The federally designated Public Health Emergency (PHE) is ending on May 11, 2023 after more than three years. While it is clear that COVID-19 has not gone away, and is still a significant risk to many people in this country, especially people who are immunocompromised or have other pre-existing conditions, COVID-19 rates and risk of severe disease thankfully have gone down.
The end of the official PHE designation, however, also means the end of many policy changes that were ushered in as a response to the pandemic—policy changes that not only were immensely successful in the middle of a public health crisis, but also would, if made permanent, continue to deliver public health benefits long after the pandemic has receded.
The PHE brought greater health insurance stability, especially for people enrolled in Medicaid.
The federal policy response to the PHE made clear that health insurance stability was important. First, the Families First Coronavirus Response Act (FFCRA), passed in March 2020, required that states maintain continuous coverage during the PHE for people enrolled in the Medicaid program as of January 1, 2020 in exchange for more money from the federal government. In other words, FFCRA ensured that people would not be kicked out of Medicaid during this period.
Before the PHE, states regularly checked whether enrollees were still eligible for the Medicaid program. This type of frequent assessment caused what is known as insurance churn—moving from one source of insurance to another or uninsurance. Sometimes this churn happens because people’s income would rise or fall, knocking them in and out of eligibility, and sometimes because administrative hurdles that are unrelated to actual eligibility still lead to the loss of coverage. This type of insurance instability or churn has real implications for health—even if people churn from Medicaid to another source of coverage. It is stressful, at a minimum; almost certainly has financial implications; can be demeaning; and interferes with access to and continuity of necessary care, which is especially challenging for people who have chronic conditions, are disabled, or in the middle of a course of treatment.
During most of the PHE, churn between different types of insurance coverage and uninsurance virtually slowed to a halt for the Medicaid population. The uninsured rate dropped and Medicaid enrollment grew significantly, due in large part to the continuous coverage requirement.
The “unwinding” of this continuous coverage requirement has since been legislatively delinked from the end of the PHE. States were allowed to begin disenrolling people from Medicaid beginning April 1, 2023. There is a risk that approximately 17 million people will lose coverage during this time; some will fall through the cracks, no longer being eligible for Medicaid but also without access to alternative forms of affordable coverage, but many people who are still eligible will also lose access because of administrative, procedural hurdles. This loss of coverage is anticipated to disproportionately impact people of color, who are more likely to be insured by Medicaid because of historic and structural lack of access to the types of employment that offer insurance.
While most of the attention during the PHE in terms of insurance stability was focused on Medicaid, federal policy also required that employer health plans make it easier for people to enroll in coverage if they had a change in employment status that affected their insurance coverage. This policy decision again reveals that insurance stability and ease of enrollment is important to public health, the driving force in the early days of the PHE.
Home- and Community-Based Services were easier to access during this time of crisis.
During the PHE, the federal government provided states with new flexibilities in administering their programs for people enrolled in Medicaid and using home- and community-based services (HCBS). For example, states were able to make it easier for people to join the program, and also to pay family caregivers for providing these types of services. The intention was to help meet people’s needs and also to address workforce shortages. In addition, states received an influx in Medicaid funding, some specifically for HCBS. The American Rescue Plan Act funding was a significant boost to states for HCBS, in particular for states ready to leverage the new flexibilities granted by the PHE and capitalize on the funding to better serve Medicaid beneficiaries. States such as California, Illinois, and Washington were ready to expand the technological infrastructure and bring services to more beneficiaries because they had strong systems and networks in place to support new initiatives and expansion of services.
Critically, the flexibilities from the PHE and funding from the relief bills allowed states to address workforce challenges, one of the key limiting factors in expansion of services in some states. States addressed workforce challenges by leveraging new funding to raise wages for the direct care workforce (including direct support providers, home health aides, in-home nurses, and more), in particular, and under the PHE flexibilities, thirty-nine states allowed family caregivers to be paid for HCBS provided. These efforts began to address recruitment and retention challenges some states face for this critical workforce. Some states plan to continue policies put in place from the PHE, but not all states. While transitioning the disaster-relief waivers to permanent authorities would help maintain the advances made in HBCS provision, not all states have decided to do this, particularly regarding whether or not to continue paying family caregivers.
