Over the past two years, the COVID-19 pandemic and recession have had significant implications for Medicaid spending and enrollment. Early in the pandemic, Congress passed the Families First Coronavirus Response Act (FFCRA), which authorized a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements, including a continuous enrollment requirement. The additional funds were retroactively available to states beginning January 1, 2020 and continue through the quarter in which the public health emergency (PHE) period ends. States must meet MOE requirements through the end of the month in which the PHE ends.

The current PHE declaration is set to expire in mid-April 2022. However, it is now expected that the PHE will be extended through at least mid-July 2022 (the beginning of state fiscal year (FY) 2023 for most states) since the Biden administration indicated it would give states 60 days-notice before the PHE is terminated or is allowed to expire. While uncertainty remains around the duration of the PHE, the unwinding of the PHE will have significant implications for state Medicaid enrollment and spending trends, which states have begun to plan for.

In February 2022, the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) fielded a rapid, mini-survey of Medicaid directors in all 50 states and the District of Columbia as a follow-up to the annual Medicaid Budget Survey conducted in summer 2021. At the time of the latest survey, most states were mid-way through FY 2022 and governors were releasing proposed budgets for FY 2023.¹  A total of 44 states responded to the survey,²  although not all states answered every survey question. At the time of this survey, a majority of responding states’ spending and enrollment projections assumed the PHE would not be extended past April 2022, meaning projections assumed the MOE continuous enrollment requirement would end April 30, 2022 and the enhanced FMAP would end June 30, 2022. This brief explores Medicaid enrollment and spending growth estimates, as reported by state Medicaid directors, for FY 2022 and projections for FY 2023. Median calculations were used throughout the analysis.³  Extensions of the PHE would likely mean that increases in state spending and decreases in enrollment will occur later than what states have projected in our survey, but still within FY 2023 if the PHE is not extended beyond July.

State Medicaid agency reported growth rates for FY 2022 show increasing Medicaid enrollment and spending, reflecting state assumptions about the end of the PHE (Figure 1). Most states assumed that the PHE would be in place through the last quarter of FY 2022 reflecting the continuation of the MOE and fiscal relief provisions. Among responding states, the median enrollment growth rate was 8.9% for FY 2022. Many states identified ACA expansion adults as the eligibility group with the most enrollment growth so far in FY 2022, but with notable enrollment growth in other eligibility groups including children, parents, pregnant women, and other adults. Among states that responded to the mini-survey, median total spending was 9.6% in FY 2022. Among responding states, the median state spending growth rate was 8.0% in FY 2202. Enrollment and total spending growth rates reported here are higher and the state spending growth rate is lower than projections provided by states in the summer 2021 annual Medicaid Budget Survey due to updated assumptions about the duration of the PHE (earlier projections largely assumed the PHE would end at the end of December 2021).

State Medicaid agencies project enrollment and total spending growth will decline or slow in FY 2023 as a majority of states assumed the PHE would end in the last quarter of FY 2022 (Figure 1). At the time of the mini-survey, over three-quarters of state projections assumed the FFCRA enhanced FMAP would expire at the end of FY 2022, or June 30, 2022. Among responding states, enrollment is projected to decline by 5.0% in FY 2023, with most states pointing to the unwinding of the PHE and the MOE requirements as the most significant downward enrollment change driver. States expect to see larger enrollment declines across eligibility groups that experienced notable growth during the PHE (e.g., expansion adults, parents, children, and other adults). The median total Medicaid expenditure growth rate for responding states slows to 2.0% in FY 2023 with almost two-thirds of responding states indicated lower enrollment as the most significant downward driver for total Medicaid spending. Despite slowing total spending growth, states identified some upward drivers for FY 2023 including increases in utilization (6 out of 44) and provider reimbursement rates (15 out of 44). Some states (9 out of 44) noted higher enrollment could remain an upward pressure as it takes states time to process redeterminations and renewals following the end of the MOE.

For FY 2023, state Medicaid agencies project the state share of Medicaid spending will increase sharply by 14.0% (Figure 1). The state share of Medicaid spending typically grows at a similar rate as total Medicaid spending growth unless there is a change in the FMAP rate, like during the PHE, causing state spending on Medicaid to decline as federal support increases. States expected state spending growth to accelerate in FY 2023 following the projected end of the PHE and enhanced FMAP, as states will need to replace the expiring federal funds with state funds unless they make other changes to reduce spending.

