The COVID-19 pandemic’s public health emergency status in the U.S. expires on May 11, 2023. And on May 5, the World Health Organization declared an end to the COVID-19 public health emergency of international concern, or PHEIC, designation that had been in place since Jan. 30, 2020.

Still, both the WHO and the White House have made clear that while the emergency phase of the pandemic has ended, the virus is here to stay and could continue to wreak havoc.

WHO Director General Tedros Adhanom Ghebreyesus noted that, over that time, the virus has taken the lives of more than 1 million people in the U.S. and about 7 million people globally based on reported cases, though he said the true toll is likely closer to 20 million people worldwide. While the global emergency status has ended, COVID-19 is still an “established and ongoing health issue,” he said.

The Conversation asked public health experts Marian Moser Jones and Amy Lauren Fairchild to put these changes into context and to explain their ramifications for the next stage of the pandemic.

1. What does ending the national emergency phase of the pandemic mean?

Ending the federal emergency reflects both a scientific and political judgment that the acute phase of the COVID-19 pandemic crisis has ended and that special federal resources are no longer needed to prevent disease transmission across borders.

In practical terms, it means that two declarations – the federal Public Health Emergency, first declared on Jan. 31, 2020, and the COVID-19 national emergency that former President Donald Trump announced on March 13, 2020, are expiring.

Declaring those emergencies enabled the federal government to cut through mountains of red tape to respond to the pandemic more efficiently. For instance, the declarations allowed funds to be made available so that federal agencies could direct personnel, equipment, supplies and services to state and local governments wherever they were needed. In addition, the declarations made funding and other resources available to launch investigations into the “cause, treatment or prevention” of COVID-19 and to enter into contracts with other organizations to meet needs stemming from the emergency.

The emergency status also allowed the federal government to make health care more widely available by suspending many requirements for accessing Medicare, Medicaid and the Children’s Health Program, or CHIP. And they made it possible for people to receive free COVID-19 testing, treatment and vaccines and enabled Medicaid and Medicare to more easily cover telehealth services.

Finally, the Trump administration used the national emergency to invoke Title 42, a section of the Public Health Service Act that allows the federal government to stop people at the nation’s borders to prevent introduction of communicable diseases. Asylum seekers and others who normally undergo processing when they enter the U.S. have been turned away under this rule.

2. What domestic policies are changing?

An estimated 15 million people are likely to lose Medicaid or CHIP coverage, according to the federal government. Another analysis projected that as many as 24 million people will be kicked off the Medicaid rolls.

Before the pandemic, states required people to prove every year that they met income and other eligibility requirements. This resulted in “churning” – a process whereby people who did not complete renewal paperwork were being periodically disenrolled from state Medicaid programs before they could reapply and prove eligibility.

In March 2020, Congress enacted a continuous enrollment provision in Medicaid that prevented states from removing anyone from their rolls during the pandemic. From February 2020 to March 31, 2023, enrollment in Medicaid and CHIP grew by nearly 23.5% to a total of more than 93 million. In a December 2022 appropriations bill, Congress passed a provision that ended continuous enrollment on March 31, 2023.

The Biden administration defended this time frame as sufficient to ensure that patients did not “lose access to care unpredictably” and that state Medicaid budgets – which received emergency funds beginning in 2020 – didn’t “face a radical cliff.”

But many people who have Medicaid or who enrolled their children in CHIP during this period may be unaware of these changes until they actually lose their benefits over the next several months.

At least five states already began disenrolling Medicaid members in April. Other states are sending out termination letters and renewal notices and will disenroll members starting in May, June and July.

Only Oregon has set up a comprehensive program to minimize disenrollments. That state is running a five-year federal demonstration program that allows it to temporarily let people stay on Medicaid if their income is up to 200% of the federal poverty level and lets eligible children stay on Medicaid through age 6. Many other states are trying more limited strategies to improve the renewal process and decrease churning.

