The burden won’t be evenly shared when COVID ‘emergency’ ends

The Biden administration announced in January that it will end the public health emergency (and national emergency) declarations on May 11. Yet nearly 500 Americans are dying from COVID-19 per day. As many as 1 in 5 U.S. adults who contract the virus experience some effects of long COVID. And the toll of the disease has never been distributed equally.

Historians have long pointed out that pandemics tend to reveal social inequalities and often make them worse, as we have seen with COVID. Studies show that people in areas of social disadvantage have died from COVID at higher rates than those in affluent areas. After controlling for differences in age, people of color have contracted COVID at higher rates, and have died at higher rates, than white people.

It was these inequities that prompted the Biden administration, Congress and some states to adopt policies designed to even the playing field. These policies meant that most Americans could access COVID testing, treatment and vaccines for free or close to free. They also addressed access issues — getting people insured — by expanding Affordable Care Act subsidies for exchange policies, offering a temporary Medicaid coverage option for uninsured people in 15 states, and by not disenrolling anyone from Medicaid in all states during the public health emergency. Between February 2020 and March 2021, at least 13 million additional people enrolled (and stayed) in Medicaid. These policy changes didn’t solve health inequity, but they blunted the impact of COVID on vulnerable communities.

But with the end of the public health emergency, so too comes the end of many of these protections. Most uninsured people will no longer be able to access free COVID tests. Medicaid continuous coverage is ending. The federal uninsured fund has already lapsed.

A direct consequence will be that the uninsured and undocumented people, almost half of whom are uninsured, won’t be able to access care for COVID. This will have broader impacts on the community and the economy as COVID will spread, workforce shortages will continue and burdens of long COVID will increase.

Perhaps the most consequential change ahead is the looming loss of Medicaid eligibility for millions of low-income Americans. Disenrollments can begin as soon as April. As many as 18 million enrollees may lose coverage.

This could have devastating consequences, further straining alreadystretched hospitals, diminishing access to necessary screenings and care for chronic disease, as well as increasing emergency department use and medical debt for low-income Americans. Black and Hispanic people are twice as likely as white people to be enrolled in Medicaid and more likely to be directly impacted.

There are actions states should take now. They can start by encouraging those who lose Medicaid coverage to get alternative coverage that will provide COVID benefits. Many will be eligible for free or reduced cost plans in the Affordable Care Act marketplace. Rhode Island is launching a program to automatically enroll those who lose Medicaid coverage during unwinding into a marketplace plan. Other states, like Maryland, plan to use navigators to contact those no longer eligible for Medicaid to help them enroll in a qualified health plan.

Good public health requires more than access to health care. States can work to enact social policies that are likely to reduce COVID-related inequalities, such as paid sick leave laws, universal basic income requirements and supplemental nutrition assistance programs.

The Biden administration’s decision to end the public health emergency is in some sense understandable. But moving out of the declared emergency doesn’t mean we should forget that the burden of COVID is borne disproportionately by vulnerable communities. Policies to prevent worsening COVID-driven inequities can — and should — be enacted now.