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A sign outside a hospital advertises COVID-19 testing on November 19, 2021 in New York City.

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The public health emergency in the United States, declared in response to Covid-19, ends on Thursday, more than three years after the pandemic began.

The Biden administration’s decision to end the state of emergency comes at a time when deaths and hospitalizations have fallen dramatically due to the availability of vaccines, antiviral treatments and widespread exposure to the virus.

The number of Covid deaths has fallen to its lowest since March 2020, when the rapid spread of the virus across the United States overwhelmed the healthcare system and led to widespread closures of schools, businesses and public facilities.

Hospital admissions due to the virus have also fallen to their lowest since data collection began in the US in August 2020.

The end of the state of emergency will bring significant changes to how the US is responding to the virus. Hospitals are losing the flexibility to quickly add bed capacity as patient admissions increase, and the Centers for Disease Control and Prevention will scale back efforts to track the virus.

After the emergency ends, the CDC can no longer compel labs to report Covid test results. The agency does not have the power to force states to report new cases.

CDC Director Dr. Rochelle Walensky, who is set to step down at the end of June, warned Congress last week that the agency still has to negotiate data-sharing agreements with individual jurisdictions, a time-consuming process that puts the nation at risk.

“That should worry us all, mostly because of the visibility we’re going to have in the next outbreak,” Walensky told the Senate Health Committee. “We’re back to square one and need to build and negotiate surveillance capabilities while fighting a pathogen.”

While public health experts agree the US now has many more tools to combat Covid, they warn the virus will continue to pose an ongoing threat to the elderly, vulnerable and the country’s fragmented, ailing healthcare system.

“I think we’re through the worst now, but there’s going to be a steady drumbeat of hospitalizations and deaths for many years to come,” said Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University.

The virus still kills

The US public health emergency has been extended 13 times since the Trump administration first declared it on January 31, 2020, when there were only six known cases of Covid and no known deaths in the US

In the three years since, Covid has killed more than 1.1 million people and hospitalized millions more in the United States, in the worst public health crisis since the flu pandemic more than a century earlier in 1918.

The virus was the fourth leading cause of death in the US in 2022 – two years after Covid first emerged, behind only heart disease, cancer and unintentional injuries.

The World Health Organization declared the end of the global Covid emergency on Friday. But WHO chief Tedros Adhanom Ghebreyesus warned national governments against dismantling the systems they had built to fight the virus.

“This virus is here to stay. It still kills and it still changes. The risk remains that new variants will emerge, leading to new spikes in cases and deaths,” Tedros said.

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More than 1,000 people are still dying from Covid each week in the US, the vast majority of whom are aged 75 or older, as the public has largely lost interest in staying up to date on vaccines.

Only 42% of seniors are up to date on their Covid vaccinations, according to CDC data. Only 17% of the entire US population has received the latest booster shot.

“You have to stay current to have proper protection,” said Dr. James Lawler, an infectious disease expert at the University of Nebraska Medical Center.

“Similar to immunity from a vaccine, surviving Covid confers immunity, but that immunity does not last,” Lawler said.

The Biden administration says the end of the state of emergency will have no impact on access to Covid vaccines and antiviral treatments because there is still federal stockpiling, but many consumers will have to start paying for Covid testing.

Gostin said a misinformation campaign against vaccines, particularly in conservative states, as well as a general vaccine fatigue, have put the country’s health at risk.

Meanwhile, millions of people are at risk of losing coverage through Medicaid, the public health insurance program for people on lower incomes, as states are allowed to review eligibility for the first time in years. Congress banned states in principle from barring people from Medicaid during the pandemic, but those protections expired in April.

“We’re going to see the social and health safety net unraveling over the next few months,” Gostin said. “There will be an increase in uninsurance and people will not have access to health care,” he said.

health system ailing

Hospitals have been hit by repeated waves of Covid over the past three years and many healthcare facilities are suffering from staff shortages as many doctors and nurses suffer from burnout.

With the end of the emergency, hospitals are losing the flexibility to quickly add beds in unconventional settings and resort to interns to help with increasing patient intake.

Leading medical associations warned the Biden administration last fall that emergency rooms were at a breaking point, and patients were being kept waiting due to insufficient bed capacity and understaffing.

And hospitals now face the ongoing threat of Covid, in addition to the flu and respiratory syncytial virus, which was already straining capacity during a period of poor respiratory viruses before the pandemic.

“We really have lost so much healthcare capacity in this country with the loss of beds and healthcare workers,” said Michael Osterholm, a leading epidemiologist and director of the Center for Infectious Disease Research and Policy in Minnesota.

“We better hope that we don’t see a big surge in infectious diseases of any kind in the coming months to years,” Osterholm said.

