Ending the federal COVID emergency was inevitable — but it will cause additional deaths

The Biden administration’s decision to end the COVID-19 pandemic emergency on May 11 was the right thing to do — for social, economic and political reasons. But adverse public health consequences are likely, including preventable deaths.  

The decision was political. But the pandemic, by any definition, is not over — globally or in the U.S. — as President Biden acknowledged in his State of the Union address on Tuesday. Versions of the virus are still causing illness and death in every nation on earth and in every state in America. And uncertainties about its future trajectory remain even as we have much better tools to blunt its affects.

The sobering fact is that federal (and most state) health care leaders know this but feel they have no choice. The pressure from conservatives and the political right to end the federally recognized COVID-19 emergency is intense. So, there’s capitulation to that. At the same time, the public health community is acutely aware of the public’s desire to “move on” after three years of admonitions to mask, quarantine and avoid crowds. 

Here’s the main problem come mid-May: Vaccines, tests, and treatments will begin to lose their government subsidy. The government purchased all three and made them free. There’s nuance here. Vaccines will continue to be free as long as the government-purchased supply lasts — possibly until early fall, depending on demand. When the supply runs dry, the shots are expected to cost between $110 and $130 each, plus the cost of the visit. Over-the-counter test kits will run $25 to $50 for two. PCR tests will be covered by insurance but may carry copays, as will the antiviral therapy Paxlovid (although free supplies of this important drug may last into fall.)

These costs will be a barrier or disincentive for many people, and especially the 28 million Americans who lack health insurance and the 20 million or so more who have inadequate coverage. As it happens, that population of 48 million is at higher risk of bad outcomes from COVID-19 infection, including Americans who are low- to middle-income, rural, Black, Hispanic and immigrants.

And the number without health insurance is going to increase. The COVID-19 emergency blocked states from kicking people off Medicaid, which now provides coverage to some 90 million Americans, 28 percent more than in February 2020. That policy alone prevented tens of thousands of deaths. But Congress in December, as part of a year-end budget law, bowed to pressure from right-leaning states to allow them to start unwinding the Medicaid continuous-coverage requirement on April 1.

Experts estimate that from 5 million to 15 million people will be dropped from Medicaid in a state-by-state eligibility “redetermination process.” Some states are exploring options to ease the loss and transition people to coverage under the Affordable Care Act.

At the same time, vaccination rates, already suboptimal, will almost certainly decline when the emergency ends. Sixty-eight percent of eligible Americans have had two vaccine doses but only 34 percent have had one or more booster shots. According to the Centers for Disease Control and Prevention (CDC) only 15 percent of people age 5 and older and 40 percent aged 60 and older have gotten the latest “bivalent” booster.

Those numbers signal a perilous recent decline in trust in vaccinations, triggered in part by anti-science disinformation.

The level of COVID-19 immunity in the U.S. was an important contributing factor leading the Biden administration to end the pandemic emergency. This is a legitimate and science-based factor, but there’s nuance here, too. Plus, the subject of immunity has caused no end of public confusion, reflected in the often-heard statement: “Oh, I’ve had COVID so I don’t have to worry anymore.” Yes, you do.

Here are the relevant basic facts:

• The majority of Americans — an estimated 250 million to 280 million — have been infected with some variant of the virus. All have some “natural immunity” because of that, whether they got sick or not. But for most that immunity is now at a low level since immunity wanes over time and new variants “breakthrough” immunity caused by prior variants. At any level of natural immunity, protection is far less against reinfection but greater against the bad outcomes of severe acute illness, hospitalization, long COVID, and death.

• Natural immunity (prior infection) plus regular updated vaccination provides greater protection against bad outcomes, and possibly reinfection, than natural immunity alone.

• Reinfection appears to be linked to a higher risk of future health problems, including long COVID and possibly heart and lung disease and other conditions. Long Covid alone is estimated to affect between 1-in-10 and 1-in-6 people who become infected. That means you really want to avoid a second, third or more bout of COVID-19 until the science is better understood. Especially if you are 60 or older.

The upshot of all this is that the end of the pandemic emergency will lead to more infections and viral spread than would be the case if the emergency declarations stayed in place. In turn, more deaths will ensue.

To be clear, the absolute number of infections and deaths could be lower in the future than we’ve seen in the past since more people have immunity and future variants could be less virulent. But deaths could remain quite high for some time to come. The COVID-19 death rate has been between 300 and 500 a day for several months. That’s mercifully less than during the surges of the last two winters. (The peak was around 3,800 a day in January 2022.) But it is still — at 109,000 to 182,000 people a year — three to five times the average annual death rate from the flu over the past decade (around 35,000).

It’s impossible to know exactly how things will play out from here, but the decision to end the federal pandemic emergency, while inevitable, is a stark tradeoff. We will transition to more regular order in society, in health care, and in our lives — with many lessons learned. In exchange, more people will get sick. And some will die.

Steven Findlay, MPH, is an independent health policy analyst and journalist. He previously worked as a senior health policy analyst at Consumers Union, as well as director of research and policy at the National Institute for Health Care Management.