Two years into the official pandemic, Covid-19 remains an emergency.
Ending the national emergency posture in the US, and the government provisions that come with it, would be costly.
Exactly two years ago today, on March 11, 2020, World Health Organization Director-General Dr. Tedros Ghebreyesus declared that Covid-19 had met the official criteria for a pandemic.
Are we still in the acute “emergency phase” of this crisis?
The day that the pandemic was declared, thousands of people in a handful of countries had died of this then-novel disease, though fewer than 50 people in the United States had. Soon, the daily death counts in the US were in the hundreds, before the first wave peaked at over 2,200 per day in late April 2020. The rest is history. In the United States alone, there have been over 1 million more deaths (“excess deaths”) in the last 2 years than would have occurred in a parallel universe in which the virus we call SARS-CoV-2 had never jumped into humans. Just yesterday, there were over 1,330 deaths attributed to Covid-19 in the US—which is around the same number that was occurring in early April of 2020.
Nevertheless, in the last few weeks, there has been debate about whether we are still in the “emergency phase” of this pandemic. The US Senate voted to end the Covid-19 national emergency declaration last week (Senate Republicans snuck this by by using a rule that allowed the vote to occur when a few Democrats were absent; the bill has no chance of becoming law, given the Democratic House majority). Meanwhile, US Department of Health and Human Services Secretary Xavier Becerra had already extended the “public health emergency” through April. And while the CDC’s new mask guidelines effectively ended mask mandates temporarily in a majority of the country, yesterday, we learned that the Biden administration will at least continue to require masks during travel through April, if not beyond.
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But whether or not we choose to de-escalate our mitigation policies does not answer whether we are still in an emergency, epidemiologically speaking. I would argue strongly that, regardless of any actions we decide to continue or sunset, we are very much still in the emergency phase.
It all hinges on what metric you want to use, of course. If your definition of an emergency would only be met if there weren't enough ventilators for sick patients, then no, we are not in an emergency—and most places rarely, if ever, were. On the other hand, if you’d argue that any active Covid-19 cases in the community means we are still in the emergency phase, I might point out that this means that declaring the end of the emergency will likely never be possible.
For me, the strongest and most reliable indicator that we are still in the emergency phase of the pandemic is that we are still recording substantial excess mortality (deaths from all causes), and by a large margin. In Massachusetts, we had excess mortality as recently as two weeks ago. In the United States, it takes longer to know because of reporting lags. However, my team found that there was extremely high excess mortality at least through the first week of February. For example, during January, among adults ages 65 and older, US death rates were nearly 130% of normal. Instead of 200,000 seniors dying in January nationwide (which would be typical) over 265,000 seniors died. (We just don’t have enough data about February and March yet, but there will certainly have been excess mortality, based on early indicators).
Now, at some point, excess mortality will no longer be happening routinely. When that happens, I’ll be the first to let you know, and the first to be celebrating. But will that mean the emergency is over? Not necessarily. But it will be a major step.
In fact, there are many other harms of the pandemic that are worth tracking as metrics to help us understand where in this emergency we are. Excess mortality is simply the most glaringly obvious metric; as long as there is all-cause excess mortality (driven by Covid-19, of course), there’s not even a coherent conversation to be had about this emergency being “over.” We’re still very much in a historic phase. A century from now, epidemiologists will look at the death statistics from winter and spring of 2022 and they’ll quickly conclude that we were still deeply in the thick of it at this moment.
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Why does it matter whether we continue to label Covid-19 as an ongoing emergency, even as we de-escalate some of our mitigation in some areas? Because federal, state, and local governments continue to do important life-saving work that in many instances hinges on formal declarations of an emergency. My public health colleagues have correctly argued that ending the emergency phase will leave the most at-risk behind, a moral failure.
Broadly speaking there are at least two major declarations that are currently active. There’s the “public health emergency” (determined by the HHS secretary) and there’s the “national emergency” (first determined by President Trump on March 13, 2020, and later renewed by President Biden)
Via email, a Biden administration official told Inside Medicine that “the public health emergency enables the administration to more effectively respond to COVID, including by:
Continuing insurance coverage for millions of Americans on Medicaid.
Offering telehealth services to millions of seniors on Medicare.
Giving flexibility to health care providers and health care workers to better care for patients.”
The "national emergency," on the other hand, gives the Executive Branch more flexibility in fighting Covid-19, including by permitting HHS to waive and modify some of its usual rules and requirements. Important actions include ensuring people have adequate healthcare items and services, including access to physicians. One way this has been achieved during the pandemic has been by temporarily allowing physicians to practice across state lines. In other words, the national emergency declaration makes life easier for both healthcare providers and patients.
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Fortunately, even if political pressure mounts and either President Biden or HHS Secretary Becerra have to sunset the public health or national emergencies this spring or summer, many key provisions will continue, some permanently and some temporarily. For example, Medicare and Medicaid has already said that it will continue to allow providers to diagnose mental health conditions via telehealth, an innovation that was long overdue. (In general, telehealth has become much more popular during the pandemic, and many states have acted to keep it around.) Other changes, like access to medical abortion drugs by mail, have also been made permanent.
But not all of the emergency provisions will remain after the declarations expire. The public health emergency put a freeze on automatic Medicaid disenrollment. If the public health emergency ends in April, as is currently scheduled unless extended, millions of Americans would suddenly lose insurance.
Then there’s the money. Even the Democrat-led Congress just stripped the new $1.5 trillion funding package of $15 billion worth of much-needed Covid-19 funding. Unless that’s reversed, access to vaccinations, tests, and therapeutics will be diminished in the coming months, as funding dries up.
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On the two-year anniversary of the Covid-19 pandemic, cases and deaths are indeed falling in the US. For now. Does that mean it’s over? Not yet. After all, we still have excess mortality, remember?
In order to eliminate that incontrovertible proof that we are still in the midst of a historic calamity, we have to continue to acknowledge that we are still in danger, and we have to continue to act like it. If we try to bluff our way into normalcy—whether by decreasing all mitigation prematurely, ending many of the pandemic-era innovations that have made healthcare delivery easier, or closing the coffers to much needed funding—we will not actually have ended or minimized the ongoing hazards. In fact, as we've painfully learned before, pretending that all of our problems have ended before they truly have only stands to extend them.
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Thanks to Shannon Firth of Medpage Today for helping me understand some of the public health emergency policies. Also, thanks to my friend and colleague Dr. Alister Martin of the White House Office of Public Engagement for sharing insights and resources (Note: Dr. Martin is not the unnamed administration official quoted above).