Lawler, who advised the Bush and Obama administrations on biodefense and pandemic preparedness issues, said hospitals may need the flexibility the public health emergency offers if large Covid surges return in the future .

“I’m not optimistic that anyone in Washington will be willing to declare a new emergency, even if warranted, once the public health declaration is lifted,” he said.

An Eli Lilly & Co. logo is featured on a box of insulin medications in this arranged photo of a pharmacy in Princeton, Illinois.

Daniel Acker | Bloomberg | Getty Images

Eli Lilli CEO Dave Ricks vowed Wednesday not to raise prices again on the company’s existing insulin products — the only executive to do so ahead of a Senate Health Committee hearing on the affordability of the life-saving diabetes drug.

Sen. Bernie Sanders, the committee chair, asked Ricks and the CEOs of Novo Nordisk And Sanofi to commit “never again to increasing the price of an insulin drug”. The three companies control over 90% of the global insulin market.

Ricks was the only executive who wholeheartedly agreed with Sanders’ request — at least for Eli Lilly’s existing insulin products.

“We will leave our prices for the insulins on the market today as they are,” Ricks told the Vermont Senator. “In fact, we cut them.”

Meanwhile, Lars Fruergaard Jørgensen, CEO of Novo Nordisk, said the Danish company has committed to limiting price increases to “single digits”.

Sanofi CEO Paul Hudson responded that the company has a “responsible pricing policy.”

He also noted that the net prices for Sanofi’s insulin products are actually falling. Net price refers to the amount insurers pay for an insulin drug after discounts and rebates. It is usually lower than the price a product is listed for.

All three companies have been under political pressure for years to make insulin more affordable for people with diabetes.

In March, they each announced that they would reduce the prices of their most commonly used insulin products.

Lilly announced that the price of the Lispro injection will be $25 per vial starting May 1, and the price of the Humalog and Humulin injections will be reduced by 70% starting in the fourth quarter.

The company also announced that it would limit the deductible for individuals with personal insurance at participating retail pharmacies to $35 per month.

Novo Nordisk announced that it will reduce the list price of its NovoLog insulin by 75% and the prices of Levemir and Novolin by 65% ​​starting next year.

Sanofi said it plans to cut the price of its most popular insulin drug, Lantus, by 78% and the list price of its short-acting insulin, Apidra, by 70%.

At the hearing, Sanders called these actions “good news” and a result of public pressure.

But the senator said the committee plans to hold a hearing next year to make sure those price cuts “actually happen.”

“We just don’t want words. We want action,” Sanders said in his opening speech.

“We need to make sure price cuts are effective enough to ensure that every American with diabetes gets the insulin they need at an affordable price,” Sanders added.

CVS, Express Scripts, Optum Rx

The hearing also brought together other key players in the insulin industry: top executives from three of the largest pharma-benefits executives.

Those executives were David Joyner, President of CVS Health pharmacy services; Adam Kautzner, President of Express Scripts; and Heather Cianfrocco, CEO of Optum Rx.

PBMs are the middlemen who negotiate drug prices with manufacturers on behalf of health insurance companies. They are often criticized for allegedly inflating drug prices and not passing on all the rebates and rebates they negotiate to consumers.

Joyner pointed out that CVS Health passes on more than 98% of all discounts to customers.

“We’ve always prioritized making really transparent offers to the market,” he said during the hearing.

But Senator Roger Marshall, R-Kan, stressed that 84 cents of every dollar goes to the PBMs.

Sen. Susan Collins, R-Maine, also highlighted a colossal gap between list and net prices of insulin from 2012 and 2021.

Collins asked Ricks to explain “who gets this money” because “I can tell you it’s not going to the consumer at the pharmacy counter.”

Ricks urged her to ask the PBMs “how this money is being redistributed.”

government caps

About 37 million people in the United States have diabetes, according to the Centers for Disease Control and Prevention. About 8.4 million diabetes patients are dependent on insulin.

High prices have forced many Americans to ration insulin or reduce their use of the drug. A 2021 study in the Annals of Internal Medicine found that nearly 1 in 5 US adults either skipped, delayed, or used less insulin to save money.

The Inflation Reduction Act, the Democratic plan Biden signed into law last year, capped the monthly cost of insulin for Medicare beneficiaries to a $35 monthly prescription but offered no protection for diabetes patients who have private insurance.

More than 2 million patients with diabetes who take insulin are privately insured, according to the Department of Health and Human Services. Another 150,000 patients who take insulin are uninsured, HHS says.

Last month, Sens. Jeanne Shaheen, DN.H., and Collins introduced bipartisan legislation that would require private health insurers to cap the price of any insulin type and dosage form to $35 a month.

These types of insulin include fast-acting, short-acting, medium-acting, long-acting, and pre-mixed. Dosage forms include vials, pens, and inhalers.