Every Thursday morning the U.S. Department of Labor releases the latest figures on the number of Americans who have filed for unemployment benefits. Last week found another 3.8 million people filing for unemployment, bringing the total initial jobless claims over 30 million adults in the past 6 weeks. While the weekly unemployment claims are staggering, an equally troubling report was released at the end of April by the Congressional Budget Office (CBO) projecting the unemployment rate through the summer will average close to 15 percent (the unemployment rate prior to the coronavirus outbreak was around 4 percent nationwide). The CBO report projects the U.S. labor market will improve after the third quarter, largely driven by a decrease in social distancing restrictions and businesses opening up, but the unemployment rate is expected to stay above 10 percent throughout 2021. This means many of those workers who have been laid off or lost jobs due to the coronavirus outbreak may not be going back to work this year.

The latest KFF Health Tracking Poll finds 55% of those who were employed either full-time or part-time on February 1, 2020 report that they have either lost their job, been furloughed, or had their salary or hours reduced (Note. the CBO report projects about total unemployment not about those who experienced partial job loss including hours or salary reduction).

This includes two-thirds of those in households earning less than $40,000 annually (65%) or between $40,000 and $75,000 (66%). Four in ten of those earning $75,000 or more annually (41%) say they have lost their job or had their income reduced due to the coronavirus outbreak.

Most of those who report losing their jobs or having their hours reduced were hourly workers (62%), and this group was also more likely than those who didn’t experience a loss of job or hours to say they were part-time workers (22% vs. 9%).

Yet contrary to the CBO projections, the vast majority of these individuals (83%) believe they will get their previous hours, income, or job back within six months, including at least eight in ten across all three income groups (less than $40,000 annually, between $40,000 and $75,000, and $75,000 or more).

In addition, among those who have lost their jobs entirely (26% of those who were employed on February 1^st), most say that while their former place of employment is closed, it is only closed temporarily (56%). Few (2%) say their business has been closed permanently.

While it is unknown how many businesses may close permanently as a result of the economic impact of the coronavirus outbreak or how long these workers will be without employment or working reduced hours, these workers are already reporting disproportionate impacts on both their economic situation and their mental health and well-being compared to those who were employed as of February 1^st and haven’t lost a job, been laid off, or had hours reduced. Two-thirds (65%) of those who lost their job or had income impacted say that worry or stress related to coronavirus has had at least one adverse effect on their mental health or wellbeing such as loss of sleep or appetite, and half say they have fallen behind on household bills or had trouble affording household expenses (48%) or that they are worried about being able to afford these expenses in the future (47%).

While those who have lost their jobs or had their employment impacted by coronavirus are incredibly optimistic about how quickly they will regain their previous employment or income, there is a lot of uncertainty about when the U.S. economy will come back. While workers expect to go back to work soon, economic experts suggest that the economic impact of COVID-19, and the personal impact that a loss of employment has on workers and their families, could last much longer than many workers may think. Depending on how the economic situation continues into the fall, these former workers may be entering the voting booths (or voting by mail which is more likely) with their expectations about a return to normal work-life being largely unmet. It is too early to tell who they will hold responsible or blame for their circumstance, but their economic hardships will most certainly be on their minds.

Every Friday we’ll recap our new coronavirus policy analysis, polling, and journalism. Total cases in the U.S. surpassed 1 million this week. Since last Thursday, actions to ease social distancing requirements went into effect in 14 states: Alabama, Alaska, Colorado, Georgia, Michigan, Minnesota, Mississippi, Missouri, Montana, Oklahoma, South Carolina, Tennessee, Vermont, and Wisconsin.

Here are the latest coronavirus stats from KFF’s tracking resources:

Global Cases and Deaths: This week, total cases worldwide passed 3 million – with approximately 549,000 new cases added between April 23 and April 30. There were approximately 40,000 new confirmed deaths worldwide between April 23 and April 30.

U.S. Cases and Deaths: There have been over 1 million cases in the U.S. There were approximately 200,000 new cases and 13,000 deaths in the United States between April 23 and April 30.

U.S. Tests: There have been approximately 6 million total COVID-19 tests with results in the United States — with over 1.5 million added since last Thursday. 17% of the total tests were positive. There were 19 tests with results per 1,000 people. Our new dashboard highlights the variability by state.

