The COVID public health emergency is ending — but what does that mean, and who will be impacted?

The White House announced last month that the COVID-19 public health emergency, or PHE, declared by the Trump administration at the beginning of the pandemic in 2020 will end on May 11. And while some Americans may incur extra costs as COVID-related expenses shift away from the federal government, there’s one group, experts say, that will likely inherit the biggest burden.

What did the COVID public health emergency declaration do?

“Many of the emergency declarations really had to do with trying to adjust our systems overall in the context of the COVID-19 pandemic,” Dr. Wafaa El-Sadr, a professor of epidemiology and medicine at Columbia Mailman School of Public Health, told Yahoo News. “Allowing more virtual medical visits is one example. Another example would be providing free testing for individuals who don't have health insurance. A third example would be providing vaccines at no cost. Another example would be providing treatment for COVID-19 at no cost.”

Keon Gilbert, a Brookings Institution fellow and associate professor at Saint Louis University’s College for Public Health and Social Justice, explained that the PHE enabled different agencies to move through processes a bit faster so everyone could get access to COVID-related screening tools and treatments more easily.

“As people began to lose their employment or became underemployed, as hours were cut back the longer that the pandemic carried on, [the PHE] allowed people, especially in states that expanded Medicaid, to get health care insurance and health care coverage through the Medicaid pathway,” he explained.

Who will likely be impacted the most?

Gilbert said those most affected by the conclusion of the PHE will “definitely [be] people who don't have insurance” — a prediction that El-Sadr agrees with.

“Often, it's the most vulnerable individuals in society that end up being the ones who are left behind. This includes, largely, the uninsured [and] people who are undocumented,” she said. “Often it is the most vulnerable people in society that will bear the brunt of gaps in services.”

El-Sadr cautioned that while the uninsured will probably encounter the most obstacles, we don’t know all the details yet, and more information should be available as we get closer to May 11. But in all likelihood, the “safety net” provided by federally funded testing kits, vaccines and treatments will eventually fall away.

Thanks to policies put in place during the pandemic to protect those who lost their job or income, the number of uninsured people in the U.S. decreased by nearly 1.5 million in 2021, to a total of 27.5 million, according to the Kaiser Family Foundation.

But expiration of the PHE could mean an uptick in uninsured people as Medicaid’s continuous enrollment provision comes to an end.

“When it was declared, [the PHE] allowed states to enroll a lot of people on Medicaid so that they would have insurance. Millions of people will get disenrolled over time when the PHE ends,” Gilbert explained. “Some of those people may have already secured employment with health benefits, so they'll be OK for the most part. It's really the people that remain unemployed or underemployed that will be the most affected.

“Also, we have to realize that there are still millions of people who are experiencing long COVID symptoms, and some of them maybe have not gone back to work full time. Some of them may still be completely unemployed. And so depending on their particular employment status, they may also be greatly affected by this as well.”

According to an analysis released by the Department of Health and Human Services, “children and young adults will be impacted disproportionately, with 5.3 million children and 4.7 million adults ages 18-34 predicted to lose Medicaid/CHIP [Children’s Health Insurance Program] coverage.” Latino and Black individuals make up nearly a third of those predicted to lose coverage.

What could change for uninsured people?

As long as the U.S.’s substantial federal stockpile of vaccines lasts, COVID primary and booster shots will, thanks to the Affordable Care Act, continue to be free for everyone regardless of insurance coverage, according to an analysis by the Kaiser Family Foundation. The availability and cost of COVID vaccines is determined by the supply of federally purchased vaccines, not by the PHE. But once that supply runs out, vaccine costs “may become a barrier for uninsured and underinsured adults,” says Kaiser. As early as this fall, the U.S. government plans to stop purchasing COVID vaccines, and vaccine manufacturers will sell them to health care providers at a higher cost — which uninsured individuals may have to pay out of pocket.

For uninsured children, Gilbert said, vaccines may be available at a very low cost or no cost. The federally funded Vaccines for Children program, for example, has been around since long before COVID and provides vaccines “at no cost to children who might not otherwise be vaccinated because of inability to pay,” with the Centers for Disease Control and Prevention buying shots at a discounted rate to distribute to registered providers with the program.

But for uninsured adults, Gilbert said, “it's going to be a little bit more tricky.”

“Hopefully, federally qualified health care centers and other places will be able to offer people both COVID tests and COVID vaccines, either at a very low cost or free, even though they don't have insurance,” he said.

For COVID-19 testing, uninsured people in many states have already had to pay out of pocket for PCR tests, the median cost of which is $127 per test, unless they got tested at a free clinic or community health center. A Medicaid coverage option adopted by 15 states, which allowed uninsured people access to testing services with no cost sharing, will expire with the PHE.

Health and Human Services says that “pending resource availability,” the CDC’s Increasing Community Access to Testing program “will continue working to ensure continued equitable access to testing for uninsured individuals and areas of high social vulnerability through pharmacies and community-based sites.”

The U.S. government also may continue to distribute free tests from the national stockpile while supplies last. But access to free at-home COVID testing kits through a government website will likely cease once those supplies have been used up.

“It seems like the free testing will come to an end, unless certain clinics will offer free tests,” Gilbert said. “I imagine for some people, especially the older population and families with children, they may stock up on some of the free tests to help them get through several more months.”

COVID treatments such as Paxlovid, an antiviral therapy that can reduce the risk of hospitalization and death, will also continue to be free as long as the federal supply lasts, but uninsured patients may need to start footing the bill once that supply runs out. As with vaccines, the cost and availability of Paxlovid are contingent on federal supply and not on the PHE, Kaiser explains. Last year the U.S. government purchased 20 million courses of Paxlovid from Pfizer at a discounted rate of $530 each.

Are we ready?

While Gilbert said there are “very mixed feelings” about the end of the PHE, public health experts do acknowledge that we’ve entered a new phase in the pandemic.

“I think we recognize that we are in a different place with COVID-19 versus where we were in early 2020, or even early 2021,” El-Sadr said. “We know a lot more about the virus itself and about how to diagnose and manage COVID-19. We're in a very different place, which means that there's reason to adjust to the moment.”

Although the PHE is ending on May 11, Gilbert said a lot of changes shouldn’t happen overnight.

“It's still going to take several months for the policy to take effect,” he explained. “Those that are going to be disenrolled [from Medicaid] won't be disenrolled immediately. They have to be given some time and a notice date for when their Medicaid benefits will end.

“Hopefully that gives people many, many months to be able to prepare for whatever new change or new costs they will incur. So I guess that's sort of one positive piece — that everything won't happen immediately.”

But the sunsetting of the PHE also calls attention to non-COVID-related gaps in U.S. health care.

“I think one of the challenges, just broadly, is that we still don't have a very clear and clean public health infrastructure that allows people to feel that even though this particular declaration is ending, that there are plenty of safeguards,” Gilbert said. “So I think what becomes important is that public health agencies like the CDC and state, county and local health departments communicate what role they will play in making sure that people continue to not only remain safe and prevent COVID, but also that there are opportunities and structures in place for them to access many of these preventative health services as well.”

El-Sadr pointed out that the PHE brought about some changes that were welcomed particularly by some of the more vulnerable members of society — such as access to virtual medical visits, making health care more available to the elderly. Understanding the broader consequences of ending what some would consider desirable changes to health care, she said, will be important as we move into a post-PHE era.

“I realize we're in a different place,” El-Sadr said, “but at the same time we have to very carefully examine what are the implications of rescinding the public health emergency in terms of access to COVID-related services and treatments and vaccines — and also in terms of access to health services overall.”