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How the End of the COVID-19 Public Health Emergency Will Impact Kids and Families

By Beth Howard
June 30, 2023
Patients In Busy Doctors Waiting Room

On May 11, the COVID-19 public health emergency (PHE) expired, leading health professionals to brace for change as states unwind many measures they took to protect Americans’ health and well-being during the pandemic.

Not everyone is comfortable with the plan. Some health care professionals are worried that many Americans will lose access to Medicaid, jeopardizing their ability to obtain important vaccines and treatments. Children may be particularly vulnerable.

Under the PHE and other emergency provisions enacted in the wake of the pandemic, health care providers were given greater flexibility to streamline patient care delivery and increase access to care. For instance, telehealth restrictions were loosened, and pharmacists were allowed to be reimbursed for administering COVID-19 vaccines. 

Importantly, the PHE included provisions that required states to keep everyone who was on Medicaid during the pandemic enrolled in order to receive a 6.2% increase in their Medicaid matching federal funds. Typically, in nonemergency times, those enrolled need to continue to reapply periodically to demonstrate that they qualify for this coverage.

“Even before a public health crisis like the COVID-19 pandemic happened, the majority of the children we care for had huge needs,” says Arturo Brito, MD, MPH, president and CEO of Children’s Health Fund (CHF), a national nonprofit that has been providing comprehensive primary care to children in underserved communities for more than 35 years. CHF pioneered the use of mobile clinics to bring healthcare directly to the children and families with the least access. Now, mobile clinics are used throughout CHF’s national network to transport primary and behavioral health services to where they’re needed most, including schools, shelters, and community centers. The AAMC and CHF have collaborated to fund three national network health care partners to increase access to vaccines and build vaccine confidence in response to the ongoing effects of the COVID-19 pandemic.

“Our concern is that people’s attention will go elsewhere,” he continues. “But we have a continual and maybe even a bigger need to serve the kids that were most impacted by the pandemic. I see a looming crisis ahead.”

Medicaid Changes Ahead

States now have a year to restart eligibility reviews, which may result in 15 million people losing their Medicaid coverage.   

“Of these, five million children could lose health care coverage in the next few years,” estimates Thresia Gambon, MD, a pediatrician in South Florida. Black, Latino, and other historically and economically marginalized people are likely to be most affected by the change, she says.

“Insurance is the entry point to getting quality comprehensive health care,” says Brito. “It’s very challenging to get that care if you’re not insured.”

Almost one-third of individuals predicted to lose Medicaid eligibility are expected to qualify for Affordable Care Act marketplace premium tax credits, and about 60% of those will be eligible to gain such coverage without having to pay premiums. However, 5 million people would have to find coverage elsewhere. And roughly 383,000 people expected to lose Medicaid reside in one of the 12 states that did not expand Medicaid under the Affordable Care Act.

Because Medicaid is state administered, dismantling emergency provisions will look a little different everywhere, Brito says. Some states will look to fill the gap left by Medicaid changes, while others won’t. (To see how the unwinding is taking place in different locations, the Georgetown University Center for Children and Families has created an interactive map and unwinding tracker.)

Unfortunately, some current enrollees, though still eligible, may nevertheless lose coverage, because agencies have outdated contact information for them. People who have moved or have language barriers or disabilities also risk losing coverage because of failing to file the required paperwork.

“There are media campaigns to make sure that people go in and update their addresses and get the right information into the system,” says Gambon. “Our concern is that patients will basically show up at the clinic and find they aren’t covered anymore, or we will find out that they are uninsured the day before an appointment.”

So far in Florida, 250,000 people have already been dropped from Medicaid rolls, Gambon says.

The Impact on Underserved Children

Gambon predicts chaos when older children show up for back-to-school visits in the fall.

“When we start seeing kids who come in for physicals for sports and vaccines for seventh grade who maybe haven’t been seen in a year or two because of COVID, we’re going to really see the impact,” she says. “If people don’t use their insurance frequently, they might not realize there have been changes, especially if they haven’t received any mail from Medicaid for up to three years.”

The consequences of losing coverage, even for a short while, could be significant.

“If parents miss a well visit for their child because of lack of insurance, there is a good chance that they would postpone getting their vaccines for their small children,” she says. “We never want to see vaccine delays. They contribute to outbreaks in vaccine-preventable diseases.”

Without insurance, families are likely to resort to seeking care in the emergency department. And reduced numbers of children on federal programs could threaten caring for chronic conditions like asthma, diabetes, sickle cell anemia, and cancer, Gambon says.

A bright spot for kids is that federal funding for the Children’s Health Insurance Program (CHIP) has been extended for an additional two years, leaving some parents with an option for uninsured kids. But, Gambon fears, parents who are disenrolled from Medicaid may not realize that their children can still access health care through CHIP. They must apply or reapply for the coverage, and families are likely to face backlogs as the system reviews applications and absorbs new members, she says. 

The Impact on COVID-19 Vaccines and Treatments

For the time being, most Americans will continue to receive free COVID-19 vaccines. But COVID-19 treatments will eventually transition to the private and government-funded health care market and be prescribed through traditional routes with co-pays, according to the Department of Health and Human Services (HHS).

However in April, HHS announced the HHS Bridge Access Program for COVID-19 Vaccines and Treatments Program, to provide access to COVID-19 vaccines for uninsured Americans. More than $1 billion has been earmarked for a public-private partnership involving pharmacies, local health departments, and health centers supported by the Human Resources and Services Administration to distribute free vaccines and the COVID-19 treatments.   

The Biden administration has also proposed a Vaccines for Adults program in its budget for fiscal years 2023 and 2024 that would be modeled after the Vaccines for Children program, which already covers recommended immunizations. It has not yet been enacted into law.

Expanded Telehealth Options — For Now

During the pandemic, the use of telehealth expanded significantly, thanks to the waiver of certain restrictions on when and how virtual visits could be reimbursed. The Consolidated Appropriations Act of 2023 extended many of those waivers until the end of 2024.

We discovered during the pandemic that there were a lot of restrictions that didn’t need to be there,” says Brito. “By waiving them, we found that you could provide as effective care through telehealth as in-person visits in a good percentage of cases.”

A lack of transportation to medical facilities is a common barrier to health care access in both rural and urban communities — one that virtual visits can address.

“Often families might have one car, and it’s being used for one of the caregivers in the house to go to work,” Brito says. “So it’s very hard for the children to get to an appointment in person on a regular basis.”

Teen and adult mental health services are particularly well suited for telehealth, data have shown. And under the PHE, the Drug Enforcement Administration allowed some controlled substances, including medications for opioid use disorder, to be prescribed remotely.

Brito hopes that the flexibility of telehealth will become permanent as policymakers assess the value of such services during the pandemic.

“A lot of data has been accumulating and anecdotally it looks positive,” he says. “We need to let the data drive our decisions, not antiquated views of how health care should be delivered.”

Brito is hopeful that other lessons gleaned from the pandemic will show states the benefits of expanding care for vulnerable kids and families. But he is still wary. 

“We are worried, particularly for the poorest communities,” he says. “They’re the least likely to benefit from programs like telehealth, and yet the first to be most impacted when those benefits go away.”