Adults at Higher Risk of Serious Illness if Infected with Coronavirus: 38% of all U.S. adults are at risk of serious illness if infected with coronavirus (92,560,223 total) due to their age (65 and over) or pre-existing medical condition. Of those at higher risk, 45% are at increased risk of serious illness if infected with coronavirus due to their existing medical condition such as such as heart disease, diabetes, lung disease, uncontrolled asthma or obesity.

States Easing Social Distancing Measures: 14 states – Alabama, Alaska, Colorado, Georgia, Michigan, Minnesota, Mississippi, Missouri, Montana, Oklahoma, South Carolina, Tennessee, Vermont, and Wisconsin – have eased some social distancing measures since Thursday, 4/23 Our tracker is updated daily as the quickly changing state responses go into effect. More will go into effect today.

Statewide Actions to Mitigate the Spread of COVID-19 (includes Washington D.C.):

• Stay At Home Order: 36 statewide orders, 3 orders for high-risk groups only, other action in 1 state, expired orders in 5 states, no action in 6 states
• Mandatory Quarantine for Travelers: 14 orders for all travelers, 1 order for all air travelers, 6 for travelers coming from certain states, other action in 1 state, no action in 29 states
• Non-Essential Business Closures: 24 orders to close all non-essential businesses; 4 orders to close all non-essential retail businesses, 14 to close certain non-essential businesses, open with reduced capacity in 3 states, no action in 6 states
• Large Gatherings Ban: All gatherings prohibited in 15 states, gatherings of 10+ people prohibited in 25 states, gatherings of 20+ people in 1 state, other actions in 4 states, expired bans in 3 states, no action in 3 states
• State-Mandated School Closures: Closed in 11 states, closed for school year in 33 states, recommended closure in 1 state, recommended closure for school year in 6 states
• Bar/Restaurant Limits: Closed except takeout/delivery in 44 states, limited on-site service in 5 states, other action in 1 state, no action in 1 state
• Primary Election Postponement: Postponement in 14 states, cancelled in 1 state, no postponement in 36 states
• Emergency Declaration: There are emergency declarations in all states and D.C.

State COVID-19 Health Policy Actions (Includes Washington D.C.)

• Waive Cost Sharing for COVID-19 Treatment: 3 states require, state-insurer agreement in 3 states; no action in 45 states
• Free Cost Vaccine When Available: 9 states require, state-insurer agreement in 1 state, no action in 41 states
• States Requires Waiver of Prior Authorization Requirements: For COVID-19 testing only in 5 states, for COVID-19 testing and treatment in 6 states, no action in 40 states
• Early Prescription Refills: State requires in 18 states, no action in 33 states
• Premium Payment Grace Period: Grace period extended for all policies in 11 states, grace period extended for COVID-19 diagnosis/impacts only in 5 states, no action in 35 states
• Marketplace Special Enrollment Period: Marketplace special enrollment period in 12 states, no special enrollment period in 39 states
• Paid Sick Leave: 13 states enacted, 2 proposed, no action in 36 states

Approved Medicaid State Actions to Address COVID-19 (Includes Washington D.C.)

• Approved Section 1115 Waivers to Address COVID-19: 1 state has an approved waiver
• Approved Section 1135 Waivers: 51 states have approved waivers
• Approved 1915 (c) Appendix K Waivers: 37 states have approved waivers
• Approved State Plan Amendments (SPAs): 23 states have temporary changes approved under Medicaid or CHIP disaster relief SPAs, 1 state has an approved traditional SPA

• Other State-Reported Medicaid Administrative Actions: 51 states report taking other administrative actions in their Medicaid programs to address COVID-19

This week’s blog posts in Coronavirus Policy Watch:   

• Taking Stock of Essential Workers (Blog)
• States are Shifting How They Cover Prescription Drugs in Response to COVID-19 (Blog)
• Public Attitudes Towards the Coronavirus Outbreak in Highly Affected Counties (Blog)

The latest KFF COVID-19 resources:

COVID-19 in the United States

• COVID-19 in Rural America – Is there cause for concern? (Issue Brief, News Release)
• Double Jeopardy: Low Wage Workers at Risk for Health and Financial Implications of COVID-19 (Issue Brief)
• Public Attitudes Towards the Coronavirus Outbreak in Highly Affected Counties (Blog Post)
• Data Note: Requirements for Nursing Homes and Assisted Living Facilities in Response to COVID-19 Vary Across States (Issue Brief)
• Updated: State Action to Limit Abortion Access During the COVID-19 Pandemic (Issue Brief)

