COVID has ended (or has it?)

Here's what it means for you

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Welcome back, Shit Givers.

It’s a pretty pivotal week, so today’s essay is a little more technical and longer than normal. Please let me know your feedback!

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COVID is over (as far as we know it). What did we learn, and what’s next?

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COVID has ended.

Or at least, the “way more influential on the past three years of your life than you can possibly imagine” COVID public health emergency has ended.

Let’s get a quick status check:

One week after the World Health Organization also called it quits on the COVID global health emergency, SARS-CoV-2 (the actual virus) and COVID (the disease) are very much still out there, though thankfully, drastically reduced in severity for most folks.

That is, folks who’ve been vaccinated who knows how many times, exposed a bazillion times, infected, tested positive, tested negative, fuuuucking tested positive again, who have taken at least one course of Paxlovid, rinse and repeat.

For the minority of (millions of) immunocompromised folks, COVID remains just as dangerous as ever. And they have much less of an idea of where it is than ever before.

Broadly, we have no real idea how many cases there are, nor levels of transmission.

Most people aren’t testing, no one who is testing is reporting it, and as of today, the CDC can’t make health departments collect or report what data they do get.

So what do we know?

We know US deaths have recently dropped from 4000 a week in January to 1000 a week in mid-May. That’s fantastic news, full stop.

And yet: 1000 deaths a week means a minimum of 50,000 people killed this year, leaving the disease a top-seven killer of Americans — mostly the elderly and medically vulnerable.

It was basically three years ago today that I pulled my kids out of school. If I’d told you three years ago that COVID would directly and indirectly kill a couple million people and then plateau into a new long-term top seven cause of death — would you have believed me? (I did advise some close friends that it might go this way, and those calls were very hard)

What would you imagine this day would look like and feel like?

You may or may not be ready for it, but it’s here. The government has postponed the end of the public health emergency more times than I’ve rescheduled cleaning out my shed (fine, and my attic), and a lot of folks and businesses and governors would very much like to move on.

Today I want to help you understand not just what policies and rules changed this week and how those changes will affect you, but also how fundamental these things have been to every day life the past three years, and how — not unlike the PATRIOT Act in 2001 — we’ve normalized the best and worst of them.

Here’s what’s changing

Let’s do a list. Who doesn’t love a list? It’s like Axios meets Buzzfeed (RIP).

  • The CDC is no longer tracking local levels of transmission. Tens of thousands of fax machines are out of jobs and, funny story! So is the CDC director

  • Vaccine mandates for federal workers and healthcare workers have ended

  • Vaccination requirements for international travelers are gone

  • Hospitals will no longer get extra dough when they take care of COVID patients

  • Free at-home COVID tests from the government are toast

    • Tests ordered by a health professional are still covered under Medicare (but maybe not your visit to the doctor itself?)

    • Medicaid coverage for tests continues until September 2024

    • Private insurers are no longer required to cover up to eight at-home tests per month

  • Speaking of Medicaid — Medicaid/CHIP working restrictions are back in effect and continuous enrollment is ending

  • Food assistance and SNAP benefits are being rolled back

  • And of course, as I wrote in last week’s Members-only Top of Mind post — Title 42 is being lifted literally right now

Here’s what’s not changing (for now, or as far as we know)

COVID vaccines and treatments are generally still available for free…for now.

Government-funded stockpiles of shots (purchased for about $21/shot and provided to you for free) will probably run out this fall, when they’ll go through the same process as any other vaccine and are projected to cost $110-$130 each.

Thanks to the Consolidated Appropriations Act, telehealth will subsist mostly as-is until December 2024.

  • The prescription of controlled medications via telehealth (without an in-person visit) will continue for six months

  • Medicare and Medicaid coverage for mental telehealth has been extended or made permanent, including how many private insurers cover treatment via video, audio, text and chat (this is America so insurers will adjust those rates and parameters over time)

Here’s how it’ll affect everyone

So much of my job is helping people understand that our problems are just choices we’ve made, and that we can make different choices, turning vast, seemingly intractable problems into foundational, society-changing opportunities.

We failed so many tests when COVID arrived, and responded by testing policies and programs that might never have been otherwise politically feasible.

Some of the most successful — like the child tax credit — have already gone away, and this formal end of the COVID public health emergency will undo many more.

