More than two years into the country’s declared public health emergency, the Biden administration faces a dilemma about whether and when to end it.
The administration is under pressure from the public and Republican lawmakers to lift the emergency this year as COVID-19 case counts come down and the virus becomes increasingly endemic. But the return to pre-pandemic normal could have downsides: Millions of Americans risk losing their health coverage and could find it harder to access care.
The emergency is set to expire on April 16, but the Health and Human Services Department said it would give at least 60 days’ notice before ending it. Several public health experts said they anticipated the administration will extend it at least for 90 days, taking it to at least July.
“Health coverage for millions of people has huge policy and political implications. It’s the responsibility of leaders from both parties — governors, Medicaid directors, administration and Congress — to make sure people don’t lose coverage in record numbers,” said Eliot Fishman, the senior director of health policy at Families USA.
The emergency not only deeply changed health care policy but also rippled into federal-state financial relationships that could be painful to end. Lawmakers and administration officials are trying to soften the blow by extending pandemic flexibilities. Complicating the choice is the risk that a new COVID-19 variant could yet emerge.
The emergency status not only opened the door for 13 million to 16 million Americans to get coverage under Medicaid and the Children's Health Insurance Program, but it also gave greater access to telehealth services, made it easier to sign up for health insurance and fast-tracked authorization for COVID-19 treatments, tests and vaccines at the Food and Drug Administration.
Congress boosted federal support to states that provided the Medicaid and CHIP coverage, but stipulated that the states couldn’t disenroll anybody until the emergency ended. States face a reevaluation of who will be eligible after federal aid ends.
The administration is signaling that the end of the emergency is approaching but is otherwise not specifying a date.
Health and Human Services Secretary Xavier Becerra said Friday the decision would come “soon,” but also that the administration would give states ample warning.
"At the end of the day, is America stressed? Do we find that we're not yet ready to cope under the normal regime of laws that we have with COVID?” Becerra said. “If COVID still poses a threat, and if we retract those authorities that let us do telehealth in ways that we had not been able to do before, do we let COVID surge again? So those are the kinds of questions that have to get resolved.”
Americans have grown accustomed to the benefits of an emergency first declared on Jan. 31, 2020, and extended eight times since.
Health insurance coverage
In an attempt to soften the blow, the Centers for Medicare and Medicaid Services released guidance giving states 12 months to redetermine eligibility for Medicaid and CHIP. The agency said it would work with states to help continuity of coverage for eligible individuals and also help transition those cut from Medicaid to the federal health care exchange.
But states face unprecedented caseloads and limited budgets to redetermine Medicaid eligibility. Only about half of states say they have a plan for prioritizing outstanding eligibility and renewal actions once the continuous enrollment requirement is lifted, according to a survey from the Kaiser Family Foundation.
A number of states will see legislative or fiscal pressure to move faster than the 12-month grace period because the enhanced federal match will disappear at the end of September, said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms. Ohio has already enacted legislation requiring its Medicaid agency to process everyone in 60 days, which she said is likely not enough time to ensure everyone keeps coverage.
"The stakes here for health care coverage are huge,” Kaiser Family Foundation Executive Vice President Larry Levitt said. “If millions lose Medicaid coverage precipitously, it will be disruptive for people and a step in the wrong direction for the Biden administration's drive to get more people insured.”
The House passed a bill to allow states to begin Medicaid redeterminations on April 1 even if the public health emergency continues. That provision would have given states more time to sort through Medicaid rolls. But that bill, known as Build Back Better, has virtually no chance of passage in the Senate.
The CMS and other agencies used the emergency to institute policies and waivers to expand the use of telehealth, and many lawmakers on both sides of the aisle lobbied for that to continue after the emergency ends.
Congress extended telehealth coverage of Medicare for the five months after the emergency ends in the fiscal 2022 omnibus spending bill (PL 117-95). The provision waives charges and the requirement for a first visit to be in person, and allows Medicare to continue covering audio-only telehealth.
Lawmakers, meanwhile, get time to decide how to proceed on telehealth waivers that have wide bipartisan support.
"The last two years have proven that telehealth works. It has made it easier and safer for people to see their doctors and stay healthy," Sen. Brian Schatz, D-Hawaii, said upon passage of the omnibus. "While this extension is helpful, these changes should be made permanent," he added, referring to a bill he has offered (S 1512) to permanently expand many of telehealth flexibilities.
Becerra said he'd like those expanded permanently and said the administration would work "aggressively" to do so.
The omnibus didn't, however, include any language regarding doctors practicing telehealth across state lines. Under the emergency, the CMS allowed physicians to practice telehealth across state lines for Medicare and Medicaid patients.
Lauren Clason contributed to this report.