Looking Ahead

While state economic conditions have improved and COVID-19 vaccines are now available for most U.S. residents, uncertainty remains around the trajectory of the pandemic and the duration of the PHE, especially with the rise of a new Omicron subvariant, BA.2. As states approach the end of FY 2022 and adopt budgets for FY 2023 (which begins in July for most states), this uncertainty has big fiscal implications. Medicaid plays a significant role in state budgets and has played a key role in the COVID-19 response and recovery across states. Unlike the federal government, states must meet balanced budget requirements, so dealing with these uncertainties makes it difficult to budget appropriately.

When the PHE and continuous enrollment requirement ends, states will begin processing redeterminations and renewals, likely leading to enrollment declines and decreased total Medicaid spending growth. The end of the PHE, however, will also end the enhanced FMAP, requiring states to increase state spending to replace the expiring federal funds.

Changes in Medicaid enrollment and spending are an inevitable consequence of the end of the PHE, but when they occur will depend on when the PHE does in fact end. And, the magnitude of the changes will depend on how states react. States will largely be responsible for managing the unwinding of the PHE and continuous enrollment requirement, which will likely lead to significant variation in Medicaid spending and enrollment growth trends across states.

1. A few states will enact biennial budgets for FY 2023 and FY 2024 and some states with previously enacted biennial budgets may introduce/consider revised or supplemental budgets. ↩︎
2. The 7 states that did not respond were: Connecticut, Georgia, Mississippi, New Mexico, Ohio, Pennsylvania, and Utah. The 44 responding states accounted for over three-quarters of total Medicaid enrollment. ↩︎
3. Medians are calculated among all states that responded to each growth rate question. Number of respondents to each question varied. For FY 2022, 44 states reported Medicaid enrollment and expenditure growth rates. For FY 2023, 33 states reported enrollment growth rates, 37 states reported total expenditure growth rates, and 36 states reported state expenditure growth rates   ↩︎

The Medicaid program finances about 4 in 10 births in the US. Federal law requires states to provide Medicaid coverage without cost sharing for pregnant individuals with incomes up to 138% of the federal poverty level and cover them up to 60 days after childbirth. In recent years, there has been growing interest in extending this postpartum coverage period for Medicaid to improve maternal health and coverage stability and to address long-standing racial disparities in maternal health outcomes.

Starting April 1, a provision in the American Rescue Plan Act (ARPA) of 2021 gives states a new option to extend Medicaid postpartum coverage to 12 months without having to seek a waiver. To date, 28 states and DC have taken steps to extend postpartum Medicaid coverage to pregnant individuals up to 12 months under this option or through a Medicaid waiver.

While this new ARPA option is taking effect, during the federal COVID-19 Public Health Emergency states already have been prohibited from disenrolling individuals from Medicaid. As a result, postpartum coverage has been continuous since the start of the coronavirus pandemic. However, once the Public Health Emergency is lifted, possibly later this year, the continuous enrollment requirement will end and many postpartum adults will be at risk of losing their Medicaid coverage, particularly those living in non-expansion states.

Visit our tracker for detailed information on state activity.

Source

In this column in The Washington Post, Céline Gounder, Senior Fellow and KHN Editor-at-Large for Public Health, and Mollyann Brodie, Executive Vice President  and Executive Director of KFF’s Public Opinion and Survey Research Program, look at the challenges in returning to normal life after the COVID-19 pandemic when many Americans, particularly people of color and workers with low incomes, do not have paid sick leave.

Against the backdrop of public concern about inflation and rising gas prices, proposals to lower what people pay out-of-pocket for drugs tops the public’s list of health care priorities for Congress, a new KFF Health Tracking Poll finds.

Most (55%) of the public say inflation is the biggest problem facing the country. Fewer cite other issues such as the Russian invasion of Ukraine (18%), climate change (6%), the COVID-19 pandemic (6%), and crime (6%).

The economy, including inflation, also ranks as the top voting issue as people begin to think about this year’s midterm elections.

Partly reflecting these concerns about inflation and prices, the public’s “top health care priorities for Congress” focus on lowering what people pay for their health care. These include limiting price increases for prescription drugs to the inflation rate (61% say it is a top priority), capping out-of-pocket costs for insulin (53%), and placing a limit on how much seniors have to pay for health care (52%). Nearly half (48%) say that allowing the federal government to negotiate lower drug prices for Medicare beneficiaries is a top priority.

