[What does it mean to end the emergency? Questions and answers
about antigen tests, vaccines, Paxlovid, healthcare coverage and more.
Why we, as a society, need to transition NOT to a 2019 world but to a
new and better 2023 world.]
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WHAT ENDING THE COVID EMERGENCY ACTUALLY MEANS  
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Katelyn Jetelina and Caitlin Rivers
February 7, 2023
Your Local Epdemiologist
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_ What does it mean to 'end the emergency'? Questions and answers
about antigen tests, vaccines, Paxlovid, healthcare coverage and more.
Why we, as a society, need to transition NOT to a 2019 world but to a
new and better 2023 world. _

,

 

The communication about ending the COVID-19 public health emergency
(PHE) has been atrocious. We’re confused. Everyone’s confused. Dr.
Rivers and I have been asking a lot of questions and getting some
answers. Here is our understanding of the situation right now and what
it means for you.

Really complex

There isn’t one national emergency declaration surrounding the
COVID-19 pandemic. There are five. Each has a different purpose for a
different part of our government. The five emergency “buckets”
are:

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FDA

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Stafford Act (i.e., FEMA)

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Public Health Emergency

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National Emergency

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PREP Act

Together, these are responsible for hundreds (thousands?) of
flexibilities that we saw throughout the pandemic. For example, the
emergency use authorization for vaccines occurred under bucket #1.
Extending Medicaid to more people happened under bucket #3. (This
recently changed; see more below).

These different mechanisms created a complicated system that needs to
be untangled without collapsing all at once. To help prevent this, the
five buckets of emergencies are ending at different times. Buckets #3
and #4 are ending in May 2023. All the others are yet to be
determined. (Apparently, #5 is being discussed among lawyers right
now, for example).

Tools

Throughout the pandemic we’ve been told that “we have the
tools.” The May inflection point means different things for
different tools:

_ANTIGEN TESTS_

Supply is going be impacted, but not necessarily because of the PHE.
It’s dependent on Congressional budget. The tests are already
commercialized. The U.S. bought a stockpile of antigen tests for the
USPS program this past winter and still has a stockpile for the coming
months. It’s not clear when this supply will run out.

The industry (i.e. test makers) are unwilling to produce a surplus of
tests because demand is unknown. Without a guaranteed purchase (like
from the government) or knowledge that more waves are coming to drive
demand, they are hesitant to manufacture more. It’s not clear
whether antigen tests, and which ones, will be available on retail
shelves after the emergency like they are now.

In addition, the PHE requires health insurers to reimburse for up to
eight antigen tests, per person, per month. After May, insurers will
be able to choose whether to reimburse for those tests or not. We
don’t have word yet, either way.

_WHAT IT MEANS FOR YOU: _Don’t stock up on antigen tests just yet,
as the tests do expire. But pick up some closer to the May deadline.

_VACCINES_

The FDA emergency (#1 above) is not ending. This means COVID-19
vaccines will still be available. BUT available is different
from _accessible_.

Vaccines will be covered by the government until the stockpile
(vaccines which the U.S. government bought from pharma) dries up.
After the stockpile dries up or we get a Fall 2023 new formula
booster, the vaccine will be covered by private insurance (through
employment) or public insurance (Medicaid, Medicare, etc.) for the 92%
of Americans who have health coverage. Most vaccines are free, with no
co-pay required, thanks to the Affordable Care Act. _What happens to
the 8% who are uninsured? _It’s not clear. We’re told there’s a
plan and that they won’t be left behind. TBD.

_WHAT IT MEANS FOR YOU: _Get your updated bivalent booster soon if
you haven’t already. For those of you wondering if you should get a
second bivalent, we may get more clarity in mid-February during the
scheduled ACIP meeting.

_PAXLOVID_

This supply is safest right now because it has the largest stockpile.
In other words, the U.S. bought a ton of Paxlovid from Pfizer, and
individuals shouldn’t have to pay for Paxlovid for a while. (Maybe
second half of 2023, or 2024?) Once that stockpile is gone, it will be
privatized. The price will be determined by Pfizer, and the price that
individuals pay at the pharmacy will depend on health insurance.

_WHAT IT MEANS FOR YOU: _Do not worry about Paxlovid supply for now.
But this may be a problem in 2024.

_MONOCLONAL ANTIBODIES/EVUSHIELD_

These don’t work against the newest subvariants, and pharma
doesn’t want to make more because the market keeps evaporating
(because the virus keeps changing). For people for whom Paxlovid
doesn’t work or the vaccine doesn’t confer protection (e.g., organ
transplant patients), it’s not clear what protections there will be.

