As COVID Emergency Ends, a New Era of Health Care Begins
The Biden administration’s plan to terminate the COVID-19 public health emergency on May 11 signifies the end of an era as the nation confronts its third year of a still-present but muted pandemic, with cases, deaths and hospitalizations all largely trending downward since the beginning of the year.
Though the availability of COVID-19 vaccinations at no cost is expected to continue while supplies purchased by the federal government last, the end of the emergency does mean a potential loss of free access to COVID-19 tests. But issues with specific COVID care aside, the coming months carry broader health implications as well, with a number of regulatory shifts that expanded health coverage or access to services scheduled to sunset or continuing on – whether in direct connection with the emergency’s end or not.
Here’s a look at three key health care areas at the onset of a new era – including things that will change and innovations that are slated to remain.
Medicaid
One major concern previously tied to the end of the public health emergency but now with a new timeline is the potential loss of health insurance coverage for as many as 15 million Medicaid and Children’s Health Insurance Program enrollees. During the emergency and under congressional legislation, states were able to receive additional funding for providing continuous Medicaid coverage to enrollees, putting eligibility renewals and redeterminations on hold. An analysis from the Kaiser Family Foundation found Medicaid/CHIP enrollment increased 29% from February 2020 to November 2022.
Originally, continuous enrollment was to stay in effect until the end of the month when the public health emergency ends. But Congress delinked the provision from the emergency with the passage of the Consolidated Appropriations Act in December, allowing states to begin removing ineligible individuals from the program as of April 1. The increased Medicaid funding states were receiving reportedly will phase out by the end of December.
The inflection point comes after the U.S. uninsured rate hit a historic low of 8% early last year.
States vary on how and when they plan to address the “unwinding” of continuous enrollment, though five reportedly were expected to begin the process of removing ineligible beneficiaries come April.
Some people removed from the Medicaid rolls “will be able to get insurance under the health exchanges, but when states do those redeterminations, we’re going to find a lot of people who will lose coverage,” says Dr. Georges Benjamin, executive director of the American Public Health Association.
An improved labor market may offer a buffer. Matthew Buettgens, a senior fellow in the Health Policy Center at nonprofit think tank the Urban Institute, says a reason many people may lose Medicaid coverage is because of new employment. “For a lot of them, the reason why they are no longer eligible for Medicaid is because their income has increased and they have gotten new jobs,” Buettgens says. “So we’ve seen employment largely recover from where it was early in the pandemic.”
In a research report predating final approval of the congressional appropriations package but assuming an expiration of the public health emergency in April, Buettgens and colleague Andrew Green estimated Medicaid enrollment would drop by 18 million over a period of 14 months, but that 9.5 million would gain or transition solely to employer-sponsored insurance. More than 3 million children would likely transition from Medicaid to coverage under a separate Children’s Health Insurance Program, according to the report, which also projected more than 1 million people would access health insurance through the nongroup market, which includes marketplaces created under the Affordable Care Act.
Overall, an estimated 3.8 million people would be newly uninsured, according to the report, though of that total, 1.5 million would be eligible for tax credits to get marketplace plans.
“If you can get more people enrolled into the marketplace, you can reduce the number of people who end up uninsured even further,” Buettgens says.
Still, Jennifer Tolbert, director of state health reform and an associate director for the Program on Medicaid and the Uninsured at the Kaiser Family Foundation, points out that as many as 6.8 million people who are otherwise eligible to remain on Medicaid could lose coverage in the wake of continuous enrollment’s end due to what federal officials call “administrative churning.” These enrollees could face hurdles such as problems navigating the renewal process, or states may struggle to get in touch with them due to a change of address.
“For those individuals, they’re still eligible for Medicaid and they don’t have anywhere else to go to get coverage,” Tolbert says. “So their only option is to either get back on Medicaid, if they can, or they will become uninsured.”