It was easier to access COVID-19 testing, treatment and vaccines during the PHE.
One of the major changes associated with the PHE was that the government made it as easy as possible for people to access COVID-19 testing, treatment, and vaccines. Prevention was a key to saving lives and reducing transmission. Private insurers were required to cover testing, treatment, and vaccines without cost sharing or prior authorization, both in- and out-of-network, and these services were also covered for people without insurance. Making it easier to afford and access tests and treatments made a dramatic difference in COVID-19 testing and mortality rates. Shifting back to a reactive mindset could ultimately be costly, as the nation hits typical months of increased transmission—the colder months, when people spend more time indoors together—as is seen with other transmissible viruses. A focus on prevention was a key lesson learned during the pandemic: prevention works and saves lives.
The need for broad, equitable access to health care and caregiving is not over.
It cannot be overstated that the past three years in the United States, since the pandemic was first declared, has been a time of chaos and stress for a lot of people—and especially people who are low-income, have pre-existing conditions, are immunocompromised, or otherwise disproportionately impacted for a myriad of reasons. But many people continue to face chaos and hardship and sickness, even though COVID-19 rates have slowed. The country is still in the middle of intersecting health crises, especially for populations who have been most marginalized, caused by a range of acute and chronic health issues, including mental health challenges, opioid use, and rising heart disease and cancer death rates; at the same time, many people are facing major issues of instability related to social determinants of health, such as housing inaffordability, food insecurity, and lack of transportation access, to name a few. In other words, the need for more equitable access to care and caregiving have not gone away.
State and federal policymakers should continue the protections put in place during the PHE.
While we are still grappling with the lives lost from the COVID-19 virus and the long-term impact of Long COVID, we must find the silver lining in what we learned the past three years. The PHE gave unprecedented opportunities for flexibilities in critical social safety net programs and allowed states to meet the needs of its constituents. The lessons learned and values shown during the PHE don’t need to stop now. There is a lot that state and federal policymakers can do to lean into the values exhibited as part of the PHE and to build on learning of what worked. While the polarized political climate at the federal level may discourage good policymaking in the coming years, there is an opportunity for federal policymakers especially to continue promoting the flexibilities at the state level that build on some of the good that emerged from the PHE, including efforts to:
- Reduce barriers to coverage and access. States can lean into opportunities to promote continuous coverage, for example, by following the lead of states such as Oregon and Washington to enact continuous coverage for children age 6 and under, expanding coverage to postpartum women for twelve months, and—of course—by expanding eligibility for Medicaid.
- Develop and expand health policies that provide services and supports to individuals where they are living and in the community to ensure equitable access. States should continue to utilize waiver flexibilities to continue to support the caregiving workforce and expand access to HCBS.
- Shift health policy to prevention rather than reaction. The most effective policies address issues prior to a disaster. Focusing our health policies on prevention will be life saving and lead to cost savings. Policymaking generally tends to focus on short-term responses to acute threats rather than investing in longer-term investments that can help prevent these threats. This is a moment to step away from that mentality by embracing some of what was done in this pandemic to help protect against future ones.
- Recognize that it is better for everyone if people have access to the supports they need to live the healthiest life possible, including in-home care and caregiving. Community health is critically important to individual health and states should build on systems and relationships established and strengthened during the PHE to advance equity especially for multiply marginalized people.
While the PHE is officially over, the virus will remain with us for years to come. We must contend with the fact that people will still die from COVID-19, that Long COVID will have a tremendous impact on life and our economy, and that the virus will continue to impact life in an unknown way throughout the years ahead. And of course, we must also recognize that even before COVID-19, and if there ever is an “after” COVID-19, the health and social needs addressed during this time are ever present. Now is the time to take stock of what we learned, build on success, and create lasting policy change that will support healthier futures for everyone.