_WHAT IT MEANS FOR YOU: _The most vulnerable will be less protected
than before. Keep this is mind as you decide what precautions to take.

_NATIONAL SURVEILLANCE_

This will continue to some extent:

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GENOMIC SURVEILLANCE: It’s our understanding the wastewater program
will remain for now.

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TEST POSITIVITY RATES: Will likely go away because CDC can’t compel
labs to report.

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HOSPITALIZATIONS: CDC will still get data, but the frequency will
likely slow down. (Weekly? Monthly?)

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VACCINE UPTAKE: Will likely remain, as CDC is working with states to
continue monitoring.

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PHARMACY TESTING: May go away. This turned out to be CDC’s fastest
way to evaluate vaccine effectiveness. So we may be going back to a
delayed system to know how well our vaccines are working, which is
beyond disappointing.

_WHAT IS MEANS FOR YOU: _We will have “skeleton monitoring” of
COVID-19. Knowing if and when we are in a new wave to inform our
behaviors, for example, will get more and more challenging.

_HEALTHCARE COVERAGE_

One of the most impactful tools during the emergency was Medicaid’s
continuous coverage. During pre-pandemic times, states regularly
checked whether people enrolled in Medicaid were still eligible. These
“checks” were removed during the pandemic. When these “checks”
resume on April 1, between 5.3 and 14.2 million adults and children
will lose Medicaid coverage.

(Technically, this _was _under bucket #3, but the Omnibus bill
passed in December uncoupled Medicaid from the PHE. So this doesn’t
have to do with the PHE ending, but it’s still a big change we are
going to see starting April 1.)

_WHAT THIS MEANS FOR YOU_: If you have Medicaid, your coverage may
change soon. This is particularly dependent on your state.

National vs. state. vs. local

So far we’ve discussed national implications. Of course, things gets
even more complicated because each state has its own authorities and
emergency mechanisms. Everything will look different depending on your
state, too.

States are responsible for what the transition from Medicaid
continuous coverage back to “checks” look like, for example. Some
states will follow up with people to let them know they are missing
information so they don’t get dropped; some states will update
mailing addresses proactively so people don’t lose coverage; some
states will do nothing.

Wastewater surveillance is additionally dependent on the state or
locality budget, for example. In California, the state budget for
COVID-19 funding will be axed by ~90%. This means wastewater
monitoring in California may reduced, regardless of a CDC grant. But
in places like NY, wastewater is more protected by the state.

The ultimate problem

One way to think of the pandemic emergency arc is to compare it to a
patient’s. For example, a patient goes through multiple stages of
care after a traumatic car accident. The U.S. has gone through similar
stages.

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Arc of a Public Health Emergency. Figure by Dr. Katelyn Jetelina/YLE

The concern that many people rightfully have is what happens once the
U.S. “leaves the hospital.” It’s a mess out there—fragmented
care, underfunded public health, burnt out hospital workers,
understaffed hospitals, disparities, pharma making a ton of money,
expensive childcare, limited sick leave, etc. “Leaving the
hospital” will mean drastically different things to different
people:

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Some will do just fine, particularly those who are healthy and
wealthy.

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Some people will do okay, like those over 65 who keep up to date with
their vaccines.

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Some people will be left behind or get really sick, like with long
COVID.

Bottom line

There are still a lot of unanswered questions, and it seems like an
evolving situation. This needs to be a national conversation.
Participate and push. (This NYT Op-Ed
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a great start.) We, as a society, need to ensure we transition NOT to
a 2019 world but to a new and better 2023 world.

Love, the Katelyn/Caitlin epidemiologists

_Caitlin Rivers, PhD, MPH, is an assistant professor and
epidemiologist at the Johns Hopkins Center for Health Security. She
has her own newsletter called Force of Infection:_

Subscribe to Force of Infections Here
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_“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn
Jetelina, MPH PhD—an epidemiologist, data scientist, wife, and mom
of two little girls. During the day she works at a nonpartisan health
policy think tank and is a senior scientific consultant to a number of
organizations, including the CDC. At night she writes this newsletter.
Her main goal is to “translate” the ever-evolving public health
science so that people will be well equipped to make evidence-based
decisions. This newsletter is free thanks to the generous support of
fellow YLE community members. To support this effort, subscribe
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* COVID-19
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* pandemics
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* vaccines
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