Put to the Test: Can the U.S. Get to the Next Phase of the COVID-19 Response?

By now, it’s well known that there have been multiple challenges to and failures in rolling out testing for coronavirus in the United States, including:

• an early, faulty test from the Centers for Disease Control and Prevention
• restrictive and changing guidelines for testing
• a delay in prioritizing testing by the federal government
• concerns about the cost of testing; and
• an ongoing shortage of testing kits, materials, reagents, and personal protective equipment (PPE) for health care workers performing the tests

As a result, the U.S. missed a critical early window to test, contact trace, isolate, and contain the outbreak early on, leaving social distancing measures as the main tool to interrupt the spread of the virus, including stay-at-home orders, closures of non-essential businesses and schools, and bans on large gatherings throughout much of the country.

Moving from the current social distancing phase to the next phase, as described in a recent expert report, the National coronavirus response: A road map to reopening, when these measures can be relaxed – will be a major challenge without being able to test on a large enough scale to identify most cases of the disease. Case numbers are rapidly rising in many areas of the country, and testing has not yet been able to catch up.

Even as testing has been ramping up in the U.S., the per capita testing rate still lags behind South Korea, a country hailed for its success in rolling out early, widespread testing, which has proven essential to the country’s ability to curb infections (as of March 30, South Korea’s testing rate, per 1 million population, was 2.7 times that of the U.S.). Further, in the U.S. testing levels vary significantly by geography and in some states with quickly escalating outbreaks (such as Florida, Texas, and Michigan) per capita rates still fall below the national average.

Some of the barriers have been lessened or removed altogether.  For example, concerns that the real or perceived cost of testing would prevent individuals, particularly those who were sick, from seeking testing would not only prevent them from getting help but put others at risk led some states to address this barrier where they could. More recently, the enactment of the Families First Coronavirus Response Act on March 18, 2020 provided sweeping coverage protections for testing, essentially making it free by requiring Medicare, Medicaid, all group health plans, and individual health insurance policies to cover testing and associated visits related to the diagnosis of COVID-19 without cost. It also gave states the option to provide Medicaid coverage of testing for uninsured residents, with 100% federal financing, an especially important option in the 14 states that have not expanded their Medicaid programs. Some of these provisions were just strengthened under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law on March 27.

There is also a promise of new testing kits and technologies which can help expand access to testing and aid in surveillance, including a just authorized rapid test that will soon be able to be used in most health care settings, an increasing number of drive through and clinic-based testing locations, and the possibility of at-home testing (although none is yet authorized by the FDA which has issued warnings about unauthorized use).

Still, shortages of testing kits and materials and PPE have meant that testing in most places in the U.S. remains focused on high-risk groups – those with severe symptoms, and health care workers. Despite the need to be able to test those with mild symptoms and their contacts in order to properly perform contact tracing and containment efforts, it is almost impossible to put that into practice without overcoming the existing limitations on testing. Without more widespread testing, surveillance, and contact tracing, we also will not know the extent of the outbreak or how it may be spreading or contracting (since we are largely only testing people who are severely ill).

As recommended in the new expert report, one of the key triggers needed to be able to relax social distancing measures is a sustained reduction in cases for at least 14 days. There is no state in the U.S. that has a sustained reduction yet, and we frankly couldn’t even tell right now if that were happening with so many people not able to access testing. We are, it seems, still very far from the next phase and we can’t get there until testing catches up to the disease.