With around 20,000 people dying of covid in the United States since the start of October, and tens of thousands more abroad, the covid pandemic clearly isn’t over. However, the crisis response is, since the World Health Organization and the Biden administration ended their declared health emergencies last year.

Let’s not confuse the terms “pandemic” and “emergency.” As Abraar Karan, an infectious disease physician and researcher at Stanford University, said, “The pandemic is over until you are scrunched in bed, feeling terrible.”

Pandemics are defined by neither time nor severity, but rather by large numbers of ongoing infections worldwide. Emergencies are acute and declared to trigger an urgent response. Ending the official emergency shifted the responsibility for curbing covid from leaders to the public. In the United States, it meant, for example, that the government largely stopped covering the cost of covid tests and vaccines.

But the virus is still infecting people; indeed, it is surging right now.

With changes in the nature of the pandemic and the response, KFF Health News spoke with doctors and researchers about how to best handle covid, influenza, and other respiratory ailments spreading this season.

A holiday wave of sickness has ensued as expected. Covid infections have escalated nationwide in the past few weeks, with analyses of virus traces in wastewater suggesting infection rates as high as last year’s. More than 73,000 people died of covid in the U.S. in 2023, meaning the virus remains deadlier than car accidents and influenza. Still, compared with last year’s seasonal surge, this winter’s wave of covid hospitalizations has been lower and death rates less than half.

“We’re seeing outbreaks in homeless shelters and in nursing homes, but hospitals aren’t overwhelmed like they have been in the past,” said Salvador Sandoval, a doctor and health officer at the Merced County public health department in California. He attributes that welcome fact to vaccination, covid treatments like Paxlovid, and a degree of immunity from prior infections.

While a new coronavirus variant, JN.1, has spread around the world, the current vaccines and covid tests remain effective.

Other seasonal illnesses are surging, too, but rates are consistent with those of previous years. Between 9,400 and 28,000 people died from influenza from Oct. 1 to Jan. 6, estimates the Centers for Disease Control and Prevention, and millions felt so ill from the flu that they sought medical care. Cases of pneumonia — a serious condition marked by inflamed lungs that can be triggered by the flu, covid, or other infections — also predictably rose as winter set in. Researchers are now less concerned about flare-ups of pneumonia in China, Denmark, and France in November and December, because they fit cyclical patterns of the pneumonia-causing bacteria Mycoplasma pneumoniae rather than outbreaks of a dangerous new bug.

Public health researchers recommend following the CDC guidance on getting the latest covid and influenza vaccines to ward off hospitalization and death from the diseases and reduce chances of getting sick. A recent review of studies that included 614,000 people found that those who received two covid vaccines were also less likely to develop long covid; often involving fatigue, cognitive dysfunction, and joint pain, the condition is marked by the development or continuation of symptoms a few months after an infection and has been debilitating for millions of people. Another analysis found that people who had three doses of covid vaccines were much less likely to have long covid than those who were unvaccinated. (A caveat, however, is that those with three doses might have taken additional measures to avoid infections than those who chose to go without.)

It’s not too late for an influenza vaccine, either, said Helen Chu, a doctor and epidemiologist at the University of Washington in Seattle. Influenza continues to rise into the new year, especially in Southern states and California. Last season’s shot appeared to reduce adults’ risk of visits to the emergency room and urgent care by almost half and hospitalization by more than a third. Meanwhile, another seasonal illness with a fresh set of vaccines released last year, respiratory syncytial virus, appears to be waning this month.

Another powerful way to prevent covid, influenza, common colds, and other airborne infections is by wearing an N95 mask. Many researchers say they’ve returned to socializing without one but opt for the masks in crowded, indoor places when wearing one would not be particularly burdensome. Karan, for example, wears his favorite N95 masks on airplanes. And don’t forget good, old-fashioned hand-washing, which helps prevent infections as well.

If you do all that and still feel sick? Researchers say they reach for rapid covid tests. While they’ve never been perfect, they’re often quite helpful in guiding a person’s next steps.

When President Joe Biden declared the end of the public health emergency last year, many federally funded testing sites that sent samples to laboratories shut their doors. As a result, people now mainly turn to home covid tests that signal an infection within 15 minutes and cost around $6 to $8 each at many pharmacies. The trick is to use these tests correctly by taking more than one when there’s reason for concern. They miss early infections more often than tests processed in a lab, because higher levels of the coronavirus are required for detection — and the virus takes time to multiply in the body. For this reason, Karan considers other information. “If I ran into someone who turned out to be sick, and then I get symptoms a few days later,” he said, “the chance is high that I have whatever they had, even if a test is negative.”

A negative result with a rapid test might mean simply that an infection hasn’t progressed enough to be detected, that the test had expired, or that it was conducted wrong. To be sure the culprit behind symptoms like a sore throat isn’t covid, researchers suggest testing again in a day or two. It often takes about three days after symptoms start for a test to register as positive, said Karan, adding that such time estimates are based on averages and that individuals may deviate from the norm.

