The latest manufactured crisis in Washington over raising the nation’s debt ceiling has been both tragic and farcical. In exchange for allowing the United States to continue paying its bills, Republicans in Congress have insisted on draconian cuts to federal spending. Yet rather than looking for savings in a military budget bigger than that of the next ten countries combined, or a tax code with loopholes worth billions to the uber-wealthy, the GOP has focused on what it sees as one of the real drivers of wasteful spending: health insurance for lazy people.
The “Limit, Save, Grow Act,” a conservative-wish-list-cum-ransom-note narrowly passed by the Republican House majority in late April, contained a provision that would impose work requirements on recipients of Medicaid, the public health insurance program for low-income Americans. Eligibility for coverage would be conditioned on either working, participating in job training, or performing community service for at least eighty hours per month, with a few exemptions based on age, disability, or having a dependent child.
The Biden administration predicts that up to 21 million people might lose their Medicaid coverage if the House Republicans’ plan were to become law. These could include people with chronic health problems who cannot pass a stringent test for disability; seasonal workers and those who work irregular hours; or others who are in fact eligible for coverage but fail for one reason or another to fill out all the right paperwork.
The administration is right: the Republican plan is both morally objectionable and economically self-defeating. Everyone deserves to have health insurance, regardless of their station in life, and people who cannot pay for medical care will be less productive workers too. But it takes real chutzpah to attack your opponents for trying to kick millions of people off Medicaid when your own policies are about to result in the very same outcome. The Biden administration is currently on track to preside over what will likely be the largest mass disenrollment of Medicaid recipients in the history of the program. What’s even worse is the fact that this disaster is entirely avoidable: it is happening only because of the president’s failure to fight for the continuation of measures implemented as part of the federal government’s response to COVID-19.
During the early phase of the pandemic in the spring of 2020, various federal agencies invoked authority under existing laws to issue emergency declarations empowering the government to respond to the crisis. President Trump declared a “national emergency,” while the secretary of Health and Human Services declared a “public health emergency” and also allowed the Food and Drug Administration to grant “emergency use authorization” to novel vaccines and treatments for COVID-19.
In addition to these executive actions, Congress passed the Families First Coronavirus Response Act (FFCRA) in March 2020, which increased federal Medicaid matching funds to state governments in exchange for their agreeing to maintain “continuous eligibility” for Medicaid enrollees throughout the duration of the public-health emergency. Ordinarily, states conduct annual checks to verify that Medicaid recipients are still eligible for the program, and those who no longer meet all the criteria—because, for example, their income has increased beyond a particular threshold—have their coverage rescinded. But for the past three years, the FFCRA had put an end to this process, allowing anyone on Medicaid at the start of the pandemic to retain their coverage—no questions asked.
However, the end-of-year budget deal signed into law by President Biden in late December of last year allowed states to bring back annual Medicaid-eligibility checks starting on March 31, even while the public-health emergency was still in effect, and a number of states have already done so. The Kaiser Family Foundation estimates that between 5.3 million and 14.2 million people stand to lose Medicaid coverage during the “unwinding” period over the next twelve months; estimates from the Department of Health and Human Services (HHS) suggest the number could be even higher. On top of that, HHS has projected that around 6.8 million of those disenrolled might still be eligible but will nevertheless go without coverage until their eligibility is verified. Given the overwhelming administrative burden this is likely to impose on state bureaucracies, even those who are entitled to coverage may have difficulty getting it back once they’ve lost it.
Biden and Democrats in Congress could have fought to prevent the repeal of continuous eligibility, but they didn’t. It’s true that the emergency declarations ushered in some policies that deserved to be phased out, like the Title 42 immigration restrictions that denied millions of migrants the opportunity to seek asylum. But the “decoupling” of the Medicaid provisions from the rest of the emergency measures only serves to illustrate how Biden could have rallied public support for extending the declarations while still revisiting particular issues as needed. Instead, he announced plans in January to terminate both the national and public-health emergencies on May 11. For Congress, even a few more months was simply too long to wait: the House and Senate passed a bill shortly thereafter to end the national emergency early, and despite some initial protestations President Biden signed it just after Easter. The public-health emergency ended on schedule in mid-May.
The end of the Covid emergency declarations is alarming not only because of the consequences for those who rely on Medicaid or other programs that were temporarily expanded, but also because the SARS-CoV-2 virus itself remains a serious threat—even as our leaders’ will to do anything about it evaporates. While the death rate from acute Covid infection has come down, it is still very high—higher than many people realize. During the past twelve months the disease has been recorded as the cause of around 125,000 deaths in the United States. To put that number in context, an average year sees between ten thousand and fifty thousand lives lost in this country to influenza; the historically brutal flu season of 2017–18, one of the worst in decades, was estimated to have claimed around eighty thousand. Despite the widespread perception that Covid is now no worse than a mild cold, it is still killing two to ten times as many Americans as the flu on an annual basis.
