The pandemic’s not over, but Colorado and the feds are winding down the public health response. So who fills in the gaps?

Starting next year, the federal government and the state of Colorado plan to play much smaller roles in managing COVID-19, raising questions about who’s going to keep people from falling through the health care system’s cracks.

For more than two years, vaccines, testing and some COVID-19 treatments were free to everyone, regardless of whether they had insurance. And while there still were big disparities between urban and rural populations and between white Coloradans and people of color, the state put resources it doesn’t have for most diseases into reaching populations that struggle to get care.

Both the state and federal governments have scaled back their part in testing since the end of last winter’s omicron wave, and White House officials have said the current booster campaign will be the last one featuring doses purchased with taxpayer funds and available to everyone for free.

In a “60 Minutes” interview last weekend, President Joe Biden declared the pandemic over — a statement that has no legal force, but may be a sign that he plans to further curtail the federal government’s role. The message is mixed, though, coming less than a month after his administration asked Congress for $22 billion for vaccines, tests and COVID-19 research.

It would be more accurate to say the societal response to the pandemic is largely over, said Dr. Michelle Barron, senior director of infection control at UCHealth.

While fewer people are getting seriously sick or dying than were last year, COVID-19 hasn’t fallen into a seasonal pattern, and it’s still not clear why some people are hit so much harder than others, she said. Long COVID also remains mysterious, despite efforts to figure out why some people aren’t recovering and what could help them.

Since essentially all government-imposed health restrictions have been lifted and the response is being shifted to the overarching health care system, it puts the onus on individuals to do whatever they can to reduce their risk of severe disease, Barron said.

“Bottom line, it’s out there,” she said. “Get your booster to protect yourself.”

There’s no scientific standard for when a pandemic is over, meaning decisions about how to respond are judgment calls. People can debate whether COVID-19 still constitutes a pandemic, or has shifted to become another disease that primarily threatens older people and those with health conditions, like flu or respiratory syncytial virus, said Dr. Connie Price, chief medical officer at Denver Health.

“It seems to be moving in that direction,” she said.

Deaths and hospitalizations have dropped significantly from their January highs, but are still significantly higher than even a bad flu season. About four people in Colorado and 400 nationwide with COVID-19 have died, on average, each day this month.

Colorado still operates a reduced number of free testing sites and temporarily reopened 10 mass vaccination sites where people can get the new boosters targeting the latest versions of the virus, but those will close whenever federal funding for them runs out.

Many people already are getting vaccinated, tested and, if necessary, treated for COVID-19 through their regular doctor, said Scott Bookman, director of the division of disease control and public health response at the Colorado Department of Public Health and Environment. The question is who is still using the publicly funded resources, and how to meet their needs once the federal money that pays for that infrastructure runs out, he said.

“Should we be testing people in parking lots for the foreseeable future? Should we be vaccinating people on buses for the foreseeable future? These are the questions we need to ask ourselves,” he said.

Federal government to stop buying

By the middle of next year, the federal government’s stockpiles of COVID-19 vaccines, tests and treatment will run out, putting an end to the practice of offering them free to everyone.

People who have insurance most will likely be covered if they need future booster shots or COVID-19 treatment, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. It’s less clear how much access uninsured people will have, or how much outreach there will be to those who are less likely to seek care, he said.

“There are a lot of those questions around how this will develop as the public health emergency ends at some point,” he said.

Most private insurance plans have to cover COVID-19 vaccines as a preventive service, as do Medicare and Medicaid.

The program through which the U.S. Postal Service mailed free at-home COVID-19 tests to anyone who wanted them already paused Sept. 2, and it’s not clear if it will restart. Administration officials said they needed to save the remaining tests for a possible fall surge, since they won’t be able to place another large order with the response money that’s left.

People with insurance can get reimbursed for purchasing at-home tests, but the process can be complicated, and, of course, that doesn’t help those who are uninsured. The most familiar brands of COVID-19 tests typically sell for around $24 for two tests. If a family of four wanted to test before seeing an older relative and followed the recommended procedure of testing twice, they’d spend close to $100 ahead of that visit — something many can’t or won’t do.