Less than half rank other issues as top health priorities, such as expanding coverage to people with low incomes in states that have not expanded their Medicaid programs (42%), increasing funding for mental health services (42%), and improving safety and quality in nursing homes (40%). Fewer rank more spending for COVID-19 (25%) and making permanent the financial help for people buying marketplace health coverage that was included in COVID-19 relief law (22%) as top priorities.

“The public’s priorities in health reflect deep concern about the prices of everything right now, including drug prices,” KFF President and CEO Drew Altman said. “That doesn’t mean other things that have long been popular do not have public support too; they do. It just means prices are the preeminent concern.”

The poll also finds other signs of how heavily inflation and health costs are weighing on Americans, with most of the public saying they are worried about being able to afford gasoline or other transportation costs (71%), unexpected medical bills (58%), or monthly utility bills (50%). The shares worried about paying for gas and utilities are up significantly since February 2020.

With many people worried about affording unexpected medical bills, the poll also finds most (56%) people with private insurance say they know nothing at all about a federal law that took effect in January that protects people from receiving unexpectedly large medical bills when they unknowingly receive out-of-network care. Fewer say they know “a lot” (3%), “some” (18%) or “a little” (22%) about the law.

The poll also finds:

• Half (51%) say they have delayed or gone without health care in the past year due to costs. This includes about a third who skipped dental care (35%), and a quarter who skipped vision care (25%) and doctor’s visits (24%). Some also skipped mental health care (18%), hospital services (14%), and hearing services, including hearing aids (10%).
• With drug prices a major part of President Biden’s agenda, 29% of adults, including 43% of those with annual household incomes under of $40,000, say they either did not fill a prescription, cut pills in half or skipped doses, or took an over-the-counter product instead of a prescription due to cost in the past year.

As the Affordable Care Act Turns 12, Most People Continue to View the Law Favorably

Twelve years after its enactment, most (55%) of the public views the Affordable Care Act favorably. About a quarter (24%) of people say that the law has helped them, while 1 in 5 (20%) say that has hurt them. The most common way that people say that they were helped is by providing coverage to someone in their family, while the most common way people say they were hurt is by increasing costs.

There are major partisan differences. Most Democrats (87%) view the law favorably, and many (43%) say it directly helped them and their families. In contrast, most Republicans (79%) view the law unfavorably, and many (40%) say it has hurt them and their families. Independents mostly view the law favorably (58%), with a quarter (24%) saying the law has helped them and 16% saying it has hurt them.

Other findings include:

• President Biden discussed improving care for residents of nursing homes and other long-term care facilities in his State of the Union address. Most of the public says that they are doing a “bad job” of maintaining adequate staffing (70%), offering affordable care (64%), and providing high-quality care (54%). Views of long-term care facilities are consistent across age groups.
• About two thirds (65%) of people living in the 12 states that haven’t expanded their Medicaid programs under the ACA to cover more low-income uninsured people say that their state should, while one third (34%) say their state shouldn’t.

Designed and analyzed by public opinion researchers at KFF, the KFF Health Tracking Poll was conducted from March 15-22 among a nationally representative sample of 1,243 adults. Interviews were conducted in English and Spanish online (974) and by telephone (269). The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

President Biden released the FY 2023 budget request to Congress on March 28, 2022. The request includes discretionary funding for U.S. global health programs at the State Department, the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). In addition, the request includes newly proposed mandatory funding for pandemic preparedness activities. Key highlights for the known amounts are as follows (see tables for additional detail):

State Department & USAID:

Funding for global health programs through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $10.6 billion, an increase of $746 million (8%) above the FY22 enacted level, almost all of which was for the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) and global health security. The FY23 request also included mandatory funding to support pandemic preparedness activities at the State Department and USAID (see below).