Moreover, looking at mortality statistics alone gives an incomplete picture of the impact that Covid continues to have on public health. A growing body of research demonstrates how infection can increase the risk of developing all manner of chronic health problems, including cardiovascular disease, auto-immune conditions, or neurological disorders. Data from the National Center for Health Statistics show that, as of March, around 6 percent of U.S. adults are experiencing some degree of post-acute or “Long Covid” symptoms. And “post-Covid conditions” are, unfortunately, not rare: according to the World Health Organization, “current evidence suggests approximately 10–20% of people experience a variety of mid- and long-term effects.”
The People’s CDC, a coalition devoted to advocacy for a more vigorous response to the Covid threat, has argued that the winding down of the national and public-health emergencies, far from reflecting any kind of genuine victory over the virus, is in fact the culmination of a “major political push to minimize public recognition of the ongoing harm of the pandemic.” Of course, Biden’s defenders will insist that the end of the emergencies does not mean that the government is no longer concerned with protecting Americans from the virus. In an interview with 60 Minutes last fall—the one in which he notoriously announced that “the pandemic is over”—Biden conceded that “we still have a problem with Covid” and claimed that “[w]e’re still doing a lot of work on it.”
Putting aside the technical question of how to define a pandemic and whether the term still applies to our current situation, the problem is not that the administration is entering a “new phase” when it comes to fighting Covid, but rather that it has very nearly given up on fighting it at all. Congressional Republicans cited Biden’s remarks on 60 Minutes to justify killing his request for $9.25 billion for vaccines, treatments, and research and development to be included in last December’s spending deal; in its March budget request for fiscal year 2024, the administration did not ask for a single dollar to be spent on the Covid response. While running for president in October 2020, candidate Biden swore that “we can and will control this virus,” and promised that, if elected, “I will never wave the white flag of surrender.” Unfortunately, that flag now seems to be flying high above the White House.
The end of the emergency declarations will cement America’s capitulation to Covid in a variety of ways. For one, vaccines, antiviral treatments, and high-quality PCR tests will no longer be paid for by the government and provided free to all Americans. Companies like Pfizer and Moderna have already signaled that they intend to jack up the prices of their vaccines well above cost (while gesturing at providing some form of assistance for the uninsured). Even those who have insurance could now face significant out-of-pocket costs for getting tested or for enduring a Covid-related hospital stay. White House Covid Coordinator Ashish Jha spoke enthusiastically about this shift last year at an event sponsored by the U.S. Chamber of Commerce Foundation, telling attendees that “my hope is that in 2023, you’re going to see the commercialization of almost all of these products.” Heaven forbid people get the idea that any aspect of health care in America could ever be exempted from the logic of the market.
In addition to the fact that testing will now be more expensive and more difficult to access, labs are no longer required to report test results to the CDC. This is likely to hamper efforts at viral surveillance. The CDC itself has acknowledged that reduced availability of data means it can no longer reliably calculate rates of community transmission—already difficult given the rise of at-home rapid tests. Even more galling is the fact that hospitals no longer have to report when cases of Covid are contracted by patients in their facilities. Donald Trump rightly got blowback from many quarters for musing in 2020 that “if we stop testing, we’d have fewer cases,” but his successor has brought his vision closer than ever to reality. When it comes to Covid, there is now a solid bipartisan consensus that ignorance is bliss.
Those who would want to portray Covid as a completely intractable problem often frame our choice as one between doing nothing at all or “lockdowns,” but there are plenty of less disruptive measures that would dramatically reduce transmission and the social burden of the disease. For instance, since SARS-CoV-2 is primarily an airborne virus, it should be a top priority to invest in infrastructure that would clean the air in all indoor public spaces, using technologies like HEPA filters or germicidal ultraviolet light. Waterborne illnesses like cholera were not vanquished in the developed world by leaving it up to individuals to boil their own water forever but by building public-sanitation systems to provide clean water for everyone. We can, and should, do the same for the air that we breathe. This is just one piece of what a comprehensive strategy for real disease mitigation could look like, one that also relies on tools like vaccination, testing, contact tracing, supported isolation, waste-water monitoring, and the use of high-quality masks.
In theory, none of this requires there to be a formal state of emergency. But without one, the most likely outcome is continued inaction. This is why many environmental activists have demanded an official emergency declaration over climate change. And for those tempted to object that a state of emergency cannot last forever, consider that the national emergency declared in response to the tragedy of the 9/11 terror attacks remains in effect more than two decades later. As Branko Marcetic wrote recently in Jacobin, we are currently witnessing “a 9/11’s worth of U.S. deaths roughly every two weeks” due to Covid, yet “the U.S. political class can’t be bothered to keep in place the policies to fight it.”
Why not? Perhaps elected officials fear that anything involving the word “Covid” is politically toxic now that the public is thought to have “moved on” from the issue. But another part of the explanation might be that many of the unprecedented actions taken by the government in response to the onset of the crisis—from imposing moratoria on evictions and student-loan payments to expanding unemployment benefits, nutrition assistance, and access to Medicaid—visibly demonstrated how the state, when it feels like it, can do far more than it usually does to provide for the needs of ordinary people. For many in power, this was a dangerous development: after all, if voters get it in their heads that access to public health insurance can be broadened not just during an emergency, but in “normal” times too, who knows what they might demand next?