If there’s a silver lining to the dire COVID-19 pandemic, it’s that the rate of Americans without health insurance has dropped to near historic lows in response to various federal initiatives related to the government’s declared public health emergency.

Now, as the acute phase of the pandemic appears to be coming to an end, millions of low- and middle-income Americans are at risk of losing health insurance. The U.S. could see one of the fastest increases in the country’s uninsured rate in years.

When the federal COVID-19 public health emergency ends — currently scheduled to end on April 15, although it may be extended — so will many of its associated insurance protections. That includes a rule that bars states from kicking anyone out of Medicaid as COVID-19 rages, while a 6.2 percent increase in federal Medicaid funding to ensure coverage for these most vulnerable patients.

Before the pandemic, states would periodically review people’s eligibility for Medicaid benefits and remove those who were no longer eligible. But with the practice on hold, Medicaid enrollments have grown by more than 12 million since the pandemic began; as many as one in four Americans are now enrolled in the program.

When the public health emergency expires and additional federal funding evaporates, states will be required to review enrollees’ continued eligibility again. Millions of people could be eliminated in the process, with an estimated 15 million over time. This includes people whose incomes have increased, who have moved to another state, or who simply haven’t returned complex paperwork to prove they continue to be eligible. Even under normal circumstances, the process is Byzantine, done by mail in many states, and especially unreliable considering how many people have relocated during the pandemic.

Many of the millions who have lost Medicaid coverage, either because they are no longer eligible or because they were dropped from the state’s roster, sometimes by mistake, may only seek medical care next time Only when they find out they are uninsured, such as when they go to a clinic or go to a pharmacy to refill their prescription.

In a country where an inhaler can cost $50 to $100, a doctor’s visit often costs more than $100, while hospitalization for COVID-19 can cost tens of thousands of dollars.

On top of that, enhanced subsidies for government purchases of Affordable Care Act health plans—the provisions of the U.S. Relief Program Act that make coverage more affordable for low- and even some middle-income people—will expire at the end of the year. For example, premiums for a “Silver” health plan that typically cost an average of $560 a month are reduced to just $390, and the government provides additional support for those earning $55,000 a year, resulting in savings of more than $2,000 a year.

When these enhanced subsidies expire, many low-income Americans could face the prospect of double paying for Medicare.

The “Build Back Better” legislation passed by the House in November would expand more generous subsidies for purchases of ACA health plans. But the bill was declared “dead” this year by Democratic Senator Joe Manchin of West Virginia, who declined to support it. Now, Democratic leaders want to negotiate a stripped-down version of the bill, but it’s unclear whether the bill will materialize through its provisions.

Now is a dangerous time to throw low- and middle-income Americans off the insurance cliff: A new omicron sub-variant is spreading, and a program to provide the uninsured with free coronavirus testing and COVID treatment expires in March, Because the government ran out of money to support it. Another program to provide free vaccinations to patients ends this month.

It is likely that the public health emergency phase of the pandemic is coming to an end. The average daily death toll is currently around 700 and is declining. Schools and offices are reopening, some without masks. But about one-third of Americans remain unvaccinated. And, going forward, will newly insured low- and middle-income Americans tend to pay for vaccines out of their own pockets? If they contract COVID, how will they pay for the treatment when the government buys Pfizer’s Paxlovid treatment for $530 a course and consumers can pay more in the free market?

Patients prone to losing health insurance may not be prepared for this change. There is little mainstream publicity about the impending changes, and many may not read government announcements or understand the ins and outs of pandemic health policy.

If people lose Medicaid this year, they will have the opportunity to enroll in the ACA health plan; the current increase in the subsidy means they may pay little or no premiums until the end of the year – when coverage may become unaffordable and they will fall back on coverage cliff.

Preserving insurance benefits for low- and moderate-income people is a major opportunity for us during a two-year nationwide catastrophe. It shouldn’t be wasted. After all, COVID is just one of many diseases that disproportionately affect the poor without insurance. A KFF poll in March found that Americans are more worried about “unexpected medical bills” than being able to afford food.

The administration has pledged to give 60 days’ notice before the end of the public health emergency, when states will have to cut their Medicaid programs. The enhanced ACA subsidy will not end until December 31st. There is still time to find funding and take action. As the risk of contracting a severe COVID case decreases, the risk of being uninsured should not increase.

KHN (Kaiser Health News) is a national newsroom that provides in-depth news coverage on health issues.Along with policy analysis and polling, KHN is one of the top three operating programs in the U.S. KFC (Kaiser Family Foundation). KFF is a donating non-profit organization that provides information to the state on health issues.