The array of telehealth services that Medicare began covering during the pandemic will continue to be covered through December 2024. Medicare is also making coverage for behavioral and mental telehealth services a permanent benefit.

The end of the emergency also means that the federal government is no longer covering the costs of COVID-19 vaccines and treatments for everyone. However, in April, the Biden administration announced a new $1.1 billion public-private “bridge access program” that will provide COVID-19 vaccines and treatments free of charge for uninsured people through state and local health departments and pharmacies. Insured individuals may have out-of-pocket costs depending on their coverage.

The end of the emergency lifts the pandemic restriction on border crossing. Large numbers of migrants have gathered at the Mexico-U.S. border and are expected to enter the country in the coming weeks, further straining already overwhelmed staff and facilities.

3. What does this mean for the status of the pandemic?

A pandemic declaration represents an assessment that human transmission of a disease, whether well known or novel, is “extraordinary,” that it constitutes a public health risk to two or more U.S. states and that controlling it requires an international response. But declaring an end to the emergency doesn’t mean a return to business as usual.

New global guidelines for long-term disease management of COVID-19, released on May 3, 2023, urged countries “to maintain sufficient capacity, operational readiness and flexibility to scale up during surges of COVID-19, while maintaining other essential health services and preparing for the emergence of new variants with increased severity or capacity.”

Former White House COVID-19 response coordinator Deborah Birx recently warned that the omicron COVID-19 variant continues to mutate and may become resistant to existing treatments. She called for more federally funded research into therapeutics and durable vaccines that protect against many variants.

Birx’s warnings come as remaining states have ended their COVID-19 press briefings and shut down their exposure notification systems, and the federal government has ended its free COVID-19 at-home test program.

With the end of the emergency, the CDC is also changing the way it presents its COVID-19 data to a “sustainable national COVID-19 surveillance” model. This shift in COVID-19 monitoring and communication strategies accompanying the end of the emergency means that the virus is disappearing from the headlines, even though it has not disappeared from our lives and communities.

4. How will state and local pandemic measures be affected?

The end of the federal emergency does not affect state-level or local-level emergency declarations. These declarations have allowed states to allocate resources to meet pandemic needs and have included provisions allowing them to respond to surges in COVID-19 cases by allowing out-of-state physicians and other health care providers to practice in person and through telehealth.

Most U.S. states, however, have ended their own public health emergency declarations. Six states – Delaware, Illinois, Massachusetts, New York, Rhode Island and Texas – still had emergency declarations in effect as of May 3, 2023, that will expire by the end of the month. So far, Massachusetts Gov. Maura Healey stands alone in having indicated that she will “extend key flexibilities provided by the public health emergency” related to health care staffing and emergency medical services.

While some states may choose to make permanent some COVID-era emergency standards, such as looser restrictions on telemedicine or out-of-state health providers, we believe it could be a long time before either politicians or members of the public regain an appetite for any emergency orders directly related to COVID-19.

This is an updated version of an article that was originally published on Feb. 3, 2023.

Marian Moser Jones, Associate Professor of Health Services Management, Policy and History, The Ohio State University and Amy Lauren Fairchild, Dean and Professor of Public Health, The Ohio State University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

In the past two decades, children have become more obese and have developed obesity at a younger age. A 2020 report found that 14.7 million children and adolescents in the U.S. live with obesity.

Because obesity is a known risk factor for serious health problems, its rapid increase during the COVID-19 pandemic raised alarms.

Without intervention, many obese adolescents will remain obese as adults. Even before adulthood, some children will have serious health problems beginning in their preteen years.

To address these issues, in early 2023, the American Academy of Pediatrics released its first new obesity management guidelines in 15 years.

I am a pediatric gastroenterologist who sees children in the largest public hospital in California, and I have witnessed a clear trend over the last two decades. Early in my practice, I only occasionally saw a child with a complication of obesity; now I see multiple referrals each month. Some of these children have severe obesity and several health complications that require multiple specialists.