Telehealth
During the early months of the pandemic, a lack of access to health care services likely helped fuel disproportionate rates of COVID-19 illnesses and deaths among various racial or ethnic groups.
A major tool in the effort to expand access and allow people to continue receiving needed services has been telehealth, which due to the waiving of certain restrictions under the public health emergency grew in use: In 2020, 44% of continuously enrolled Medicare fee-for-service beneficiaries had a telehealth visit – compared with 1% in 2019 – and the share remained elevated at 28% in 2021, according to a report by the Bipartisan Policy Center. Kaiser Family Foundation analysts also found that telehealth went from accounting for less than 1% of outpatient visits before the pandemic to a peak of 13% during the first six months of the crisis.
Authorities clearly have acknowledged the boom. The federal Centers for Medicare & Medicaid Services notes that various Medicare telehealth flexibilities created during the pandemic have been extended through December 2024, such as allowing some services to be delivered using an audio-only platform and permitting patients in any area of the U.S. – not just those in rural areas – to use telehealth services. Other flexibilities have been made permanent, including allowing beneficiaries to receive mental or behavioral health care via telehealth in their home. Set to expire is the ability of Medicare providers to use a wider range of remote communication tools to meet with patients.
According to CMS, Medicaid and CHIP telehealth flexibilities will vary by state but are not tied to the end of the public health emergency. Coverage under private insurance will continue to vary as well.
At the same time, at least some states are allowing telemedicine to be rendered to patients by health care providers licensed in a different state outside of the COVID-19 crisis.
Benjamin feels the benefits of telehealth were proved throughout the pandemic and that many of the regulatory flexibilities put in place should stay.
“We very well demonstrated the value of telemedicine, and I think we learned a lot of best to use it,” Benjamin says. “I think the dam has been broken on the use of telemedicine.”
Addiction Treatment
Many credit the growth of telehealth with increasing access to mental health and substance use disorder treatment during the pandemic: Telehealth went from making up less than 1% of such outpatient visits before the pandemic to accounting for roughly a third during 2021, according to a Kaiser Family Foundation analysis. Meanwhile, the number of reported drug overdose deaths rose 36% from 74,679 during the 12-month period ending March 2020 to 101,751 for the yearlong period ending October 2022, according to provisional data from the Centers for Disease Control and Prevention.
In response to the public health emergency, rules regarding the distribution of the addiction treatment medication buprenorphine were relaxed to allow for clinicians to prescribe it via telemedicine or by phone without the need for an initial in-person visit. In a similar move, federal authorities cleared the way for certain patients to take home an increased amount of up to 28 doses of methadone to treat opioid use disorder.
A study published in JAMA Psychiatry found the use of telehealth for opioid use disorder services was associated with better medication retention among Medicare patients and lower risk of medically treated overdose. And despite potential for abuse, another study did not find a link between increased take-home doses of methadone and negative treatment outcomes.
In February, the Drug Enforcement Administration announced a proposal to make the buprenorphine rule change permanent, but to limit the amount providers are allowed to prescribe to a 30-day supply. Public comments on the proposed rule were being accepted until March 31.
Brandee Izquierdo, director of behavioral health programs for The Pew Charitable Trusts, says having the ability to prescribe buprenorphine through telehealth has been extremely impactful for people in recovery, lessening their risk of a relapse. She says she is worried the DEA’s proposed rules that effectively would require patients to have an in-person visit within 30 days of their initial prescription in order to get a refill could create barriers for some to continue their treatment.
“That’s a very scary place to be when we’re dealing with a lot of different challenges,” according to Izquierdo, who says she herself at one time was in recovery for substance use disorder for a number of years. “It can become very difficult for individuals to access that treatment.”
Izquierdo feels the past three years have proved that a relaxation of the rules governing the administration of medication-assisted treatment for substance use is an effective means of expanding access.
“It’s imperative that we eliminate these barriers,” she says.
Notably, federal officials also have moved toward making the increase in methadone take-home doses permanent.