Global COVID-19 Response

• Archived Recording: KFF and Global Health Council Present a Virtual Town Hall on COVID-19 Response in Low- and Middle-Income Countries (Archived Recording)
• Pandemic, Global Warming Can Spur Nations To ‘Rebuild Our World For The Better,’ U.N. SG Says In Climate Dialogue Address (KFF Daily Global Health Policy Report)

Trackers and Tools

• COVID-19 Coronavirus Tracker – Updated May 1, 2020 (Tracker)
• COVID-19 and Related State Data (State Health Facts)
• State Data and Policy Actions to Address Coronavirus – Updated April 30, 2020 (Issue Brief)
  • This tracker has been updated with a new data dashboard that integrates data on cases, deaths, testing, hospitalizations, and race/ethnicity into a single resource. The tracker also includes new data on cases in long-term care facilities
• Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19 – Updated April 30, 2020 (Issue Brief)

The latest KHN COVID-19 stories:

• Trump’s Claim That U.S. Tested More Than All Countries Combined Is ‘Pants On Fire’ Wrong (KHN)
• Do-It-Yourself Cheek Swab Tested As Next Best Thing To Detect Coronavirus (KHN)
• California To Widen Pipeline Of Psychiatric Nurse Practitioners (KHN, Chico Enterprise-Record)
• Lost On The Frontline (KHN, The Guardian)
• KHN’s ‘What The Health?’: SCOTUS Decides An ACA Case. No, Not THAT Case. (Podcast)
• Free Clinics Try To Fill Gaps As COVID Sweeps Away Job-Based Insurance (KHN)
• ‘An Arm And A Leg’: If Insurer Bills You For COVID Testing, Talk — And Maybe Tweet — It Out (Podcast)
• As Coronavirus Strikes, Crucial Data In Electronic Health Records Hard To Harvest (KHN, Fortune)
• Trump Says N95 Masks Can Be Sterilized For Reuse. Only In A Pinch, Experts Warn. (KHN)
• COVID Tests Are Free, Except When They’re Not (KHN, NPR)
• Amid Coronavirus Distress, Wealthy Hospitals Hoard Millions (KHN, Washington Post)
• Telehealth Will Be Free, No Copays, They Said. But Angry Patients Are Getting Billed. (KHN, NPR)
• Health Insurers Prosper As COVID-19 Deflates Demand For Elective Treatments (KHN, Los Angeles Times)
• Widely Used Surgical Masks Are Putting Health Care Workers At Serious Risk (KHN, The Guardian)
• Lost On The Frontline (KHN, The Guardian)
• Lawmaker Pushing Mental Health Reform: It’s ‘More Needed Than Ever’ (KHN)
• Consumer Beware: Coronavirus Antibody Tests Are Still A Work In Progress (KHN)
• The Challenges Of Keeping Young Adults Safe During The Pandemic (KHN)
• Fear Of Coronavirus Propels Some Smokers To Quit (CHL)

On April 24, 2020, the Paycheck Protection Program and Health Care Enhancement Act was signed into law, marking the fourth major legislative initiative to address COVID-19. The three earlier initiatives include:

• the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, which was signed on March 6 and provided emergency funding relief for domestic and global efforts;
• the Families First Coronavirus Response Act, which was signed on March 18 and provided emergency funding relief for domestic efforts; and
• the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law on March 27 and provided emergency funding relief for domestic and global efforts.

The Paycheck Protection Program and Health Care Enhancement Act includes a number of health provisions to address the domestic outbreak, which are summarized in the table below. This summary does not include other aspects of the domestic response addressed by the Act, such as additional funding provided for the paycheck protection program under the Small Business Administration.

