emergency until there’s a sustained period of low Covid transmission. The hospital group wants expanded telehealth, hospital care at home and other flexibilities to be made permanent.

Millions of struggling families also received additional money to purchase food during the pandemic through the federal government’s Supplemental Nutrition Assistance Program, or SNAP for short.

The number of people receiving SNAP benefits increased significantly from about 36 million to 43 million from February 2020 to June 2020 as the pandemic caused massive economic disruption, according to data from the U.S. Department of Agriculture. Today, there about 41 million participating in SNAP which is still well above pre-pandemic levels, according to the data.

Family food benefits were increased by the states to the maximum allowed. Poorer households that were already receiving the maximum got an extra $95 per month. The average monthly benefit per household jumped from $276 per month in March 2020 to $416 as of June 2022, according to federal data.

It also became easier for people to remain enrolled in SNAP. Before the pandemic, adults ages 18 to 49 who were unemployed and didn’t have children could only receive benefits for three months every three years. That time limit was suspended during the public health emergency.

The additional food benefits kept 4.2 million people out of poverty in the fourth quarter of 2021, according to an August report from the Urban Institute. The increased food benefits reduced child poverty by 14% across the board. The greatest impact was among Black families with child poverty dropping by about 18%, according to the report.

The increased food benefits will end when HHS declares the Covid public health emergency is over. Households participating in SNAP will lose $82 a month on average, according to the Food Research Action Center. Those who qualify for the minimum SNAP benefit will see their monthly subsidy drop from $250 to $20, according to the group.

Ellen Vollinger at the Food Research & Action Center said an abrupt loss of pandemic-era SNAP benefits will result in more food insecurity in the U.S.

“As much hardship and disruption there was in this country during this period, this was one of the ingredients that helped protect against food insecurity and hardship,” Vollinger said of the increased food benefits.