These observations prompted my reporting for the California Health Equity Fellowship at the University of Southern California.

It’s important to note that not all children who carry extra weight are unhealthy. But evidence supports that obesity, especially severe obesity, requires further assessment.

How obesity is measured

The World Health Organization defines obesity as “abnormal or excessive fat accumulation that presents a risk to health.”

Measuring fat composition requires specialized equipment that is not available in a regular doctor’s office. Therefore most clinicians use body measurements to screen for obesity.

One method is body mass index, or BMI, a calculation based on a child’s height and weight compared to age- and sex-matched peers. BMI doesn’t measure body fat, but when BMI is high, it correlates with total body fat.

According to the American Academy of Pediatrics, a child qualifies as overweight at a BMI between the 85th and 95th percentile. Obese is defined as a BMI above the 95th percentile. Other screens for obesity include waist circumference and skin-fold thickness, but these methods are less common.

Because many children exceeded the limits of existing growth charts, in 2022 the Centers for Disease Control and Prevention introduced extended growth charts for severe obesity. Severe obesity occurs when a child reaches the 120th percentile or has a BMI over 35. For instance, a 6-year-old boy who is 48 inches tall and is 110 pounds would meet criteria for severe obesity because his BMI is 139th percentile.

Severe obesity carries a heightened risk of liver disease, cardiovascular disease and metabolic problems such as diabetes. As of 2016, almost 8% of children ages 2 to 19 had severe obesity.

Other health problems associated with severe obesity include obstructive sleep apnea, bone and joint problems that can cause early arthritis, high blood pressure and kidney disease. Many of these problems occur together.

How obesity affects the liver

The liver disease associated with obesity is called nonalcoholic fatty liver disease. To store excess dietary fat and sugar, the liver’s cells fill with fat. Excess carbohydrates in particular get processed into substances similar to the breakdown products of alcohols. Under the microscope, a pediatric fatty liver looks similar to a liver with alcohol damage.

Occasionally children with fatty liver are not obese; however, the greatest risk factor for fatty liver is obesity. At the same BMI, Hispanic and Asian children are more susceptible to fatty liver disease than Black and white children. Weight reduction or reducing the consumption of fructose, a naturally occurring sugar and common food additive – even without significant weight loss – improves fatty liver.

Fatty liver is the most common chronic liver disease in children and adults. In Southern California, pediatric fatty liver doubled from 2009 to 2018. The disease can progress rapidly in children, and some will have liver scarring after only a few years.

Although few children currently require liver transplants for fatty liver, it is the most rapidly increasing reason for transplantation in young adults. Fatty liver is the second-most common reason for liver transplantation in the U.S., and it will be the leading cause in the future.

Links between obesity and diabetes

Fatty liver is implicated in metabolic syndrome, a group of conditions that cluster together and increase the risk of cardiovascular disease and diabetes.

In a telephone interview, Dr. Barry Reiner, a pediatric endocrinologist, voiced his concerns to me about obesity and diabetes.

“When I started my practice, I had never heard of type 2 diabetes in children,” says Reiner. “Now, depending on which part of the U.S., between a quarter and a third of new cases of diabetes are type 2.”

Type 1 diabetes is an autoimmune disease previously called juvenile-onset diabetes. Conversely, type 2 diabetes was historically considered an adult disease.

However, type 2 diabetes is increasing in children, and obesity is the major risk factor. While both types of diabetes have genetic and lifestyle influences, type 2 is more modifiable through diet and exercise.

By 2060, the number of people under 20 with type 2 diabetes will increase by 700%. Black, Latino, Asian, Pacific Islander and Native American/Alaska Native children will have more type 2 diabetes diagnoses than white children.

“The seriousness of type 2 diabetes in children is underestimated,” says Reiner. He added that many people express a misconception that type 2 diabetes is a mild, slow-moving disease.

