Health Care

9 ways Covid changed state health, safety net policy

Nebraska State Sen. Lynne Walz of Fremont, left, backs a bill allowing pharmacists to administer vaccines (AP Photo/Nati Harnik)

States are still adjusting three years after the pandemic forced policymakers to rapidly rethink the country’s public health and safety net system.

The expiration of the federal Covid-19 public health emergency in May meant an end to most of the waivers and flexibilities — and the federal funding — that allowed states to take extraordinary measures to protect their citizens’ health and financial security. 

But that has not meant a return to normal. States prepared for the shift by passing laws in the 2023 session that made some Covid-emergency measures permanent. 

Provisions, such as those expanding health care providers’ ability to care for patients remotely, have proven popular across the political spectrum. Others, such as safety net expansions on the left or permanent mask mandate restrictions on the right, have been more partisan. 

Some states have also been able to use budget surpluses from Covid-era federal aid to finance permanent programs that started as temporary responses to the pandemic.

But while many post-Covid changes have been dramatic, they have not amounted to the wholescale overhaul that many predicted in spring 2020. State public health departments are still overworked and understaffed, maybe even more so as they disenroll tens of millions of people from their Medicaid programs after the expiration of Covid-era flexibilities. The racial and socioeconomic gaps laid bare by disparities in Covid infection rates persist. Rural hospitals continue to close at alarming rates. 

That is partly because state health departments — the agencies that would respond most to a pandemic — rely on federal spending that has not allowed much room for change, said Jill Birnbaum, senior vice president of field advocacy operations for the National Center of the American Heart Association. “A lot of what we see in terms of change or not change, you know, can be very locked in,” Birnbaum said.

Here are nine long-term state policy changes that came out of the Covid-19 pandemic. 


Telehealth was on the rise before the pandemic, but a surge in demand in 2020 prompted numerous changes in the patchwork of confusing state and federal regulations that had hampered its growth. “It took a pandemic to show us how this could actually work,” New Hampshire Sen. Sue Prentiss (D) said in May after her chamber unanimously passed a bill permanently extending a Covid-era rule allowing opioid prescriptions via telehealth “We are shifting the paradigm.” 

That bill, signed by Gov. Chris Sununu (R), was one of hundreds in the past three years that sought to extend temporary measures enacted during the early months of the pandemic and revise out-of-date regulations. 

Medicaid unwinding

The national uninsured rate reached an all-time low of 7.7% in early 2023, due in part to federal prohibitions on state Medicaid disenrollments during the pandemic that ended in May. By August, states had shed 3,991,000 Medicaid recipients, with available state data showing that 75% were dropped for “procedural reasons” such as incomplete renewal documentation. 

California and Rhode Island responded with new programs designed to automatically enroll Medicaid recipients losing coverage into state-based marketplace plans. Massachusetts, Nevada and Pennsylvania introduced plans to ease transitions to state-based plans. But the long-term repercussions are still unclear.  

Postpartum Medicaid extension

At least eight states decided in 2023 to seek federal approval to extend postpartum Medicaid coverage to 12 months, leaving only a handful of states that have not taken advantage of Covid-era incentives made permanent by the consolidated Appropriations Act of 2023. 

The option has proven popular in red and blue states as they grapple with high maternal mortality rates and seek to care for expected increases in birth rates after the overturning of Roe v. Wade. 

School meals

Federal emergency funding for universal free school meals fed millions of children during the pandemic. That was the boost many states needed to adopt their own programs after the federal money dried up last year. States that have come on board include California, Colorado, Connecticut, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Mexico and Vermont. 

A bill that passed the Illinois legislature is awaiting Gov. J.B. Pritzker’s (D) signature. At least 20 other states are working on programs for the 2023-24 school year and beyond. That includes Pennsylvania, where Gov. Josh Shapiro (D) signed a bill last week creating a universal free school breakfast program that he had prioritized in his state budget.

“Students can’t learn on an empty stomach,” he said at the bill signing. 

SNAP online

All 50 states now allow the Supplemental Nutrition Assistance Program, also known as food stamps, to be used for online groceries. That’s up from just a handful before the pandemic, and the nationwide increase in online grocery shopping it inspired.

“A lot of people don’t have transportation to be able to get to places,” said Cindy Huddleston, an attorney with the Florida Policy Institute. “So if you could have it delivered, especially if you’re low income and you don’t have a car and you’re not really close to public transportation, that is really important.”

Vaccination, medicine access

Millions of people got their Covid vaccinations and flu shots at pharmacies and grocery stores during the pandemic, thanks to a federal emergency measure that expired in May. But the habit can continue in more than a dozen states that have enacted laws to make it easier for pharmacists to prescribe and administer vaccines.

Proponents say people are more likely to get routine shots if they do not have to go to the doctor’s office.

“It’s important that Nebraskans that live in rural areas of our state have equal access to immunizations,” Nebraska Sen. Lynne Walz (D) said in February. “Oftentimes pharmacies are the only health care facility in a community, making this even more important.”

Data collection, protection

The pandemic highlighted issues around the collection, storage, sharing and safekeeping of public health data, and a number of states have made changes to their data collection laws, according to the Association of State and Territorial Health Officials. 

Examples include New York, which clarified protections for identifiable information held in the state’s immunization information system, and Washington State, where the My Health, My Data Act provided comprehensive protections for consumer health data. Some states also introduced legislation to improve the collection of race and ethnicity data.

Bills that ASTHO is tracking include a New York measure that established a health care disparities data collection system. California introduced a measure to improve disaggregated information by requiring state agencies to update their data collection to reflect Hispanic and Indigenous subpopulations. Missouri introduced a measure that would establish a standard for disaggregated data collection by public health entities.

Mandate prohibitions

Backlash against Covid precautions inspired new laws in some Republican-controlled states. 

Florida Gov. Ron DeSantis (R), whose national profile was built on his commitment to keeping the state’s businesses open during the pandemic, signed a package of laws in May that permanently prohibited mask and vaccine mandates and vaccine passports; asserted patients’ rights to choose “alternative” Covid treatments in a hospital; and gave health care practitioners the right to opt out of participation in or payment for health care services “on the basis of conscience-based objections.” 

DeSantis called the move a strike against “medical authoritarianism.” 

Health equity

The pandemic amplified health inequities in historically marginalized rural and urban communities. Some states responded by applying for federal waivers that allow them to use Medicaid money to address health-related social needs, such as housing supports, case management and nutritional assistance, according to the ASTHO. States that received waivers in 2022 included Arizona, Arkansas, Massachusetts, and Oregon.