The pool of money to reimburse providers who vaccinate uninsured people dried up this spring. For now, pharmacies and other providers still get the vaccines themselves for free, though they’re no longer paid for the staff time and incidental expenses of giving them to uninsured people.

But even that will come to an end in a few months. The U.S. Department of Health and Human Services ordered about 175 million doses of the new vaccines, which would cover about half of all Americans — likely enough for a fall campaign, since only about a third of Americans have gotten their third shot.

But next year, Americans will be on their own in paying for future shots, which may be offered annually.

Dawn O’Connell, assistant secretary for preparedness and response with the U.S. Department of Health and Human Services, said the idea was always to transition COVID-19 response to the private sector. But that’s going to have to happen faster than initially planned, because Congress hasn’t appropriated more funds, she said.

“Our goal is to transition procurement and distribution of COVID-19 vaccines and therapeutics from a federally managed system to the commercial marketplace in a thoughtful, well-coordinated manner that leaves no one behind,” she said in a blog post in late August.

The federal government is no longer buying and distributing the monoclonal antibody treatment bebtelovimab, which insurers will cover. Monoclonal antibodies, like antiviral treatments, are given to people with mild symptoms who are at a higher risk of severe disease.

If use continues as expected, the federal government will run out of Evusheld, an antibody product for people with compromised immune systems who don’t get protection from vaccines, in early 2023, O’Connell said. The stocks of the antivirals molnupiravir and Paxlovid will probably be depleted by the middle of the year, she said. The medications will remain available, but patients will have to pay for them with insurance or out-of-pocket.

Free shots are available for uninsured kids through the Vaccines for Children program, but help for adults is more limited. Health care providers may opt to offer free vaccination clinics for uninsured families, but if not, those people may have to pay the full price, leading to lower uptake of boosters in the future, Fox said.

“When there is any cost, even if it’s a fairly small copay, it can have a discouraging effect,” he said.

Buses and testing sites continue for now

While the federal government purchased vaccines and treatments, Colorado and other states were largely responsible for seeing they got to people who needed them.

At the height of the COVID-19 response, the state contracted to operate dozens of testing sites, offered drive-thru vaccinations in population centers, sent buses to bring testing and shots to rural communities and briefly even had mobile clinics to give antibody treatments to people at high risk of severe disease. As of Sept. 14, the buses and pop-up clinics in underserved areas had delivered more than 450,000 vaccine doses in all 64 counties.

In February, Gov. Jared Polis unveiled a “roadmap” to get the state out of the business of COVID-19 care. It called for all state-run testing centers to close and for the vaccine call center to shut down by Sept. 1.

The state did reduce its footprint over the summer, but not quite that drastically. It still operates 22 testing sites, the call center is available seven days a week and 10 mass-vaccination sites opened in September to offer boosters targeting the BA.4 and BA.5 variants of the virus.

Demand has fallen significantly. Vaccinations peaked at about 85,000 on one day in early April 2021, but now it’s unusual if more than 3,000 people get a shot on any given day. Testing also has dropped from a high of more than 60,000 on the busiest days of January 2022 to rarely topping 20,000 in a day (not counting home tests that aren’t reported to the state).

The state reports the 22 community testing sites can handle about 8,000 tests per day, and could scale up to 17,000 per day if needed. A spokesman for the state health department said those sites will stay open at least until the end of 2022, and perhaps longer if there’s high demand — assuming federal funding continues. The vaccine buses also will keep running through the end of the year.

The state’s school testing program also remains in place. As of late August, 28 schools were signed up for weekly rapid testing and five were in the process, according to the Colorado Department of Public Health and Environment.

For now, the Federal Emergency Management Agency still covers about 90% of the cost of public testing and vaccination sites, which makes it feasible for Colorado to continue offering them, Bookman said. There’s no sign that the federal emergency declaration will end in the immediate future, but there needs to be a plan to avoid disruption when it does and the state is no longer backstopping the system, he said.

