This brief on COVID-19 testing is designed to support philanthropic discussion and aid in the coordination of the sector’s response. Philanthropy California offers a series of policy issues for consideration and action.
Testing is a critical component in tracking and combating the COVID-19 pandemic. Individuals are asymptomatic for up to 2 weeks post-exposure, which influences their judgement on where and how to interact socially. Many have unwittingly put others at risk through social interaction or through community contact (e.g. spreading the virus to door handles, grab bars, etc.) before detection. Early and reliable testing could track COVID-19 and identify hidden hot spots.
Disagreements about the efficacy of early testing kits resulted in a month-long delay in deployment. Experts suggest the delay impacted the government’s ability to get ahead of the surge of infections. Testing kits are still in short supply and only high-priority populations have access to them. In early March, federal and state officials announced lockdowns, social disruption, and intensive medical treatment as means to contain the spread of COVID-19. In early April, Governor Newsom announced his desire to expand testing five-fold. As of this writing, 126,700 Californians have been tested for COVID-19; 13,000 are awaiting results. The state currently has 15,238 confirmed cases and 351 deaths. The peak of infections is expected within four weeks.
What are the types of tests?
Publicly developed/endorsed tests: The World Health Organization developed and deployed a test. Some early testing kits endorsed by the CDC had inconclusive results, which led to temporarily halting their use, but they were then redeployed with precautions. It took up to 13 days to receive results. New testing kits now in the field are processed through public health, clinical, or commercial labs.
Privately developed tests: U.S.-based biotech companies are developing, producing, and releasing innovative tests. One company is leveraging their at-home allergy testing products to provide at-home COVID-19 testing kits. The kit will be sold online, and should produce test results within 3-5 days. Another company created a test that can provide results in minutes. Although private companies received “emergency use authorization” from FDA they have been slow to scale up production.
Who can get tested?
The delay in the onset of symptoms complicates containment of the virus. If people are showing advanced symptoms, such as bluish lips or trouble breathing, they should seek immediate medical attention, wearing protective gear to limit exposure to others (e.g. masks and gloves). In California, the guidance has been as follows-- patients must have COVID-19 symptoms AND meet one of the following conditions: recent exposure to someone known to carry COVID-19; recent international travel or exposure to high-risk areas (e.g. New York City); are immunocompromised; or, are over the age of 60. Access is slowly expanding to include people working in high-risk environments (e.g first responders, healthcare workers). People who test positive, and are likely to recover, will be asked to self-quarantine at home. Complex cases will be treated at a local healthcare facility. Patients who test positive using at-home testing will receive a tele-visit from a medical provider with instructions to self-quarantine at home unless their condition worsens, then they must seek immediate care.
Where are tests administered?
Within healthcare settings: This form of testing is reserved for symptomatic, hospitalized patients. Healthcare providers are proactively urging people not to come in if they are symptomatic. They are encouraged to contact their providers virtually to assess their risk and receive testing instructions.
Standalone staging settings: A number of healthcare providers across the country are staging tents near their facilities to decrease the risk of infection for others. Access to testing is usually determined by early symptoms (e.g. fever). Most individuals are screened before receiving access to tests. If they are considered low-risk for advanced symptoms, they are asked to self-quarantine at home.
Drive-up testing: Individuals showing possible symptoms of infection are able to stay in their car while they are screened and, if they meet criteria, are tested and asked to quarantine at home.
At-home testing: Private companies are developing and deploying at-home testing kits that allow individuals to self-administer tests, mail in their samples and receive results online. These tests are growing in popularity, but some companies have had issues scaling production to meet demand.
Who pays for testing?
In early March, Governor Newsom and Commissioner Lara asked insurance companies to waive cost-sharing and surprise billing related to COVID-19 testing. They worked with commercial plans to:
- Immediately eliminate cost-sharing (e.g. co-pays, deductibles), for medically necessary screening and testing for COVID-19 and associated healthcare visits for COVID-19 screening and/or testing
- Educate providers and the public that cost-sharing is waived for medically necessary COVID-19 screening and testing, and for the associated healthcare visits for such screening or testing
- Remind plans that California law requires emergency care without prior authorization, whether it is at an in-network or out-of-network hospital
- Protect policyholders from unlawful “balance bills” from providers related to COVID-19 testing
- Ensure adequate provider networks can handle an increase in health care services
- Cover tests if they were ordered by a clinician, and administered on or after February 4, 2020.
The agreement is valid with commercial plans, which exclude undocumented immigrants. However, in California, all uninsured people will receive presumptive eligibility for Medicaid, which covers the costs of testing and care. According to this NILC brief, “U.S. Citizenship and Immigration Services issued an alert clarifying that it will not consider testing, treatment, or preventive care related to COVID-19 in a ‘public charge’ admissibility assessment,” even if the services are provided by Medicaid. While the federal guidance addresses free testing, states may have to cover treatment costs.
What are some policy issues related to COVID-19 testing?
- Overcoming Public Charge Fears. Undocumented immigrants will have coverage under California’s testing plans, but the fear of public charge can act as a barrier to accessing COVID-19 related tests and care. It is important understand which services can be safely accessed by this population, and to work with trusted non-profit organizations to raise awareness that these services should not count toward admissibility assessments. However, there is always a risk that these rules could be misapplied, especially since guidance parameters change frequently. Some people may simply fall through the cracks. Also, as with the reversal of protections for DACA recipients, there are fears that federal agencies could use tracking information to punish undocumented immigrant communities. Legal aid for non-profit organizations that serve these populations may be needed in the near future.
- Expand testing criteria to include other high-risk populations, such first responders, frontline hospital workers, and frontline essential workers (e.g. grocery stores, Rx, etc.). Community-based surveillance testing could facilitate a better understanding of COVID-19 spread.
- Protect frontline hospital workers. In preparation for the peak of infections, California healthcare providers anticipate needing additional personal protective equipment, including gloves, masks, and shields . New equipment stockpiles are slowly being filled; however, it is unclear how resources will be channeled to settings that need them most. Rapid tests, when available should also become the standard of care. Other essential workers, such as grocery workers and caregivers, also need access to protective equipment in the short-term.
- Leverage data and analytics. Centralize processing labs, and the tracking and reporting of test results. Data files should be made available to public health researchers to better understand the spread of infection and to inform the channeling of resources in communities across California. Additionally, the inclusion of race/ethnicity in future reporting will be essential to understanding key health disparities that may have been amplified through response efforts.
This assessment and others to follow provide actionable content to inform your grantmaking. Please let us know which issues matters to you. We must align our efforts to address this pandemic and its aftermath.
Crispin Delgado, is a consultant for NCG's policy work. He has over 15 years' experience in health policy and philanthropy. Crispin lives in the East Bay where he is supported by his loving Latino family who still live nearby.