• The request includes $2.0 billion for the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), an increase of $440 million (28%) above the FY22 enacted level, and states this funding would be the first contribution towards a $6 billion pledge to the Global Fund’s 7^th Replenishment (2024-2026).
• Funding for global health security totals $995 million, an increase of $295 million (42%) above the FY22 enacted level ($700 million).
• Bilateral HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) is $4.7 billion, a slight decrease of $20 million (-0.4%) compared to the FY22 enacted level ($4.72 billion).
• Funding for tuberculosis (TB) totals $350 million, a decline of $21 million (-6%) compared to the FY22 enacted level ($371 million).
• Funding for malaria totals $780 million, a slight increase of $5 million (0.6%) compared to the FY22 enacted level ($775 million).
• The request includes $880 million for maternal and child health (MCH), a slight decrease of $10.5 million (-1%) below the FY22 enacted level ($890 million). Other specific areas under MCH include multilateral contributions to:
  • Gavi, the Vaccine Alliance which totals $290 million, matching the FY22 enacted.
  • UNICEF which totals $135.5 million, a decline of $3.5 million (-3%) compared to the FY22 enacted level ($139 million).
• Funding for the nutrition program totals $150 million, a decline of $5 million (-3%) compared to the FY22 enacted level ($155 million).
• Bilateral family planning and reproductive health (FP/RH) funding totals $572 million through the GHP account (additional funding that may be provided through the ESF account is not yet known), an increase of $48 million (9%) above the FY22 enacted level ($524 million). Funding for multilateral contributions to the United Nations Population Fund (UNFPA) totals $56 million, $23.5 million (72%) above the FY22 enacted level ($32.5 million)
• Funding for the vulnerable children program totals $25 million, a decline of $2.5 million (-9%) compared to the FY22 enacted level ($27.5 million).
• Funding for neglected tropical diseases (NTDs) totals $114.5 million, an increase of $7 million (7%) compared to the FY22 enacted level ($107.5 million).
• The request also included $10 million for a newly established Health Resilience Fund to “support cross-cutting health systems strengthening in challenging environments or countries emerging from crisis.”

Centers for Disease Control and Prevention (CDC): Funding for global health provided to the CDC totals $748 million, an increase of $101 million (16%) above the FY22 enacted level ($647 million), almost all of which ($100 million) is to support global health security activities; all other areas declined slightly except for parasitic diseases funding. The FY23 request also included mandatory funding to support pandemic preparedness activities at the CDC (see below).

National Institutes of Health (NIH) [i]: Funding for the Fogarty International Center (FIC) at NIH totals $96 million, $9 million (10%) above the FY22 enacted level ($87 million).

Mandatory Funding for Pandemic Preparedness: The FY23 budget request proposes to establish mandatory funding to support both domestic and international pandemic preparedness efforts including $6.5 billion at USAID and the State Department as well as significant additional resources at CDC (it is not possible to determine a specific amount for global activities at the CDC as some funding is designated to support both global and domestic efforts; the table below highlights funding that was designated as either 1) specifically for global efforts, or 2) could potentially be used to support global activities).

Resources:

• White House FY 2023 Budget Resources
• State/USAID FY 2023 Congressional Budget Justification
• CDC FY 2023 Congressional Budget Justification
• NIH FY 2023 Congressional Budget Justification

Table 1 below compares global health funding in the FY 2023 request to the FY 2022 enacted funding amounts as outlined in the  “Consolidated Appropriations Act, 2022” (P.L. 117-103; KFF summary here). Note that total funding for global health is not currently available as some funding amounts provided through USAID, the Department of Health and Human Services (DHHS), and the Department of Defense (DoD) are not yet available. Table 2 below details mandatory funding for pandemic preparedness through the Department of State, USAID, and the Centers for Disease Control and Prevention in the FY 2023 request. The tables can be downloaded here.

See the KFF budget tracker for details on historical annual appropriations, including Senate and House amounts, for global health programs.

[i] Total funding for global research activities (e.g. HIV/AIDS and malaria programs) at NIH is not yet known.

With an impasse in Congress over additional COVID-19 emergency funding, uninsured people could lose access to free testing and treatment services, a new KFF brief explains.

For people without health insurance, the Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program has reimbursed hospitals, doctors and other providers for the COVID-19 care and services that they provide to uninsured people. However, with federal funds running out, the program is no longer accepting new claims for testing and treatment services and will stop accepting claims for administering vaccines on April 5.

Many uninsured individuals would likely need to pay out of pocket for testing and some treatment services or rely on safety-net providers absorbing those additional costs without any way to get reimbursed. So long as supplies remain available, vaccines would continue to be paid for by the federal government and people could not be charged, but vaccine providers would not get paid for administering vaccines to uninsured people and could restrict access. This could exacerbate existing racial and ethnic disparities, as people of color are more likely than their White counterparts to be uninsured and face other potential barriers to accessing care.