If a person feels healthy and wants to know their status because they were around someone with covid, Karan recommends testing two to four days after the exposure. To protect others during those uncertain days, the person can wear an N95 mask that blocks the spread of the virus. If tests remain negative five days after an exposure and the person still feels fine, Chu said, they’re unlikely to be infected — and, if they are, viral levels would be so low that they would be unlikely to pass the disease to others.

Positive tests, on the other hand, reliably flag an infection. In this case, people can ask a doctor whether they qualify for the antiviral drug Paxlovid. The pills work best when taken immediately after symptoms begin so that they slash levels of the virus before it damages the body. Some studies suggest the medicine reduces a person’s risk of long covid, too, but the evidence is mixed. Another note on tests: Don’t worry if they continue to turn out positive for longer than symptoms last; the virus may linger even if it’s no longer replicating. After roughly a week since a positive test or symptoms, studies suggest, a person is unlikely to pass the virus to others.

If covid is ruled out, Karan recommends tests for influenza because they can guide doctors on whether to prescribe an antiviral to fight it — or if instead it’s a bacterial infection, in which case antibiotics may be in order. (One new home test diagnoses covid and influenza at the same time.) Whereas antivirals and antibiotics target the source of the ailment, over-the-counter medications may soothe congestion, coughs, fevers, and other symptoms. That said, the FDA recently determined that a main ingredient in versions of Sudafed, NyQuil, and other decongestants, called phenylephrine, is ineffective.

Jobs complicate a personal approach to staying healthy. Emergency-era business closures have ended, and mandates on vaccination and wearing masks have receded across the country. Some managers take precautions to protect their staff. Chu, for example, keeps air-purifying devices around her lab, and she asks researchers to stay home when they feel sick and to test themselves for covid before returning to work after a trip.

However, occupational safety experts note that many employees face risks they cannot control because decisions on if and how to protect against outbreaks, such as through ventilation, testing, and masking, are left to employers. Notably, people with low-wage and part-time jobs — occupations disproportionately held by people of color — are often least able to control their workplace environments.

Jessica Martinez, co-executive director of the National Council for Occupational Safety and Health, said the lack of national occupational standards around airborne disease protection represents a fatal flaw in the Biden administration’s decision to relinquish its control of the pandemic.

“Every workplace needs to have a plan for reducing the threat of infectious disease,” she said. “If you only focus on the individual, you fail workers.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.

JACKSONVILLE, Ill. — Heather Crivilare was a month from her due date when she was rushed to an operating room for an emergency cesarean section.

The first-time mother, a high school teacher in rural Illinois, had developed high blood pressure, a sometimes life-threatening condition in pregnancy that prompted doctors to hospitalize her. Then Crivilare’s blood pressure spiked, and the baby’s heart rate dropped. “It was terrifying,” Crivilare said.

She gave birth to a healthy daughter. What followed, though, was another ordeal: thousands of dollars in medical debt that sent Crivilare and her husband scrambling for nearly a year to keep collectors at bay.

The Crivilares would eventually get on nine payment plans as they juggled close to $5,000 in bills.

“It really felt like a full-time job some days,” Crivilare recalled. “Getting the baby down to sleep and then getting on the phone. I’d set up one payment plan, and then a new bill would come that afternoon. And I’d have to set up another one.”

Crivilare’s pregnancy may have been more dramatic than most. But for millions of new parents, medical debt is now as much a hallmark of having children as long nights and dirty diapers.

About 12% of the 100 million U.S. adults with health care debt attribute at least some of it to pregnancy or childbirth, according to a KFF poll.

These people are more likely to report they’ve had to take on extra work, change their living situation, or make other sacrifices.

Overall, women between 18 and 35 who have had a baby in the past year and a half are twice as likely to have medical debt as women of the same age who haven’t given birth recently, other KFF research conducted for this project found.

“You feel bad for the patient because you know that they want the best for their pregnancy,” said Eilean Attwood, a Rhode Island OB-GYN who said she routinely sees pregnant women anxious about going into debt.

“So often, they may be coming to the office or the hospital with preexisting debt from school, from other financial pressures of starting adult life,” Attwood said. “They are having to make real choices, and what those real choices may entail can include the choice to not get certain services or medications or what may be needed for the care of themselves or their fetus.”

Best-Laid Plans

Crivilare and her husband, Andrew, also a teacher, anticipated some of the costs.

The young couple settled in Jacksonville, in part because the farming community less than two hours north of St. Louis was the kind of place two public school teachers could afford a house. They saved aggressively. They bought life insurance.

And before Crivilare got pregnant in 2021, they enrolled in the most robust health insurance plan they could, paying higher premiums to minimize their deductible and out-of-pocket costs.

Then, two months before their baby was due, Crivilare learned she had developed preeclampsia. Her pregnancy would no longer be routine. Crivilare was put on blood pressure medication, and doctors at the local hospital recommended bed rest at a larger medical center in Springfield, about 35 miles away.

