Experts worry the end of the Covid-19 public health emergency slated for May 11 could leave some rural hospitals struggling financially and some Americans without medical insurance coverage. 

Brock Slabach, COO of the National Rural Health Association (NRHA), said healthcare facilities are determining how they will be affected by the end of public health emergency, which was put into effect nearly three years ago by the Trump administration early in the Covid-19 pandemic.

In August 2022, the Centers for Medicare & Medicaid Services released a roadmap for rural hospitals as the “unwinding” of the emergency nears.

“There was a sense of anticipation for a long time now, wondering when this will end,” Slabach said. “I don’t think that it’s a surprise to anyone that there’s a deadline now… because everybody knew it was coming.”

After the public health emergency ends, some flexibilities that rural hospitals depended on will go away, according to the plan. Slabach said the policy reimbursing hospitals an additional 20% for treating Covid-19 patients during the pandemic will end. 

In a February 9 letter to governors, U.S. Department of Health and Human Services Secretary Xavier Becerra said while some Covid policies – like free Covid-19 vaccines – will not change, coverage of Covid-19 tests and treatments for those on Medicaid will end in September 2024.

Reimbursement rates for telehealth services, however, will continue. 

“Major Medicare telehealth flexibilities will not be affected,” Becerra wrote. “The vast majority of current Medicare telehealth flexibilities that Americans—particularly those in rural areas and others who struggle to find access to care—have come to rely upon over the past two years, will remain in place through December 2024 due to the bipartisan Consolidated Appropriations Act, 2023 passed by Congress in December 2022.”

Michael Topchik, national leader for the Chartis Center on Rural Health, said rural hospitals saw a slight improvement in their operating margins as a result of telehealth, but he said research still needs to be done on what effecttelehealth will have on their future bottom lines. 

The biggest impact, experts said, may be on rural residents’ access to Medicaid. 

At the start of the pandemic, legislation intended to provide pandemic relief to the American people included provisions that barred states from dropping people from Medicaid during the public health emergency if they wanted to receive federal matching funds. As a result, Medicaid numbers rose dramatically.

With the official end of the emergency, Medicaid recipients will now have to re-enroll to ensure they met the requirements for coverage, Slabach said.

“If they have an income higher than what meets the threshold, then they would now no longer be eligible for Medicaid, so they would be eliminated from the rolls,” he said. “That can create, for a lot of rural providers who disproportionately depend on Medicaid for a larger portion of their business, potential uncollectible accounts because these individuals likely would not be able to pay.”

An analysis by HHS in August put the number of people who will potentially be dropped from Medicaid and the Children’s Health Insurance Program (CHIP) close to 15 million – 8.2 million who would no longer qualify for the program, and 6.8 million terminated even though they might still be eligible.

When and how re-enrollment begins is up to the individual states, said Tim McBride, co-director for the Center for Health Economics and Policy at Washington University in St. Louis. That process would determine how many people in that state would fall off Medicaid rolls. In Missouri, McBride said, officials anticipate as many as 200,000 people would be dropped.

While some will be determined to be ineligible, others may just not know they need to re-enroll, he said. 

“What happened the last time (they required people to re-enroll in the program in 2008) is they sent letters out to people and said you have to tell us that you belong on the program,” he said. “Frankly, we have a lot of evidence suggesting that people just ignored the letters; that they didn’t know that they had to send a letter back; or that they thought the letter was telling them they were remaining on the program.”

McBride said he was the chair of the program at the time and got emails from people desperate to find out what had happened to their health coverage.

“All of a sudden, they went to the doctor and the doctor said you don’t have any coverage anymore,” he said. “When they called the state, (the operators) said, ‘Well you got a letter, you didn’t respond to it.’ ”

Even when they did respond, he said, some residents waited months to hear whether they met the eligibility requirements. 

At this point, he said, questions about the unwinding of Medicaid extensions are unanswered. 

“I think the short answer is we don’t know (what’s going to happen),” McBride said. “Having lived through this before, I will tell you that the way it’s going to play out here [in Missouri] is going to be very different than New York and California and Alabama.”

For those who lose their Medicaid coverage, the result will be a return to life before Covid, said NRHA’s Slabach. 

“We’re going back to the pre-pandemic reality,” he said. “It’s problematic… We still haven’t fixed some of the underlying problems, especially in the 11 states that didn’t pass Medicaid expansion, that existed before and that’s just one of the realities we will be returning to.”

The loss of coverage will also affect rural hospitals’ bottom line, he said. 

“What this creates for a lot of rural providers who disproportionately depend on Medicaid for a larger portion of their business is a lot of potentially uncollectible accounts because these individuals likely would not be able to pay if it weren’t for the Medicaid program,” Slabach said. 

Former President Donald Trump declared the public health emergency in March 2020 near the start of the pandemic’s spread to the United States. The state of emergency was extended every 90 days as new outbreaks and variants emerged. President Joe Biden announced he would end the emergency on January 30, due to dropping Covid-19 infection numbers. 

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