Among the areas addressed is $100 billion for the Public Health and Social Services Emergency Fund at the Department of Health and Human Services (HHS), including $75 billion for additional funding to reimburse hospitals and other health care entities for health care related-expenses or lost revenues attributable to coronavirus (referred to as the CARES Act Provider Relief Fund, which now totals $175 billion overall) and $25 billion for necessary expenses related to COVID-19 testing. The testing funding includes:

• Not less than $11 billion for states, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes, of which:
  • Not less than $750 million shall be allocated to tribes and tribal organizations, and
  • Not less than $4.25 billion shall be allocated to States, localities, and territories according to a formula based on the relative number of COVID-19 cases;
• Not less than $1 billion for the Centers for Disease Control and Prevention (CDC);
• Not less than $1.8 billion for the National Institutes of Health (NIH);
• Not less than $1 billion for HHS’ Biomedical Advanced Research and Development Authority (BARDA);
• $22 million for the Food and Drug Administration (FDA);
• $600 million for the Health Resources and Services Administration (HRSA);
• $225 million for rural health clinics; and
• Up to $1 billion to cover the cost of testing for the uninsured.

Prior to the pandemic, the Trump Administration was encouraging and states were pursuing a range of changes to state Medicaid programs through Section 1115 waivers that ranged from waivers to enable states to receive federal Medicaid funds for services delivered in an institution for mental disease (IMD) for treatment of substance use disorder or serious mental illness, condition Medicaid eligibility on meeting work requirements, and, more recently, not to apply an array of federal rules in exchange for capped federal financing. The focus of Section 1115 waivers has taken a sharp turn to using waivers as a vehicle to respond to needs tied to COVID-19. Historically, Section 1115 authority has provided states with broader flexibility to expand coverage and/or provide uncompensated care to address the direct impact of natural disasters and public health emergencies (like New York City after 9/11, Hurricane Katrina, and Flint Michigan) on state Medicaid and Children’s Health Insurance Program (CHIP) programs. State actions under Section 1115 can help complement what states are doing under other emergency authorities (e.g., Section 1135 and 1915 (c) Appendix K) as well as their own existing authority to respond to emergency needs if approved by CMS.

In response to the COVID-19 public health emergency, CMS developed a new Medicaid section 1115 demonstration opportunity and application template. These demonstrations are intended to enable states to provide medical assistance in ways to help protect the health, safety and welfare of individuals and providers affected by COVID-19. There are requirements for monitoring and evaluation, but CMS is not requiring states to submit calculations showing that the waiver would be budget neutral to the federal government like traditional waivers due to the unprecedented emergency nature of the pandemic. These demonstrations can be retroactive to March 1, 2020 and will expire no later than 60 days after the end of the public health emergency. To date, at least 15 states have submitted Section 1115 COVID-19 related emergency waivers.

CMS approved the first emergency COVID-19 Section 1115 waiver for Washington on April 21, 2020. Most of the approved provisions in the waiver relate to long-term services and supports (LTSS) and follow the “pre-printed” waiver and expenditure authorities outlined in the CMS template. Most of the provisions extend HCBS flexibilities available under 1915 (c) home and community-based services waiver Appendix K to beneficiaries receiving LTSS under SPA authorities. The changes can help support HCBS enrollees and providers.

In the letter to the state, CMS noted that some provisions requested by the state were not approved and others were still under consideration.

• New temporary coverage: CMS did not approve the state’s request to establish a temporary eligibility group for individuals with incomes at or below 200% FPL. Washington had proposed using Medicaid funds to provide additional subsidies for people enrolled in Qualified Health Plans (QHPs) with income at or below 200% FPL to allow individuals to purchase and use Marketplace coverage with no or low out-of-pocket costs.
• Coverage for COVID-19 treatment for the uninsured: CMS is continuing to review Washington’s request for Medicaid expenditure authority to create a Disaster Relief Fund to cover costs associated with the treatment of uninsured individuals with COVID-19, housing, nutrition supports and other COVID related expenditures.
• Other provisions still under review: Other requests under continuing review include the state’s request to make retainer payments to HCBS providers beyond the 30-day limit, other payments to providers beyond those approved, and to allow transportation brokers to directly provide Non-Emergency Medical Transportation (NEMT).