“I remember thinking when they insisted that I ride an ambulance from Jacksonville to Springfield … ‘I’m never going to financially recover from this,’” she said. “‘But I want my baby to be OK.’”

For weeks, Crivilare remained in the hospital alone as covid protocols limited visitors. Meanwhile, doctors steadily upped her medications while monitoring the fetus. It was, she said, “the scariest month of my life.”

Fear turned to relief after her daughter, Rita, was born. The baby was small and had to spend nearly two weeks in the neonatal intensive care unit. But there were no complications. “We were incredibly lucky,” Crivilare said.

When she and Rita finally came home, a stack of medical bills awaited. One was already past due.

Crivilare rushed to set up payment plans with the hospitals in Jacksonville and Springfield, as well as the anesthesiologist, the surgeon, and the labs. Some providers demanded hundreds of dollars a month. Some settled for monthly payments of $20 or $25. Some pushed Crivilare to apply for new credit cards to pay the bills.

“It was a blur of just being on the phone constantly with all the different people collecting money,” she recalled. “That was a nightmare.”

Big Bills, Big Consequences

The Crivilares’ bills weren’t unusual. Parents with private health coverage now face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance, researchers at the University of Michigan found.

Out-of-pocket costs are even higher for families with a newborn who needs to stay in a neonatal ICU, averaging $5,000. And for 1 in 11 of these families, medical bills related to pregnancy and childbirth exceed $10,000, the researchers found.

“This forces very difficult trade-offs for families,” said Michelle Moniz, a University of Michigan OB-GYN who worked on the study. “Even though they have insurance, they still have these very high bills.”

Nationwide polls suggest millions of these families end up in debt, with sometimes devastating consequences.

About three-quarters of U.S. adults with debt related to pregnancy or childbirth have cut spending on food, clothing, or other essentials, KFF polling found.

About half have put off buying a home or delayed their own or their children’s education.

These burdens have spurred calls to limit what families must pay out-of-pocket for medical care related to pregnancy and childbirth.

In Massachusetts, state Sen. Cindy Friedman has proposed legislation to exempt all these bills from copays, deductibles, and other cost sharing. This would parallel federal rules that require health plans to cover recommended preventive services like annual physicals without cost sharing for patients. “We want … healthy children, and that starts with healthy mothers,” Friedman said. Massachusetts health insurers have warned the proposal will raise costs, but an independent state analysis estimated the bill would add only $1.24 to monthly insurance premiums.

Tough Lessons

For her part, Crivilare said she wishes new parents could catch their breath before paying down medical debt.

“No one is in the right frame of mind to deal with that when they have a new baby,” she said, noting that college graduates get such a break. “When I graduated with my college degree, it was like: ‘Hey, new adult, it’s going to take you six months to kind of figure out your life, so we’ll give you this six-month grace period before your student loans kick in and you can get a job.’”

Rita is now 2. The family scraped by on their payment plans, retiring the medical debt within a year, with help from Crivilare’s side job selling resources for teachers online.

But they are now back in debt, after Rita’s recurrent ear infections required surgery last year, leaving the family with thousands of dollars in new medical bills.

Crivilare said the stress has made her think twice about seeing a doctor, even for Rita. And, she added, she and her husband have decided their family is complete.

“It’s not for us to have another child,” she said. “I just hope that we can put some of these big bills behind us and give [Rita] the life that we want to give her.”

About This Project

“Diagnosis: Debt” is a reporting partnership between KFF Health News and NPR exploring the scale, impact, and causes of medical debt in America.

The series draws on original polling by KFF, court records, federal data on hospital finances, contracts obtained through public records requests, data on international health systems, and a yearlong investigation into the financial assistance and collection policies of more than 500 hospitals across the country. 

Additional research was conducted by the Urban Institute, which analyzed credit bureau and other demographic data on poverty, race, and health status for KFF Health News to explore where medical debt is concentrated in the U.S. and what factors are associated with high debt levels.

The JPMorgan Chase Institute analyzed records from a sampling of Chase credit card holders to look at how customers’ balances may be affected by major medical expenses. And the CED Project, a Denver nonprofit, worked with KFF Health News on a survey of its clients to explore links between medical debt and housing instability. 

KFF Health News journalists worked with KFF public opinion researchers to design and analyze the “KFF Health Care Debt Survey.” The survey was conducted Feb. 25 through March 20, 2022, online and via telephone, in English and Spanish, among a nationally representative sample of 2,375 U.S. adults, including 1,292 adults with current health care debt and 382 adults who had health care debt in the past five years. The margin of sampling error is plus or minus 3 percentage points for the full sample and 3 percentage points for those with current debt. For results based on subgroups, the margin of sampling error may be higher.

Reporters from KFF Health News and NPR also conducted hundreds of interviews with patients across the country; spoke with physicians, health industry leaders, consumer advocates, debt lawyers, and researchers; and reviewed scores of studies and surveys about medical debt.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.