“A lot of this normalization has already occurred,” he said.

Disparities likely to widen

Of course, even with unprecedented intervention to increase access to vaccines, testing and treatment, significant disparities remained. About 79% of Colorado residents who list their race as white have received at least one dose of a COVID-19 vaccine, compared to about 41% of those who identified themselves as Hispanic.

And in two counties on the Western Slope and seven on the Eastern Plains, less than half of the population has had even one shot.

It’s not just a Colorado problem. A study published by the Centers for Disease Control and Prevention found that even when care is free and widely available, it isn’t always enough to ensure equal access. While more sites offered oral antiviral drugs in areas with high poverty, those sites only dispensed about half as many prescriptions as in areas with the lowest poverty rates, as of May.

In the United States, care tends to go to those who are most motivated and able to navigate the system, rather than those who are necessarily in greatest need, said Dr. Preeti Malani, an infectious disease physician at the University of Michigan. It’s not just a question of insurance; a lack of reliable transportation, inflexible work schedules or even not seeing a doctor very often can be stumbling blocks to getting care, she said.

“The people that have really sought this out are not the most vulnerable medically,” she said.

Colorado performed better than many states in bringing vaccines to people who were less likely to get them, Malani said. Still, states couldn’t remove all of the barriers, meaning some level of disparity remained, and that will likely increase as the money for outreach goes away, she said.

“By making it harder, I think it’s certain the people on the fence will forgo it,” she said.

Even at the height of the COVID-19 response, there were gaps in testing in some parts of Colorado, which were partly filled by the mobile units. Unless more pharmacies and clinics sign up to offer tests, those counties won’t offer full access once those go away. As of August, 33 counties had no COVID-19 testing sites listed on the state’s website, though a health department spokesman said the state’s data wasn’t complete and that at least one of those counties offered testing at its local health department.

Treatment access appeared better, with only 13 counties showing no locations offering COVID-19 treatment. Most of those counties were clustered in the San Luis Valley and on the Western Slope, however, which could mean a longer drive for those who need care. About one-quarter of counties didn’t show access to Paxlovid — the most popular treatment, but one that’s not safe for people with certain health conditions — and at least one other option.

The state doesn’t track who is receiving COVID-19 treatment, but overall demand has been strong, said Dr. Eric France, the state’s chief medical officer. He advised people to check out the options in their area or for telehealth in advance, since the window to start taking antivirals once infected is narrow.

People in 34 counties didn’t appear to have access to Evusheld, an antibody product to offer protection to people who can’t produce their own antibodies or can’t be vaccinated for medical reasons.

All but five counties listed at least one vaccine provider. But some didn’t show vaccines were available for all age groups: 19 didn’t appear to have shots for children under 5; 18 didn’t list shots for the 5-to-11 age group; 28 didn’t show the omicron-specific shot for teens; 17 appeared to be missing the omicron shot for adults; and nine didn’t list the original shot formulation for people 12 and older. The omicron-specific shots aren’t authorized as first and second doses, because they contain less of the vaccine.

States, local public health agencies, employers and schools can all work together to try to make vaccinations as accessible as possible, Malani said. For example, some universities found that students were far more likely to get a flu shot when they set up a table outside the dining hall — while the students might not be motivated enough to seek out a shot, they were willing to take it when it came to them, she said.

“This is a time when we need to think creatively,” she said.

The health system has always had gaps in who gets treatment, but the pandemic taught hospitals about the need to work with each and with groups that their communities trust, said Price, the chief medical officer at Denver Health.

“Rather than thinking of it as a problem specific to COVID, I hope it forces us to take a more holistic look,” she said.

It’s unlikely that the existing health system will meet everyone’s needs for vaccines, testing and treatment, but it also isn’t feasible to maintain the current level of response permanently, Malani said.

“I worry that the disparities will grow, but I do understand the need at some point to wrap this into the regular health system,” she said.

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