But of course we cannot simply go back to 2019, nor would we want to. Our people, politics, and policies have changed irrevocably, and systems that were teetering on the edge before COVID — from nursing to public transportation to voting rights — are in very deep shit.

Let’s explore two big ones:

One. It’s helpful to understand that more than 1 in 4 Americans are currently on Medicaid, the highest it’s ever been. The aforementioned changes may lead 17 million newly uninsured people by May 2024.

From KFF: “Between February 2020 and March 2023, Medicaid enrollment grew by an estimated 20 million people, contributing to declines in the uninsured rate, which dropped to the lowest level on record in early 2022.”

But here’s the thing: Many, if not most of these people were uninsured before COVID.

I hesitate to frame it this way, but here goes: there are incredibly few silver linings from a pandemic that has killed millions and millions of people, deprived millions more of loved ones and caregivers, and devastated frontline workers across the healthcare field.

But since 2010, when (41 and counting) states started taking that sweet sweet Obamacare Medicaid Expansion money, and since 2020 as the pandemic emergency Medicaid support kicked in, tens of millions of people got health insurance for the first time.

Losing it will make life much, much more difficult.

It is criminally unsurprising that the disadvantaged and historically marginalized will get hurt the worst.

Two. Our data efforts are were (eventually) built around lagging indicators, like positive tests. Those efforts were terrible. I don’t want to rehash, well, everything, but testing was terrible because:

  1. The pandemic hit after decades of slashed budgets for health departments everywhere

  2. For the first two years of the pandemic, our institutions dropped the ball in a very big way on making testing accurate, accessible, and affordable

  3. We gave up on contact tracing pretty quickly, a vital public health tool that has worked since the plague

  4. None of our data systems talk to each other

  5. As opposed to the UK, US health data sharing is opt-in

Now we’re going to have even less lagging data, which will make it more difficult to track and assess the risk of new variants (there’s some good news on the data front, but let me get through this part first, ok?).

Combine these factors — tens of millions of folks losing their health insurance over the next year (and thus, their health care options), and a lack of data around who is infected with and transmitting whatever COVID variant(s) — and there will be significantly more stress on our brittle, understaffed healthcare systems.

There isn’t a single one of us that won’t feel that stress.

You might say — but shouldn’t those systems be rebuilding since we still have all of these shots and treatments?

First: It’s pretty important to understand that we’ve lost more people to COVID since vaccines became available to all adults than we did before that.

Second, COVID doesn’t always end in death. In fact, it usually doesn’t. Yes, it’s obviously more deadly to a single person than the flu, but it won’t kill the vast majority of people. It might, however, make you really sick, or even just sick enough to miss work.

Maybe you get paid sick leave, maybe you don’t. Them’s the apples in the USA.

But COVID does obviously kill, too, and it’s left hundreds of thousands of children to grieve the loss of caregivers or grandparents — who are sometimes the same thing.

This generation of children — the same generation who practices administering first aid to one another in case a mass murderer kicks down their 1st grade classroom door, whose parents struggle every day to find or pay for childcare or preschool or food or internet access at home — will be affected in every conceivable way.

And finally, some unknown millions of people — including parents and caregivers and young people — have been left with a version of Long COVID, a post-viral nightmare we’re aching to minimize and forget.

In April, Ed Yong returned to his post at The Atlantic and wrote:

“Almost every aspect of long COVID serves to mask its reality from public view. Its bewilderingly diverse symptoms are hard to see and measure. At its worst, it can leave people bed- or housebound, disconnected from the world. And although milder cases allow patients to appear normal on some days, they extract their price later, in private.

For these reasons, many people don’t realize just how sick millions of Americans are — and the invisibility created by long COVID’s symptoms is being quickly compounded by our attitude toward them.“

We have actually made some strides in understanding Long COVID. But on the surface, because it manifests in many different and unpredictable ways, it is drastically more difficult to identify people who have it.

There is no single test for Long COVID, and some studies and surveys — using traditional measurements — have ended up diminishing the condition, devaluing the stories of those unable to do more than an hour of work a day, or even walk around the block.

If we cannot establish a baseline measurement tool, we cannot count those folks — if they want to be counted at all, for fear of shaming on social media, and/or issues with insurance or at the workplace.

But this is a sociological condition we’re used to.