Reiner pointed to an important study showing that type 2 diabetes acquired in childhood can rapidly progress. As early as 10 to 12 years after their childhood diagnosis, patients developed nerve damage, kidney problems and vision damage. By 15 years after diagnosis, at an average age of 27, almost 70% of the patients had high blood pressure.

Most patients had more than one complication. Although rare, a few patients experienced heart attacks and strokes. When people with childhood onset diabetes became pregnant, 24% delivered premature infants, over double the rate in the general population.

Heart health

Cardiovascular changes associated with obesity and severe obesity can also increase a child’s lifetime chance of heart attacks and strokes. Carrying extra weight at 6 to 7 years old can result in higher blood pressure, cholesterol and artery stiffness by 11 to 12 years of age. Obesity changes the structure of the heart, making the muscle thicken and expand.

Although still uncommon, more people in their 20s, 30s and 40s are having strokes and heart attacks than a few decades ago. Although many factors may contribute to heart attack and stroke, obesity adds to that risk.

Talk about being healthy, not focusing on weight

Venus Kalami, a registered dietitian, spoke with me about the environmental and societal influences on childhood obesity.

“Food, diet, lifestyle and weight are often a proxy for something greater going on in someone’s life,” says Kalami.

Factors beyond a child’s control, including depression, access to healthy food and walkable neighborhoods, contribute to obesity.

Parents may wonder how to help children without introducing shame or blame. First, conversations about weight and food should be age appropriate.

“A 6-year-old does not need to be thinking about their weight,” says Kalami. She adds that even preteens and teenagers should not be focusing on their weight, though they likely already are.

Even “good-natured” teasing is harmful. Avoid diet talk, and instead discuss health. Kalami recommends that adults explain how healthy habits can improve mood, focus or kids’ performance in a favorite activity.

“A 12-year-old isn’t always going to know what is healthy,” Kalami said. “Help them pick what’s available and make the best choice, which may not be the perfect choice.”

Any weight talk, either criticism or compliments for weight loss, may backfire, she adds. Praising a child for their weight loss can reinforce a negative cycle of disordered eating. Instead, cheer the child’s better health and good choices.

Dr. Muneeza Mirza, a pediatrician, recommends that parents model healthful behavior.

“Changes should be made for the whole family,” says Mirza. “It shouldn’t be considered a punishment for that kid.”

Christine Nguyen, 2023 California Health Equity Fellow, University of Southern California

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The legislative package the U.S. House of Representatives passed on April 26, 2023, by a narrow margin would pare federal spending over the next decade while also raising the debt ceiling. One important measure in the Republican-backed bill would restrict access to Medicaid for millions of Americans.

About 1 in 4 Americans have health coverage through the program, which primarily serves low-income and disabled people and which is funded jointly by the federal government and the states. Should the Republican-backed legislation prevail, the federal government would require adults insured by Medicaid who are 19 to 55 years old and don’t have children or other dependents to spend 80 hours a month doing paid work, job training or community service.

The Conversation asked Simon F. Haeder, a public health scholar, to explain what the proposed work requirements would do and why the Republican effort to institute them matters for the millions of Americans who rely on Medicaid.

What would change if this policy took effect?

Unlike some other government programs that assist low-income Americans, including the Supplemental Nutrition Assistance Program, or SNAP, and Temporary Assistance for Needy Families, Medicaid currently has no work requirements.

The package the House recently passed would require all states to implement this policy. An estimated 15 million Americans with Medicaid would need to comply with the requirements.

This change would dramatically increase bureaucratic hassles for Medicaid beneficiaries who are disproportionately low-income, disabled and nonwhite. KFF, a health care research nonprofit, estimates that 1.7 million people would lose federal coverage. However, states have the option to continue to pay for these individuals solely with state funds.

Those who would be subject to the new rules would not be the only ones at risk. It is well known that many of the exempt populations, including the aged and disabled, struggle to complete paperwork or fail to understand complex bureaucratic rules. Many experts predict that coverage losses could be even higher among these demographics, as states would consider them to be out of compliance with work requirements.