The brief also outlines how the federal government has used previously authorized funds to purchase COVID-19 tests, medications, and vaccines, and the implications for efforts to help ensure equitable access to and ongoing availability of these resources as that funding runs out.

For people with health coverage, including Medicare and Medicaid, existing rules and protections will ensure that they will continue to have access to COVID-19 tests, treatment, and vaccines, though some limits on cost sharing will end when the ongoing federal COVID-19 Public Health Emergency ends. If the federal government is no longer able to pre-purchase tests, treatment medications, and vaccines, supplies may run short if and when the next COVID-19 wave hits and demand increases.

A current impasse in Congress threatens continued funding for COVID-19 testing, treatment, and vaccines. The White House asked Congress for an additional $22.5 billion to support domestic and global COVID-19 efforts. During the recent negotiations to fund the federal government for FY 2022, Congress reduced this amount to $15.6 billion and it was subsequently stripped from the final bill. Without additional resources, the White House has said that several programs will need to be discontinued, including the Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program, established to reimburse health care providers for the costs of delivering COVID-19 testing and treatment services and administering vaccines to those who are uninsured. HRSA has announced that due to lack of funding, the program stopped accepting reimbursement claims for COVID-19 testing and treatment services on March 22, 2022 and will stop accepting claims for vaccine administration on April 5, 2022. In addition, the federal government has said it does not have funding to purchase additional COVID-19 tests, treatments, and vaccines once current supplies run out, and that it does not currently have a sufficient supply for vaccines to cover fourth doses if they are eventually recommended (also the subject of a recent KFF analysis). The lack of additional COVID-19 funding has broad implications for access to these services, particularly for people who are uninsured, and could undermine efforts to ensure equitable access to these resources.

How have COVID-19 testing, treatment, and vaccines been paid for so far?

The federal government has purchased COVID-19 tests, treatments, and vaccines and made them available to individuals at no cost, regardless of their insurance status. During the pandemic, the federal government has used emergency COVID-19 funding provided through multiple appropriations to purchase supplies of vaccines, rapid and some PCR tests, and some treatments (such as monoclonal antibodies and antivirals) and has distributed these resources through pharmacies, community health centers, federal sites, and allocations to states and localities. The availability of these government-purchased supplies has been instrumental in supporting large-scale testing and vaccination efforts and, to a lesser extent, treatment. A distribution program with health centers has also promoted more equitable distribution of tests, antiviral pills and vaccines and helped improve access in medically underserved communities.

Federal funding has also supported the HRSA COVID-19 Uninsured Program, which reimburses providers for the costs of providing COVID-19 testing and treatment services and vaccine administration to people who are uninsured. While providers are not required to participate in the program, those that do agree to accept reimbursement from the program, generally paid at Medicare rates, and are prohibited from balance billing the patient for any costs not covered by the payment. Although the program did not eliminate all barriers uninsured individuals face in accessing care, it did offer an avenue to obtain testing and vaccines as well as some treatment services without cost-sharing. Since the beginning of the pandemic, the program has provided about $19 billion in reimbursement for COVID-19 related uninsured claims, with 60% of reimbursements for COVID-19 testing claims, 31% for treatment claims, and 9% for vaccine administration.

Beyond the HRSA program, in 15 states, Medicaid coverage is available to cover the cost of providing COVID-19 testing, treatment services, and vaccines to uninsured individuals. Provisions in the Families First Coronavirus Response Act (FFCRA) gave states the option to provide Medicaid coverage for COVID-19 testing to people who are uninsured, regardless of their income, and receive 100% federal matching funds to cover the costs of providing care.¹  This coverage was later expanded to include provision of COVID-19 treatment services and vaccines. As of July 1, 2021, 15 states had adopted this option. While this coverage is not dependent on further federal funding, it is only available through the end of the month in which the COVID-19 public health emergency (PHE) ends.