More from Ed:

“Disability is often a secret we keep,” Laura Mauldin, a sociologist who studies disability, told me. One in four Americans has a disability; one in 10 has diabetes; two in five have at least two chronic diseases.

In a society where health issues are treated with intense privacy, these prevalence statistics, like the one-in-10 figure for long COVID, might also intuitively feel like overestimates.“

Next: Immigration.

Some context:

If you're unfamiliar with Title 42, it’s the horrendously inhumane emergency immigration policy conveniently used by both the Trump and Biden administrations to immediately shun and expel migrants and (typically-allowed) asylum seekers “coming from countries where a serious contagion was present.”

And wouldn’t you know, there was this pandemic, which is defined as "a widespread occurrence of an infectious disease over a whole country or the world at a particular time“.

Sorry! We’re closed.

Title 42 is why we have record unemployment rates and rising wages and yet not have enough workers to go around, much less in the occupations and industries where we need them the most, where we feel their absence the very most.

And that’s just right now. With falling fertility rates everywhere, we have to build a new workforce for the future with every tool we have.

As I’ve written about ad nauseam, we are short millions of nurses, electricians, home care workers, and more.

It’s weird! It’s almost as if about two million extra people died (from COVID, with COVID, from overdoses, from cars, from guns, and from being unable to seek ongoing or emergency care for other shit because of COVID), many millions more retired, and a couple million additional immigrants that would have usually entered the country and found work doing these exact jobs never made it through.

Of course some migrants did make it through — border facilities have been overwhelmed for a long time — but the luckiest of those are still waiting anywhere from 4-10 years to make it through the courts.

With the public health emergency over, Title 42 is over, too. Sort of.

For all of his empathy and meaningful wins, Joe Biden and Congress have failed to build any sort of cohesive, meaningful immigration plan to take on the many, many people who want and need to come to this country — and who we need to come.

And that’s before climate migration really even gets going. There has never ever been a better moment for us to recruit, train, and put to work millions of new immigration attorneys and judges, to set to work the millions of new folks who could drastically improve our fundamental frontline and service workforce.

Because as of right now, the situation on the border just isn’t getting any better, or humane.

My friend Issac Saul at Tangle wrote about the new policies this week:

They will automatically reject asylum seekers who illegally cross into the U.S. without first seeking asylum protections in one of the countries they travel through. This is a change to the United States' longtime policy, which allowed migrants to seek asylum regardless of whether they crossed the border illegally. The US will also change rules to allow more migrants to be sent back to Mexico and impose severe penalties, like a five-year ban on re-entry, for those who cross illegally.

It’s bad. It’s probably illegal, it’s inhumane, it’s a crisis, it’s self-defeating, and it’s only going to get worse.

And to be very clear, this is mostly Congress’s fault. This Congress, the Congress before them, and the one before them, and so on.

It’s been decades of this shit, as incumbents who are terrified of being voted out because of increased immigration — despite every single indicator that immigration made our country, and makes our country better, full stop — fucked around and now we’re all finding out.

Crises don’t happen overnight, and so here we are, a proven haven for people from across Central and South America and else where who want a better life for themselves and their families. People who want to contribute, who we need to contribute — but we won’t let them in, so the systems which usually rely on those people are on the brink.

Whether you have Long COVID, or get COVID for the first or third time, or literally get sick or injured really any other way, you will continue to feel the effects of a public health system that is in tatters, as one-third of existing public health workers are planning on leaving their jobs over the next year.

Senator Tim Kaine (VA) introduced a new bill to provide better pay, better benefits, real training and actual career advancement opportunities for direct care workers, but it’s still just a bill, and one way or another, we simply do not have enough people to actually do the job.

Finally, politics. You may have noticed we are increasingly divided, as states venture in markedly different directions.

Someone polled voters recently, and those voters said among all of the new lawmakers many priorities, COVID should be ranked last. Which is both reductive and self-defeating, because like climate change, COVID touches everything and everyone, including immigration and politics itself, and also it’s not how viruses work?

Immigration will undoubtedly play an enormous role in campaigns and elections at every level as even progressive “sanctuary” cities like Chicago are furious with the president and Congress for their ineffective patchwork policies.

And if another real variant does come around, you may be surprised at how many of the public health abilities states relied on the last time around have been banned by Republican-led state legislatures around the country.