Are there precedents for this policy?

This is not the first time that Republicans sought to make access to Medicaid contingent on meeting work requirements for at least some beneficiaries. The Trump administration worked with various Republican-led states to use what are known as 1115 demonstration waivers for that purpose. These waivers allow states to make temporary changes to their Medicaid programs that depart from certain statutory requirements. However, those efforts were quickly blocked in court. Most were never even piloted before the Biden administration rescinded them.

One exception is Arkansas.

Arkansas began imposing work requirements on Medicaid recipients on adults ages 30 to 49 starting in June 2018. As a result, about 1 in 4 Arkansans subject to that policy ended up losing their coverage by the end of that year before courts deemed it unlawful.

The Arkansas experience, which was particularly burdensome for beneficiaries, reaffirmed many concerns of those who oppose work requirements. Importantly, the reason many lost coverage was not that they failed to complete the required hours of paid work, job training or community service, but that they struggled to overcome bureaucratic challenges.

Efforts are also underway in Georgia to impose work requirements on Medicaid beneficiaries despite legal hurdles and the Biden administration’s objections. With President Joe Biden in office, it’s going to remain difficult to experiment with this policy unless Congress approves a measure like the one in the House package.

What would be different this time?

States had to actively seek out those waivers that Republicans embraced when former President Donald Trump was in the White House. That meant that Medicaid beneficiaries in states with Democratic leadership, such as California, were unlikely to ever confront them.

The proposed changes in the House legislation would force all states to implement work requirements for adults from 18 to 55 without dependents. Failure to comply would put states at risk of losing federal funding, so even Democratic-led states would have to adopt these rules. The proposed changes would also circumvent many of the legal concerns that previously prevented the widespread implementation of Medicaid work requirements.

Importantly, this policy change would coincide with ongoing upheaval for Medicaid beneficiaries. This is because millions of Medicaid beneficiaries are already losing coverage because of the expiration of the COVID-19 public health emergency declaration on May 11 and states’ restarting eligibility determinations of Medicaid beneficiaries on April 1. As long as the government’s continuous enrollment policy was in effect, states couldn’t kick anyone off of Medicaid.

The number of people covered by the program soared to 93 million as of January 2023.

Is this policy compatible with the purpose of Medicaid?

The point of Medicaid has always been providing eligible low-income people with access to comprehensive health coverage for as long as they need it. That is, Medicaid is exclusively a health insurance program.

Some other safety net programs are supposed to achieve multiple goals. For example, the official mission of Temporary Assistance for Needy Families is to “end the dependence of needy parents on government benefits by promoting job preparation, work and marriage,” rather than just to help those needy parents make ends meet.

At the same time, there is evidence that Medicaid leads to greater workforce participation, because it provides affordable health coverage as well as access to needed medical care. If you have an illness, it can be much easier to stay on the job if you’re getting the treatment your condition requires. Indeed, most able-bodied adults on Medicaid are employed.

Ironically, pushing people off Medicaid, either for failing to fulfill work requirements or because they struggle with navigating the bureaucracy, would likely reduce the number of people who work.

Why is this significant?

It seems unlikely that Medicaid work requirements will become law in 2023 or 2024, because Democrats have steadfastly opposed their implementation and the party commands a majority in the Senate. However, given the potentially dramatic implications of defaulting on the federal debt, some Democrats may be willing to compromise.

For now, I think it’s far more likely that the Republicans in Congress are setting the stage for future efforts to make more public assistance programs contingent on complying with work requirements, especially the next time a Republican becomes the president of the United States.

If measures like the one the House passed as part of the Republican debt-ceiling package were to become law, even states with entrenched Democratic leadership could have little recourse to fight back.

Simon F. Haeder, Associate Professor of Public Health, Texas A&M University

This article is republished from The Conversation under a Creative Commons license. Read the original article.