The COVID-19 public health emergency (PHE) will end tomorrow, and with it, so will many pandemic-era provisions for COVID-19 vaccines and treatments, telehealth, provider flexibilities, and more — changes that some experts are worried will decrease patients' access to care and increase costs.

COVID-19 PHE to end tomorrow

In January, the Office of Management and Budget  announced that the national COVID-19 PHE, which was first declared by the Trump administration in January 2020, will end on May 11. During the pandemic, the PHE allowed the government to enact temporary measures to curtail the spread of the coronavirus, increase access to care, and ease the strain on the healthcare system.

So far, health experts have been divided on the end of the PHE, with some saying that it is time, while others say that the end of certain pandemic-era measures will lead to more care disruptions.

"COVID-19 is still a significant problem, but emergencies can't go on forever," said Marcus Plescia, CMO for the Association of State and Territorial Health Officials. "I think we're living in a place where we're treating COVID similar to flu."

Howard Markel, a physician and a professor at the University of Michigan School of Public Health, was more concerned. "History says that all pandemics end," he said. "But we have never had an infectious event like this — ever."

Changes to expect with the end of the PHE

As the COVID-19 PHE ends tomorrow, so will several pandemic-era waivers and flexibilities.

COVID-19 tests, treatments, and vaccines

During the pandemic, the federal government purchased supplies of COVID-19 tests, treatments, and vaccines and made them available to the public free of charge. Medicare and private insurers were also required to cover up to eight at-home COVID-19 tests per month.

Although the federal government plans to continue providing free tests, vaccines, and treatments while supplies last, cost-sharing is expected to begin soon for people with private insurance, particularly for tests and treatments. In addition, while Medicare beneficiaries can have lab tests that are ordered by a provider covered, they will have to pay for over-the-counter tests out of pocket.

Medicaid beneficiaries will have their COVID-19 testing, vaccines, and treatments covered for a year after the PHE ends, but following that, coverage will be determined by individual states.

Access to COVID-19 vaccines, tests, and treatments that are currently authorized for emergency use by FDA will likely continue for the time being as the agency works with manufacturers to transition the products to full approval.

COVID-19 data tracking

CDC will end some of its COVID-19 data tracking efforts, including for new infections. However, the agency will continue tracking COVID-19 hospitalizations and deaths, conducting genetic analysis for new variants, and monitor viral spread through wastewater surveillance.

"We will continue to keep our eye on the COVID-19 ball," said Nirav Shah, the CDC's principal deputy. He noted that a recent analysis of the agency's new approach showed that it will be effective.

Going forward, COVID-19  tracking  will eventually shift to something similar to seasonal flu surveillance, which largely monitors trends from data samples. Currently, the agency, "along with jurisdictional partners, is assessing ongoing surveillance needs and potential revisions to surveillance systems to efficiently continue tracking COVID-19 after the PHE ends," a CDC spokesperson said.

Telehealth

So far, Congress and the Biden administration have extended some telehealth provisions through 2024, but not all pandemic-era policies will continue in the long-term.

For example, the waiver of in-person requirements for the prescriptions of controlled substances, including opioids, is ending, which could make it difficult for patients who sought care virtually during the pandemic to continue accessing their treatments.

The Drug Enforcement Administration (DEA) has already proposed new rules requiring in-person visits for prescriptions of certain controlled substances. However, after criticism about these proposed rules from lawmakers, medical experts, and patients, DEA on Tuesday announced that it would extend the waiver on in-person visits for an additional six months. Provider-patient telehealth relationships established before Nov. 11 will then be allowed to continue until November 2024.

According to a senior agency official, the timeline for the final decision on the policy is still uncertain, but DEA plans to have clear regulations in place before the extension expires this November.

In addition, providers that accept Medicare payments will no longer be able to use video applications like Apple's FaceTime, Facebook Messenger, or WhatsApp to provide virtual care after a temporary relaxation of HIPAA policies end.

Providers

Hospitals will no longer receive a 20% increase in Medicare reimbursements for treating COVID-19 patients. According to Stacey Hughes, EVP at the American Hospital Association, the end of these payments will likely add to hospitals' financial difficulties as they struggle with both workforce shortages and inflation.

There will also likely be workforce changes as pandemic waivers for staffing flexibilities end. For example, nurse anesthetists will now be required to be supervised by a physician again after a waiver allowing them to work without supervision ends.

Some healthcare facilities, such as free-standing EDs, will no longer be able to receive reimbursement from Medicare, Medicaid, or Tricare.

Providers will also no longer be able to ship specialty drugs to patients once a waiver to the Stark Law, which is also known as the Physician Self-Referral Law, ends. During the pandemic, many oncologists used couriers to deliver specialty cancer medications to patients in areas where transportation is difficult to access.

Hospitals will also lose flexibility with certain reporting requirements and administrative tasks, such as extended timelines to complete medical records and waivers for utilization review requirements. HHS plans to begin penalizing hospitals for not complying with certain HIPAA requirements again.

Medicare's  three-day rule, which requires traditional Medicare beneficiaries to spend three full days in acute care before Medicare will cover their care at skilled nursing facilities after discharge, will also return. A similar rule requiring patients to spend three days in an ICU before being eligible to move to a long-term, acute care hospital will return as well.

Insurance coverage

In 2020, states that received enhanced Medicaid funding were prohibited from dropping individuals from the program while the PHE was in place. During the pandemic, Medicaid enrollment increased significantly, and over 91 million people were enrolled in either Medicaid or CHIP as of October.

However, the continuous coverage requirement recently ended on March 31. If someone is ineligible for Medicaid, they will have until July 31, 2024, to sign up for coverage via the federal Affordable Care Act marketplace.

Although health officials have said they are working to ensure that people don't lose coverage, KFF estimates that up to 24 million people may lose Medicaid coverage, including millions who may still be eligible but miss out due to administrative issues.

Currently, states are working with several organizations, including Medicaid plans, hospitals, insurance marketplaces, and nonprofit groups, to reach people who are at risk of losing coverage. They are also planning media campaigns through social media, television, radio, and billboards to raise awareness among enrollees.

Pharmacist authorities

During the pandemic, pharmacists gained additional powers through the Public Readiness and Emergency Preparedness (PREP) Act. Under the PREP Act, HHS allowed pharmacists and pharmacy technicians to order and administer COVID-19 tests, vaccines, and treatments for patients as young as three.

These flexibilities are active through Oct. 1, 2024, but since pharmacists typically operate under state laws, it is not clear what will happen once the federal PHE ends. So far, industry groups have been urging both state and federal lawmakers to make these expanded authorities permanent after the PHE ends. (Reed/Dreher, Axios, 5/8; Simmons-Duffin, "Shots," NPR, 5/8; Payne et al., Politico, 5/9; Moreno, Axios, 5/9)