For people with health coverage, COVID-19 diagnostic testing, treatment, and vaccines are generally covered services and providers can seek reimbursement for COVID-19 related costs from insurance companies and public programs. Federal law requires all private insurance plans, Medicaid, and Medicare to cover diagnostic COVID-19 testing during the PHE, although the Medicaid and Medicare programs may require a physician’s order. While testing services are provided at no cost to individuals, providers can seek reimbursement from insurers, Medicaid, and Medicare for the costs of administering the tests and any related costs. Similarly, providers are required to provide COVID-19 vaccines without cost-sharing regardless of insurance status, but they can bill insurance plans and public programs for the costs of administering the vaccine (with the vaccines themselves paid for by the federal government). Currently, COVID-19 treatment medications, including monoclonal antibodies and antiviral pills, are limited and most available medications have been purchased by the federal government and allocated to states for distribution to providers and pharmacies. Individuals cannot be charged for the cost of government-purchased treatments, and reimbursement for the costs of administering or dispensing the medications is available through insurers and Medicaid and Medicare. People may face cost-sharing for other treatment services, such as physician visits and/or hospital care. Some insurers waived cost-sharing for COVID-19 treatment early in the pandemic, but most have since phased out these waivers.

Who will pay for testing, treatment, and vaccines when federal COVID-19 funding runs out?

The current supply of tests, treatments, and vaccines that have already been purchased by the federal government will remain free to people regardless of insurance status. The federal government will continue allocating these resources to states and localities and to federal partners, including pharmacies and health centers, though allocations of treatment medications may be reduced to stretch existing supplies.

Even while existing supplies remain, some providers will lose access to reimbursement for vaccine administration and other costs associated with providing testing and treatment for uninsured people without additional funding from Congress. As noted above, the HRSA COVID-19 Uninsured Program is no longer accepting reimbursement claims for COVID-19 testing and treatment services and will stop accepting claims for vaccine administration on April 5, 2022. In states that have not adopted the temporary Medicaid coverage option, providers will no longer have a source of reimbursement for administration costs or other services provided to uninsured individuals. Although all providers must continue to provide vaccines at no cost, some providers may start billing patients for other COVID-related services, while others may stop providing the services altogether. In other cases, the loss of funding may increase the financial strain on safety net providers that continue to provide the services regardless of patients’ ability to pay. Whichever way providers respond, the result will likely be reduced access for uninsured patients in most states due to more limited provider access and/or potential out-of-pocket costs.

Some uninsured children and adults may be able to access the COVID-19 vaccine through existing immunization programs. There are currently two federal programs that provide vaccines to uninsured children and adults—the Vaccines for Children Program (VCF) and the Section 317 Vaccine program. The VCF program is an entitlement program guaranteeing eligible children access to vaccines recommended by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP). The CDC will determine if the COVID-19 vaccine will be included in the VFC program. Providers participating in the VFC program may charge a vaccine administration fee but cannot deny access to the vaccine if the patient or parent is unable to pay. The Section 317 Vaccine program, which provides approved vaccines for uninsured adults, is dependent on available funding. The CDC will similarly determine if the COVID-19 vaccine will be included in the Section 317 program. If it is, uninsured adults will be able to access the COVID-19 vaccine through the Section 317 program; however, without additional funding, it is likely that only a limited supply of COVID-19 vaccines would be available through this program.

Existing rules and protections will ensure that most people with health coverage will continue to have free access to COVID-19 tests, some treatment services, and vaccines, though some limits on cost sharing will end when the PHE ends.

• Medicaid is required to cover COVID-19 testing and treatment services for full-benefit enrollees with no cost sharing for at least a year after the PHE ends, although states may require a prescription for or place other limits on COVID-19 tests. Medicaid must also cover COVID-19 vaccines and administration for nearly all enrollees, and states receive 100% federal matching payments for the costs of administering the COVID-19 vaccine for more than a year after the PHE ends.
• For privately insured individuals, rules in place during the PHE require insurers to cover COVID-19 testing without cost sharing and prohibit insurers from requiring prior authorization for COVID-19 testing. However, when the PHE ends, these requirements will also end, and insurers could begin charging cost sharing for COVID-19 tests or otherwise limiting access. Most privately insured individuals can also access the COVID-19 vaccine at no cost because the vaccine is recommended by ACIP and the Affordable Care Act requires insurers to cover ACIP-recommended vaccines without cost-sharing. This requirement is not tied to the PHE, although once the PHE ends, insured consumers who receive vaccines from out-of-network providers could face higher costs. COVID-19 treatment medications, including monoclonal antibodies and antiviral pills, are generally covered for people with private insurance but once government-purchased supplies run out, will be subject to existing cost sharing requirements, including copayments, coinsurance, and deductibles, as is currently the case for most other treatment-related services, such as physician or hospital care. Though for a time private insurers and employers were waiving out-of-pocket cost sharing for COVID-19 physician or hospital care, the vast majority of the largest insurers and employers have phased out those waivers. Meaning, privately insured COVID-19 patients are expected to pay deductibles and other cost-sharing under their plan.
• Medicare will continue to provide diagnostic COVID-19 testing and testing-related services with no cost sharing during the PHE, though a health care provider’s order may be required. When the PHE ends, while the test will be provided at no cost, beneficiaries will face cost sharing for testing-related office visits and other testing-related services. Medicare will also cover the COVID-19 vaccine under Part B with no cost sharing for the vaccine or its administration for Medicare beneficiaries in both traditional Medicare and Medicare Advantage plans. Medicare covers monoclonal antibody infusions authorized for use by the U.S. Food and Drug Administration (FDA) under an emergency use authorization (EUA), prior to full FDA approval that are provided in outpatient settings, and beneficiaries currently face no cost sharing for this treatment (though that may change when the PHE ends). Antiviral treatments for COVID-19 will likely be covered under Medicare Part D once they are approved by the FDA; however, the definition of a Part D covered drug does not include drugs authorized for use by the FDA but not FDA-approved. CMS recently issued guidance to Part D plan sponsors, including both stand-alone drug plans and Medicare Advantage prescription drug plans, that provides them flexibilities to offer these oral antivirals to their enrollees and strongly encourages them to do so, though this is not a requirement. It is not yet known what beneficiaries may be required to pay for these drugs when covered under Part D, nor how beneficiaries who are not enrolled in Part D plans would get coverage of these medications.

