On May 11, the COVID-19 public health emergency officially comes to a close in the U.S., and with it comes an end to largely free access to all related healthcare. House Republicans might want to declare it over this instant, but a cushion is needed — and this one might not even be enough — to ensure everyone from insurers to drug companies to each of us knows what the unwinding means.
The transition timing is sensible. Thanks largely to vaccines, tests and treatments, COVID is no longer overwhelming hospitals (even as it continues to kill thousands each week). Millions of people will continue to get sick each year, with some portion of those needing treatment. And many of us — though unless we develop better vaccines, nowhere near as many as in 2021 — will want whatever booster comes next. The question is how easily each of us will access those interventions after May 11.
The answer comes down to a choose-your-own-aadventure based on insurance status — one that ends with less happy outcomes for some versus others. The complexity of how various people will be able to access and pay for care could lead to a rather clunky transition after three years of a single plan: free vaccines, drugs, and treatment for all.
The people most directly impacted will be the uninsured and those who treat them, says Lindsay F. Wiley, a professor of law and Faculty Director of the Health Law and Policy Program at the UCLA School of Law. The public health emergency declaration included provisions that allowed hospitals and healthcare providers to seek reimbursement through Medicaid after treating uninsured people for COVID. Now, “that reverts to our ordinary, inequitable, really poor healthcare system,” Wiley told me. In other words, uninsured patients will be on the hook for those costs.
For some, the new reality hit when federal funding for the program began to dry up last spring. Now, the number of uninsured people could grow by the millions as pandemic-era provisions that ensured continuous enrollment in Medicaid lapse, albeit on a timeline no longer tethered to the emergency declaration.
People with Medicare and Medicaid, meanwhile, will still be eligible for free vaccines, but will likely share the cost of treatments like Pfizer Inc.’s Paxlovid, Merck & Co.’s Molnupiravir, and Gilead Sciences Inc.’s Remdesivir, and, eventually, tests.
For people with private insurance, COVID prevention and treatment will generally be covered like any other infectious disease, with some nuances. Vaccines, like other preventive care, should be fully covered, but the ending of the PHE means it will now matter where you get it. Under the PHE, the appointment and the shot itself were both free whether you stayed within your insurer’s network or not. Now, you’re going to want to be sure the provider is in-network, or risk an unexpected bill.
If you get sick, you’ll likely have to jump through the same insurance hoops as with other care. Insurers and drug companies will be setting treatment costs, rather than the government, explains Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security. “It’s going back to the norm.”
Another nuance worth noting: Private insurers will no longer be required to pay for eight at-home tests per person, per month, and it’s unclear how they’ll approach covering those once the PHE ends. “One of the challenges is that our healthcare financing system isn’t really set up with public health benefits in mind,” Wiley says. If you’re at low risk for a serious case of COVID, your main purpose in taking a test is to ensure you don’t spread the virus around — in other words, the benefits of that test largely accrue to society, not your insurance company.
Insurers might decide it isn’t worthwhile to cover at-home tests, or at least not for anyone who isn’t at risk of severe disease. And if people are paying out of pocket, it’s hard to imagine families will use as many. Even pegged to the $12 per test that the government currently covers, costs will add up. That could be another implication of the end of the PHE: We simply won’t feel as motivated to test, which could in turn increase community spread.
Full approval for Paxlovid or any future COVID antiviral pills, which are only useful if people know they have COVID, might alter that scenario. Because Paxlovid is currently available under so-called “emergency use authorization,” a status that will remain after the PHE ends, Pfizer can’t market the drug. But once it has full approval and can, it would seem prudent for the company to find a way to ensure everyone has access to affordable testing to maximize the drug’s uptake.
Navigating this new world order, one where COVID is treated like any other infectious disease, is sure to have hiccups. Fortunately, not all the PHE benefits will go away at the same time: services such as telehealth for everything from cancer care to therapy appointments are in some cases not tied to the ending of the emergency. And some have been made permanent, for example, virtual visits with a mental health provider are now covered for people with Medicare.If healthcare providers, insurers, and companies use the runway left to smooth out questions around coverage and embrace the need to contain community spread, we can hope it all amounts to a softer landing for patients.
Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.
