🎙️ Voice is AI-generated. Inconsistencies may occur.
The country is beginning to reopen even as most states have not met public health officials' metrics for doing so safely. In that risky situation, the best, most feasible way to protect the most vulnerable and to limit community spread of the coronavirus is universal testing of workers and patients in nursing homes.
Federal officials recently signaled that such testing could be on the horizon. In a report shared with Congress, the Department of Health and Human Services recommended nursing home testing as part of a comprehensive national coronavirus testing program.
The report wisely recommends providing federal guidance and letting states take responsibility for implementing testing. However, a critical question remains: Where will the money come from to pay for this badly needed testing? Right now, states are set to receive $11 billion for testing through the federal Paycheck Protection Act. Yet that amount is likely only 10 percent of what testing and provision of personal protective equipment (PPE) will cost states each year.
The new report rightly identifies several high-risk locales that need special attention, including living facilities for the elderly. Of these, the highest-risk locations are nursing homes, which are the epicenter of the pandemic. Less than 1 percent of the population resides there, yet they produce 15 percent to 25 percent of all COVID-19 cases nationally. And in states that keep the best data on the pandemic, it's clear that nursing homes account for at least half of all deaths from COVID-19.
Nursing homes became hotbeds of COVID-19 in part because of the critical role they play in our health care system. After common hospital procedures like hip fracture repair and heart surgery, some patients are discharged to nursing homes for several days to several weeks.
Early in the pandemic, many COVID-19 patients were discharged from hospitals to nursing homes for post-hospital rehabilitation. In retrospect, it's obvious that this was a deadly mistake, and one that helped nursing homes become wells of infection.
Even now, short-stay patients recuperating from a hospital visit are often just down the hall from long-term patients, such as those with dementia, heightening the risk of viral spread. Patients arriving from the hospital can bring the virus into nursing homes, and they can take it back out into the community when they are discharged home.
Nursing home workers pose another set of risks. They are at risk of occupational exposure to the virus at work, especially when they lack the needed PPE. They also provide a transmission route that helps the virus to spread. They can bring the virus into the nursing home from the community and vice versa.
By testing all nursing home workers and residents, even those who are not showing symptoms, we would shut down one of the virus' most active and deadly transmission paths while we wait for an effective vaccine.
Focusing testing in nursing homes will protect the most vulnerable elderly members of society. It will help the workers who care for the elderly well despite low wages, lack of paid sick leave and not enough personal protective equipment.
Regular testing in nursing homes will also benefit the rest of us, even if we never go near such a place, because testing can help to disrupt spread into the community. Such testing will certainly slow the virus' spread. It might even bring the pandemic under control while we await a vaccine or effective treatment.
Such testing will be expensive. A recent estimate showed that testing every nursing home patient and worker once, at a cost of $150 per test, would cost $440 million nationally. The new federal guidelines require that workers be tested weekly. All patients would tested initially, with repeated tests any time one patient or one worker in their nursing home tests positive. The cost of this level of testing in nursing homes alone—excluding assisted living and other types of long-term care facilities—is at least $25 billion per year, nationally. In New York, the cost for one year's testing would be $1.7 billion, while in my home state of North Carolina it would be $600 million.
As we roll out testing in the states, we should also collect evidence about what works, by addressing many important questions. For example, what type of test works best, under what conditions? How often is testing needed, and how does that vary by setting and risk level? What is the relative importance of testing as compared to better PPE? How should the results be shared? How long must sick workers remain away from the job before they can safely return? Can testing allow family members to be reunited with their loved ones who live in nursing homes and are now cut off from visits? And how should patients who test positive for the virus be provided with the post-hospital rehabilitation that they need—without risking the health of others?
While these questions must be addressed, the good news is that they are all answerable. Extreme social distancing measures require convincing millions of people to change their habits, which requires patience that already shows signs of waning. By contrast, a testing effort focused on nursing homes seems eminently doable.
We can test our way out of this mess with focus and action, and by allowing flexibility to devise programs that work for local communities. In doing so, we can protect all of us, including the most vulnerable members of society.
To do testing effectively, though, states will need far more money than the amount the federal government has provided so far—billions more. The societal and economic costs of our "new normal" are enormous. Weighed against those costs, targeted spending focused on nursing home testing may be the wisest investment we'll ever make.
Don Taylor is a professor of public policy in Duke University's Sanford School of Public Policy, a founding faculty member of the Duke-Margolis Center for Health Policy and director of Duke's Social Science Research Institute.
The views expressed in this article are the author's own.