What will happen when the current supply of federally purchased tests, treatments, and vaccines runs out?

Once the current supply runs out, the federal government cannot purchase more tests, treatments, or vaccines without additional Congressional appropriations. Without federally purchased supplies, uninsured individuals would likely need to pay out of pocket for testing and treatment services and/or safety-net providers would have to absorb the cost of providing these services without a reimbursement mechanism. As noted, there are some federal programs that may help cover the costs of providing vaccines to uninsured people, but, without additional funding, it is unlikely that these programs will be able to fully absorb the costs of providing COVID-19 vaccines for adults. People covered by Medicaid and Medicare will continue to have access to COVID-19 clinical diagnostic tests and vaccines without cost sharing and while COVID-19 treatment medications will be covered at no cost for people on Medicaid, Medicare beneficiaries may face out-of-pocket costs for these medications when the PHE ends. For privately insured people, if the costs of treatment medications and vaccines are shifted to private insurers, the insurers will need to establish new contracts and negotiate prices to purchase these supplies, which will take time and may lead to higher costs that could translate into higher premiums for employers and individuals. Insurers may also have a difficult time competing with other countries in purchasing vaccines.

The federal government’s inability to purchase additional supplies of COVID-19 tests, treatment medications, and vaccines could exacerbate existing disparities in health and financial security. People of color are more likely to be uninsured than their White counterparts and face more potential barriers to accessing care, including more limited transportation options and less flexibility in work and caregiving schedules. Even when COVID-19 vaccines have been available for free, survey data show that concerns about costs have been a bigger barrier to vaccination for people of color. While overall disparities in COVID-19 cases and deaths have narrowed over time, data continue to show that people of color are disproportionately impacted by surges caused by new variants, and, as such, may have increased needs for testing and treatment. Moreover, data show a continued gap in vaccinations among Black people and point to racial disparities in uptake of booster shots so far. Any changes that result in more limited access to COVID-19 testing, treatment services, or vaccines, or that require people to pay out-of-pocket for these services, will likely exacerbate these disparities and may also result in more financial burden. Such changes would also disproportionately affect low-income people and those who are uninsured.

Beyond the challenges individuals may face accessing COVID-19 testing, treatments, and vaccines, there are broader implications for the ongoing availability of these resources if the federal government is no longer able to purchase these supplies. Federal pre-purchasing of these supplies to date has provided a guaranteed market to manufacturers (locking in their availability for domestic use) and ensured that the U.S. has had initial access to the supplies. Without such pre-purchasing, manufacturers may reduce or halt production when demand declines (as has happened already with rapid tests) and/or it may become more difficult for the U.S. or for insurance companies to access supplies, as they will be in line with other purchasers globally. Together, this could contribute to shortages of supplies if and when the next COVID-19 wave hits and demand increases.

1. In states that have taken up this option, providers cannot claim reimbursement from the HRSA COVID-19 Uninsured Program for individuals that qualify for the Medicaid uninsured program. ↩︎