Based on the Washington approval, it is not clear whether/when/how far CMS will go beyond the template to approve other state requests. Similar to CMS’ approach to reviewing/approving Section 1135 emergency waivers, CMS has approved provisions in the template but noted they will continue to consider other requests. During state stakeholder calls, CMS has said they will consider other available federal funds before approving state requests for expenditure authority for certain activities. For example, CMS pointed to relief funds available through CARES as rationale for not approving Washington’s request to cover treatment costs for the uninsured through Medicaid. In addition to Washington, other states have turned to Section 1115 waivers seeking additional flexibility to address pressing health coverage, benefit, delivery, and payment issues. For example, states are seeking to provide temporary housing for homeless individuals who test positive for coronavirus, extend/broaden coverage of home delivered meals, and the authority to use Medicaid funds to cover coronavirus-related testing and treatment for individuals in jails and prisons. During state stakeholder calls, CMS has noted they will not be approving Medicaid expenditure authority now for housing or additional nutrition services nor will they approve provisions that states could implement through other authorities. As the cases and deaths from the pandemic continue to rise, states continue to struggle to address the myriad of issues related to COVID-19. Whether CMS will consider other state requests and how quickly they will respond are outstanding questions.

The COVID-19 pandemic has changed the reality of working life for most of the U.S. workforce. Whether they find themselves laid off, working from home, or continuing to go to a workplace while taking measures to protect themselves and their families from infection, nearly all workers have felt some form of disruption in their jobs. In this post, we use data from the latest KFF Health Tracking Poll to examine the experiences of essential workers – those who are still required to work outside of their home during the coronavirus outbreak. Since the start of the pandemic, essential workers have been on the front lines making sure that people are able to continue to access their basic needs. While states have determined different criteria for what is deemed an essential business and essential worker, some jobs are universally essential across the country: hospital and health care delivery workers, grocery store clerks, pharmacy and convenience store employees, airline workers, and first responders, to name a few. While most workplaces have put measures in place to protect workers, essential workers still have a higher risk of contracting coronavirus compared to those who are able to stay home. So, who are these essential workers?

One-third (34%) of U.S. adults say they have been deemed an essential worker and are currently working outside their home. Compared to others who are currently employed (most of whom are presumably able to do their jobs from home), essential workers working outside the home are more likely to be Black (15% vs 5%), have a household income of less than $40,000 (31% vs 19%), and a majority (70%) of essential workers do not hold a college degree, while six in ten (61%) non-essential workers have at least a 4-year degree. One-fourth (26%) of essential workers say that they or someone in their family is a health care worker, one classification of employment that has been considered essential across the country.

Workplaces across the country look very different now than they did just a few months ago, regardless of whether that business or service has been deemed essential or not. While many non-essential workers have been able to adapt to conduct their work online and over the phone, essential places of employment have had to restructure their hours and occupancy to accommodate both the demand of their services and the safety of their workers. Hospitals have also had to reprioritize in order to help care for the influx of possible coronavirus patients. Life has been disrupted for the vast majority of workers, with members of both groups reporting their lives have been disrupted at least some by the pandemic (82% and 90% respectively). Our polling finds that essential workers are more likely than their non-essential counterparts to say that they have had their working hours reduced because of the outbreak (35% vs 24%), while one in five in both groups report experiencing pay cuts (19% of essential workers and 20% of non-essential workers).

In addition to being more likely to live in lower-income households, essential workers also report experiencing a heavier financial burden due to the coronavirus pandemic. Essential workers report having more difficulty affording necessities, such as credit card bills (19% vs 11%), utilities (15% vs 5%), and food (10% vs 4%), and are also more likely to say they are “very worried” or “somewhat worried” about affording food (24% vs 12%) specifically because of the crisis.

Essential workers working outside their homes may have an elevated risk of contracting coronavirus, and by extension, an increased risk of incurring expenses related to coronavirus treatment. Yet this group is less likely to have the financial resources to pay an unexpected medical bill without going into debt. When asked how they would pay for an unexpected $500 medical bill, a larger share of essential workers say they would have to borrow money to pay back the bill (31% compared to 19% of currently employed non-essential workers) or say they would not be able to pay the bill at all (16% vs 9%).

Furthermore, as some of the most vulnerable members of the workforce, essential workers are experiencing the pandemic up-close and personal. KFF polling finds at least three in ten workers—both essential and non-essential—report knowing someone who has tested positive for the coronavirus (33% and 30% respectively). However, a larger share of essential workers say they know someone who has died from complications related to coronavirus (13% vs 6%).

Despite being more likely to report financial challenges and knowing someone who has died from the virus, essential workers are no more likely than non-essential workers to report any adverse effects on their mental health and well-being due to the pandemic. About half of essential workers (49%) and a statistically similar share of non-essential workers (58%) say the coronavirus outbreak has caused them to experience at least one negative effect, including trouble sleeping, appetite problems, increased alcohol or drug use, or worsening chronic health problems.

