Secretary of Health and Human Services, Xavier Becerra on January 16 renewed the public health emergency declaration through April 16. (Shawn Thew/Pool via AP, File)

For hospitals and residents in rural areas, the end of the national public health emergency (PHE) could mean an end to some health care services. 

From financial and staffing problems at rural hospitals, to a reduction in Medicaid benefits and telehealth services, the end of the public health emergency could mean turning the clock back on healthcare rural patients and providers have come to rely on. 

But experts at the White House say it’s too early to worry about the end of the public health emergency, and that those things will be taken into consideration as the administration moves forward. 

Dr. Cameron Webb, Senior Advisor to the Covid-19 Task Force, said no determination has been made about the public health emergency yet and that it may be too premature to worry about changes on the horizon. 

“The most recent public health emergency determination is a continuation of a number of determinations,” he said in an interview with the Daily Yonder. “I don’t want people to have the impression this is different from any other determination during the pandemic.” 

On March 13, 2020, then-President Donald Trump declared a public health emergency over the Covid-19 pandemic. That declaration triggered what’s known as “1135 waivers” – a blanket waiver of certain requirements of care from the Centers for Medicaid and Medicare Services (CMS) – covering everything from licensing requirements to reporting requirements. Earlier this year, on January 16, Secretary of Health and Human Services Zavier Becerra renewed the public health emergency declaration through April 16.

But the end of the PHE means the end to many policies that benefit rural communities, said Brock Slabach, COO of the National Rural Health Association, in an interview with the Daily Yonder. One of the biggest issues facing rural communities is the end of higher family income eligibility for Medicaid in states that did not expand Medicaid prior to the pandemic. 

“In states like Missouri (which did not expand Medicaid prior to the pandemic), there will be a lot of individuals enrolled in Medicaid by virtue of the public health emergency that will have their benefits terminated at the end of the public health emergency,” Slabach said.

As part of the public health emergency, a federal mandate stated that anyone enrolled in their state’s Medicaid program could not lose their coverage during the pandemic. But when the emergency ends, state Medicaid officials will have one year to reevaluate each recipient’s eligibility.

According to CMS, one in four Americans were enrolled in Medicaid as of July 2021. In rural areas, the Medicaid and CHIP Payment and Access Commission found, 14 million of the estimated 60 million rural Americans were Medicaid recipients.

“Ensuring states are prepared to return to normal eligibility and enrollment operations successfully is a top priority for the Biden-Harris Administration and CMS,” a CMS spokesperson said in an email interview. “CMS is working closely with states now to plan and prepare for the return to normal operations through regular workgroups, biweekly calls with states, and development of additional tools and resources for state use in their planning efforts. Working with and investing in states now, with as much lead time as possible, will help to ensure the best outcomes possible for Medicaid and CHIP enrollees.”

Other services may also be affected, Slabach said.

“The other big deal is the end of the telehealth expansions for rural providers, particularly rural health clinics and Federally Qualified Health Centers,” Slabach said. “They had qualified as distant site providers under the public health emergency, so that would expire as well, which would severely limit their ability to provide telehealth services.”

The public health emergency loosened the guidelines for telehealth appointments and gave providers the flexibility to provide telehealth services across state lines, in some instances, and to prescribe controlled substances via telehealth. Additionally, it required private insurance providers and Medicaid and Medicare to cover the cost of telehealth sessions.

Once the public health emergency ends, those changes to the guidelines would revert back to pre-pandemic policies.

At McKenzie Health Systems in Sandusky, Michigan, about 10%of patients use telehealth services, said Steve Barnett, president and CEO, in an interview with the Daily Yonder. Plans to expand telehealth services that would expand access to care would be affected by reverting to the way things were, he said.

His hospital has also been able to expand access to care through a waiver that eliminated the requirement that physicians supervise advanced practice providers like nurse practitioners and nurse anesthetists. The waivers allowed his hospital to expand their workforce, he said. The end of the public health emergency could end all that too.

“Given the workforce shortages, it will be difficult to go backwards when you’ve found that you can provide a higher level of care and that you can meet more needs by expanding and fully using the people that have the skills to do that,” he said.

The end of the public health emergency will also mean the end of additional SNAP benefits. Passed in March 2020, the Families First Coronavirus Response Act authorized an additional $100 per month in emergency supplemental funding. An estimated 16% of rural residents receive SNAP benefits.

Slabach said the NRHA is urging Congress to address the issues ending the waivers would create.

“We are working with Congress to develop legislation that would make this so that they would be extended permanently or extended well beyond the end of the public health emergency,” he said. “But as with anything else legislation wise, that’s always an uphill battle.”

Republicans in Congress have urged President Joe Biden not to further extend the public health emergency.

In a February 10 letter, 70 Republican members of Congress asked Biden to “accept that Covid-19 is endemic, recognize that current heavy-handed government interventions are doing more harm than good, and immediately begin the process by which we unwind the public health emergency so our country can get back to normal.”

On the other side, the Federation of American Hospitals is asking the Biden Administration to extend the public health emergency.

“While we are encouraged by the recent downward trend in Omicron infections nationwide, we believe that the threat of Covid-19 and the operational challenges it continues to impose on providers and caregivers remain,” the FAH said in its February 10 letter. “Given Covid-19’s sustained damage, unpredictable nature, and the threat of new variants that can quickly emerge, we urge you to continue to appropriately extend the PHE well beyond its current expiration date in April 2022.”

Webb said that any determination about the public health emergency would be made by the Department of Health and Human Services and would be guided by science, not politics. How to deal with the end of 1135 waivers would also be a part of discussions on the public health emergency, he said.  

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