What we’ve learned

(Desperately grasping for straws) So much! So much.

Wastewater monitoring is amazing and we should do so much more of it, and not just for COVID. The CDC’s National Wastewater Surveillance System now covers 138 million or so Americans and provides leading indicators for everything from COVID to the norovirus and more (more on wastewater’s incredible potential in my convo here).

Translating all that data under continually changing conditions will be a priority as we (hopefully) rebuild public health around wellness and prevention.

What else?

Well, mRNA vaccines are amazing and scientists have expanded the platform to go after prostate cancer next, which is incredible.

The Child Tax Credits worked so, so well. We should do more of those and it’s all I think about.

Our healthcare institutions clearly shouldn’t be run by doctors, they should be run by people who have broad skills and experience in sociology, anthropology, in local organizing and yes, medicine, too.

Collaborative surveillance works. Not the PATRIOT Act kind. The version that includes epidemiological investigation, contact tracing, adjusting public health measures on the fly and with real messaging, plus a growing, living/breathing organism of modern labs and diagnostics.

We’re pretty sure that, FWIW, COVID doesn’t appear to be seasonal, coming and going in mini-waves as it keeps evolving.

And we know it’s going to keep evolving. We also know we haven’t had a major “hospitals are fucked again” mutation in a while, which is great, but as with any virus on earth, every person that’s infected is another chance for it to mutate more fundamentally.

What we haven’t learned

There are myriad policies and practices that weren’t working before COVID that we haven’t fixed yet, there are ones we did try and never really followed through on, and ones we’re just outright cancelling.

  • Funding for pandemic preparation

  • Funding for pandemic response

Despite Biden begging Congress for $88 billion in pandemic preparedness funds, he got zero.

Friend of the pod Sam Scarpino tried to find a win and told NPR that "continuing wastewater, traveler screening, and genome sequencing will be important to ensure the infrastructure is maintained for the next time we need it."

On the other hand, Beth Blauer, who helped administer the invaluable Johns Hopkins COVID data tracker I relied on every day, told NPR the moves are “further evidence that these investments were always temporary and not part of a long term strategy to be better public health data stewards.”

These should be obvious but apparently they are not because we’re not doing them.

  • Devastatingly inequitable distribution of vaccines

I could go on about this for hours and did in this conversation and this conversation. We are still fucking this up and it’s a human rights crime.

  • Terrible messaging

It’s unclear to me why there was never a movement to recruit our best advertising and marketing people to educate our medical leadership (who probably shouldn’t also be our public health leadership) on how to convince people to take care of one another.

  • At-home testing

  • The FDA still exists as one very dysfunctional unit

Our testing infrastructure still sucks, and the FDA can’t handle either the food side or the drugs side, much less both.

Sure, the USDA oversees SNAP, but per The New Yorker, “SNAP recipients are expected to lose, on average, around a third of their monthly allotments.” And that’s before we find out what happens with the debt ceiling.

Senate Agriculture Chairwoman Debbie Stabenow told Helena Bottemiller Evich: “I don’t know how taking $6 a day away from a mom and her kids, or a senior citizen, or a person with disabilities, or a veteran is a winning strategy for Republicans,” Stabenow said. “It’s just mean.“ Yep!

  • Indoor air quality

The administration coughed up tens of billions for schools and offices to improve HVAC systems and air cleaning, but most of the money was never used.

  • The desperate need for millions of new well-paid, well-insured trusted community health workers

I have so much more to say about this.

Where this leaves us

Most importantly, we didn’t decide that this was the moment to learn how to take care of one another from the ground up.

To build new baseline systems that provide a way for everyone to reach higher in good times, and as first line of defense in the hard ones.

Collectively — for a while at least — we endured this massive, unifying threat that tested every medical, economic, societal, and political decision we’d ever made, and we failed across the board. We crashed down a slalom course of red flags that told us we had to start over and build something far, far better.

And in many ways, we did, albeit temporarily. America has passed through our very own Sliding Doors (About Time? The Family Man?) era and now we have to choose the future we want.

We know now how to support each other, however comprehensive our approach to each problem will need to be.

COVID is over — as far as we’ve known it.

The new era starts today, as we unwind everything we’ve done to fight it. An era where so much has changed, and so much has not, and with wild and unpredictable changes to come.

— Quinn

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