While to date big cities and major urban areas have seen the greatest number of coronavirus cases and deaths, a new KFF analysis finds the growth rate is now higher in rural areas, where the population tends to be older, younger people are more likely to have high-risk health conditions, and there are fewer intensive-care beds.

The analysis finds that in the two-week period ending April 27, non-metro, mostly rural counties saw a 125% increase in coronavirus cases (from 51 to 115 cases per 100,000 people) and a 169% increase in deaths (from 1.6 to 4.4 deaths per 100,000 people). Meanwhile, metro counties saw a 68% increase in cases (from 195 cases per 100,000 people to 328) and a 113% increase in deaths (from 8.0 deaths per 100,000 people to 17.0).

Some counties with the highest rates of cases and deaths are located in Georgia, Oklahoma and Montana, which are beginning to ease social-distancing measures originally implemented to slow the spread of coronavirus. The analysis suggests such states could face particular challenges in easing such restrictions, given recent case and death trends in their rural counties.

More recent data on COVID-19 in rural America is available here.

While the earliest cases of coronavirus in the United States were reported primarily in urban areas, which still remain hardest hit, there is increasing concern about the impact of the pandemic in rural America. To the extent that rural areas face an increasing impact, they could experience particular challenges given their relative lack of hospital capacity, older average age, and higher shares of their populations with underlying health conditions.

In this analysis, we compare coronavirus cases and deaths in metropolitan and non-metropolitan counties in the United States. We find that while metro counties still have significantly higher cases and deaths per capita, non-metro counties are experiencing faster growth rates, potentially signaling challenges ahead. Some counties with the highest rates of cases and deaths are located in Georgia, where the state has moved to significantly ease social distancing measures.

Differences in Coronavirus Cases and Deaths in Metro and Non-Metro Counties

In the United States, about 86% of the population lives in more densely populated metro counties, while 14% lives in non-metro (largely rural) counties. Even adjusting for population size, metro counties have nearly three times as many confirmed coronavirus cases as non-metropolitan counties, and nearly four times as many deaths from COVID-19 as of April 27 (Figure 1), similar to findings in other recent analyses. The general pattern holds true whether we include counties in or around New York City, which has seen the largest number of infections and deaths in the country.

The death rate (COVID-19 deaths per confirmed coronavirus case) is only slightly higher in metro compared to non-metro counties (4.2% compared to 3.8%), meaning that differences in deaths are largely due to differences in infection rates.

The county with the most cases per capita (Lincoln County, Arkansas) is a metro county, while the county with the most deaths per capita (Randolph County, Georgia) is a non-metro county (Table 1).

The map below shows the per capita number of coronavirus cases and deaths across metro and non-metro counties.

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While non-metro areas currently have fewer coronavirus cases per capita, both cases and deaths are growing at a faster rate compared to metro counties (Figure 2). In the two-week period between April 13 and April 27, non-metro counties saw a 125% increase in coronavirus cases (from 51 cases per 100,000 people to 115), on average, and a 169% increase in deaths (from 1.6 deaths per 100,000 people to 4.4). Meanwhile, metro counties saw a 68% increase in cases (from 195 cases per 100,000 people to 328) and a 113% increase in deaths (from 8.0 deaths per 100,000 people to 17.0).

Discussion

Less densely populated rural areas initially saw slower spread of the new coronavirus, and both cases and deaths remain lower in non-metro areas than metro areas. However, there are troubling signs that the rates of growth in both cases and deaths are increasing more rapidly in rural areas, where the population tends to be older, younger people are more likely to have-risk health conditions, and hospitals have fewer ICU beds per capita.

Due to concerns over the economic effects of stay-at-home orders, some states have started to ease social distancing measures previously put in place. For example, Georgia has started to reopen certain businesses and allow limited dine-in at restaurants, despite some of its counties rising toward the top of this list of U.S. metro and non-metro counties with the highest numbers of COVID-19 deaths per capita. Similarly, Oklahoma and Montana have also begun easing restrictions, despite each having a county among the top five for non-metro COVID-19 deaths per capita. The findings presented here suggest that there may be particular challenges in these states and others, given recent case and death trends in their rural counties.

Methods

Data are current as of April 27, 2020.

We used the Federal Office of Rural Health Policy definitions of metro and non-metro counties, and then compared their reported case and death rates, as well as recent changes in cases and deaths.

This analysis does not include up to 6,971 confirmed COVID-19 cases and 503 COVID-19 deaths for which an associated county cannot be identified.

Medicaid covers 70 million Americans, many with chronic conditions who may be at increased risk for COVID-19. Medicaid beneficiaries, particularly those with chronic conditions, will need access to medications even during social distancing and their ability to meet with providers to obtain refills may be hindered. States are updating policies to allow beneficiaries to access medications during this public health emergency. States can allow beneficiaries to have more of their medication on hand and reduce the barriers to receiving medication by eliminating cost sharing, changing administrative requirements and reducing the need for in-person contact by encouraging mail delivery or eliminating signatures.

States can use many of the tools traditionally used to manage prescription drug utilization to increase beneficiary access to medications during an emergency, like COVID-19. These tools include prior authorization (PA) requirements, use of preferred drug lists (PDLs), quantity limits and restrictions on refill frequency.  States have flexibility in how they administer their programs and can make a number of changes without the need for approval from CMS. We are tracking state changes to the pharmacy benefit in response to COVID-19 on our SPA and Other Administrative Actions Tracker (Figure 1). We also just posted a comprehensive survey of how states administer the Medicaid pharmacy benefit, which can serve as benchmark going forward.

Most of the changes states are making apply to the fee-for-service (FFS) benefit but some apply more broadly to managed care plans as well and are noted as such in the tracker.  In response to COVID-19, states are:

• Relaxing restrictions on quantity limits. Quantity limits set the amount of a particular prescription that a beneficiary can have on hand as well as the total number of prescriptions they can access in a month without PA. Most states are allowing beneficiaries to have up to a 90 day supply of maintenance medications. Other states are lifting any limits on the number of drugs a beneficiary can receive at one time or increasing the amount of emergency medication supply allowed. Thirty-two states have either increased quantity amounts or reduced limits on prescriptions.
• Allowing early refills. States typically set a certain percentage of the medication that must be used before a refill is allowed but many are relaxing these limits and allowing beneficiaries to refill their prescriptions sooner. So far at least thirty-three states have taken action to relax policies around refills.
• Suspending prior authorization. Prior authorization requires prescribers to obtain approval from the state Medicaid agency before a particular drug can be dispensed. At least nineteen states are suspending prior authorization requirements for specific drugs or extending prior authorization for drugs that have already been authorized. Eleven states have changed the status of certain drugs to “preferred” on their PDLs, like asthma medications, which make them easier for beneficiaries to access. At least five states have eliminated cost-sharing specifically for medications (others have eliminated cost-sharing more broadly in Medicaid).
• Increasing mail delivery. To assist beneficiaries with social distancing and those in quarantine, states are encouraging mail delivery and relaxing restrictions for delivery. At least eight states have eliminated the need for a signature to show receipt of a prescription.

Our pharmacy benefits survey reports on state management of the pharmacy benefit prior to the COVID-19 emergency, providing context for state policy changes. According to our survey, 46 states maintain a PDL of outpatient prescription drugs, which is a list of drugs states encourage providers to prescribe over others. Prior authorization is also widely used: forty-six states reported that new drugs are “always” or “sometimes” subject to prior authorization. Thirteen states set limits on prescription amounts and total number of prescriptions a beneficiary can have on hand.  States may also charge nominal cost-sharing; 37 states require pharmacy copayments for certain adults. Because states can operate prescription drug programs in fee-for-service (FFS) or managed care, rules and policies may differ based on how the state administers their program – in some cases MCOs must follow rules set by the state for FFS, but in other states MCOs may have more flexibility to manage most of the prescription drug program and assume the risk.  Thirty-five states carve prescription drugs into managed care.

State pharmacy benefit decisions will be important to watch going forward as cases of COVID-19 grow and impact more communities across the US. Medicaid will be a major source of health coverage as individuals lose income and become unemployed. For current and any new enrollees, ensuring access to prescription drugs will be important to manage on-going chronic conditions, particularly as the health system is strained dealing with COVID-19.  We are continuing to update our tracker with the latest information from states and are watching for federal policy and legislative changes.