Texas has one of the lowest coronavirus test rates in the US. Here’s how that happened.
Tarrant County public health director Vinny Taneja offered a reassuring coronavirus update to the county commissioners on Tuesday. He told them Texas had performed almost 190,000 tests, the fourth-highest amount of any state in the United States.
But Taneja left out some context. Texas, the second-most populous state in America, has one of the worst views of how coronavirus has affected its residents because of a lack of testing relative to its population of 29 million. Its testing struggles have existed since mid-March at the outset of the crisis and lasted through the early part of last week.
As of April 20, about 0.63% of Texas residents had been tested for coronavirus, according to the COVID Tracking Project. Only Kansas had tested a smaller proportion of its residents.
And Texas’ average daily testing rate for mid-April was about 7,800 tests per day, or 27 per 100,000 people. That was worse than all but eight other states.
From April 22-24, Texas recorded between 15,000 to 20,000 new coronavirus tests daily, its highest totals yet. Still, according to numbers crunched in a recent Harvard study shared with The New York Times, states should have a baseline testing rate of 152 tests per day per 100,000 people if they want to safely reopen.
That means Texas would need to do a minimum of about 45,000 tests a day.
As Texas mulls reopening businesses and loosening stay at home restrictions, testing has never been more important. The more testing, the better public health experts can detail which areas and communities are most at risk to COVID-19, said Catherine Troisi, infectious disease epidemiologist at UTHealth School of Public Health in Houston. They can best decide where to target increased testing efforts and ensure better contact tracing.
“Right now we do not have enough data because of a lack of testing,” Troisi said.
Almost every state needs to improve its testing capacity. California, the largest state in the U.S., had tested just 0.71% of its population as of April 20. (New York, the fourth-largest state, had tested 3.3% of its population.) But how did Texas get far behind, far enough to where Oklahoma, which a month ago lagged behind every state, had tested nearly twice as many residents per capita as Texas by April 20?
It’s about a lack of statewide cooperation, a strained supply chain and a slower strategy of partnering with private groups at the state level.
How Texas got here
In early March, it was difficult even for sick Texans to get tested, even with a doctor’s request. Health care workers in Tarrant County found out they couldn’t get tested despite having symptoms.
A Nueces County woman was denied testing five times before finally being administered a test and testing positive.
Because a change in FDA policy didn’t loosen restrictions on private labs until Feb. 29, local public health laboratories performed the bulk of tests in early March. And labs in Texas were slow to build capacity. Private testing, when it ramped up in the last half of March, became a saving grace for Texas.
Some 90% of tests in the state have been processed by private labs and hospitals, compared to about 66% nationally.
Many private sites have been offering free testing in Texas cities the last couple weeks. But last month, free testing was less available, and private tests could cost up to $2,400 for the 18% of Texans who lack health insurance, the largest share of any state. On April 16, Texas announced it requested funding from the federal government to cover testing for the uninsured.
Anne Dunkelberg, who studies health care for the Center for Public Priorities, said in March fears over the cost of testing would give uninsured Texans “a strong disincentive to getting early attention.”
Despite safety assurances by state and national leaders, undocumented immigrants were also deterred from seeking testing because of a fear that hospitals would request Social Security information and the lingering effects of a February order from the Trump Administration discouraging immigrants from obtaining public benefits.
Texas has the second-highest share of undocumented immigrants in the country.
Delay in private-public partnerships statewide
In other states, widespread free testing happened early from statewide private-public partnerships. New York ramped up testing, in part, because of a partnership between the state and BioReference Laboratories. The deal, announced March 13, led to the opening of a drive-through testing site and other sites capable of performing a cumulative 5,000 tests a day.
Texas was recording about 1,000 tests per day back then. Wisconsin announced a state partnership with a private company in late March that doubled its testing capacity at the time. Rhode Island made a deal with CVS for free testing on April 6 that also doubled its testing capacity. Some 40% of Rhode Island’s total testing has been done by CVS.
Texas counties and cities have regularly partnered with private companies, universities and hospitals on testing, but Gov. Greg Abbott did not make an announcement of a similar state testing partnership until April 15, when the state and Harris County partnered with Walgreens for two drive-through testing sites that could test up to 200 people for free per day.
Like many governors, Abbott negotiated with the federal government for 10,000 rapid testing kits from Abbott Laboratories in early April.
State leaders have been reluctant to answer questions about why Texas was slow to build up testing for its large population. A spokesman for Abbott did not respond to an interview request for this story, and neither did a spokesman for the Texas Department of State Health Services.
Rep. Chris Turner, a Grand Prairie Democrat, was on a conference call with Abbott and state legislators last week. He said he asked him why Texas had done less testing than other states, accounting for population.
“I didn’t really get a clear answer,” Turner said. “We consistently hear the number of tests will continue to increase and they’ll increase substantially. We’ve been hearing that now for over a month. While clearly the raw numbers have increased, proportionally we’re not increasing to where we are testing more Texans on a per capita basis. ... I think the state leadership needs to put a higher emphasis on this.”
The complicated coronavirus testing supply chain
Coordination between the state, local governments and the private sector has taken on added importance during the coronavirus crisis because of supply chain issues.
Most diagnostic coronavirus tests require reagents, swab sticks and a red liquid protein called media that keeps the virus alive in transport, and the demand for those materials greatly outpaced supply in March. Anyone who performs a test must be outfitted in a mask, gloves and protective suit, which have also been scarce.
Supply of testing materials is better than a month ago but remains low, especially for swab sticks and media, which are primarily manufactured in China and Italy.
Scott Becker, executive director of the Association of Public Health Laboratories, said, “We’re seeing minor improvements.” Chrissie Juliano, executive director of the Big Cities Health Coalition, said the federal government should be expanding and controlling the supply chain — in part by getting more American manufacturers to produce testing materials through the Defense Production Act — to alleviate burdens of states and local jurisdictions.
“The way you access supplies in an emergency is through the federal government. They have the purchasing power, the sway, and so on and so forth,” she said. “When you have a shortage such that we have, that is really the role of the federal government and where they need to respond.”
Absent the cogent planning and support at the federal level, competition has been fierce. States, local public health authorities, private companies and FEMA have been competing for the same materials, turning the process into what New York Gov. Andrew Cuomo described as a version of eBay.
The public and private entities that combine to increase their buying power have more success: Public health departments route orders through their states; states and counties pool with hospitals and universities; and hospitals combine with other hospitals and research laboratories.
Not getting to the front of the line
Among many competitors and with outbreaks of greater severity on the coasts, Texas has often found itself at the back of the line.
“At the beginning the federal government was talking with those labs and directing those reagents to states like New York, Washington and California,” said Tarrant County Judge B. Glen Whitley. “They were not allowing the Abbott (Laboratories) and those other lab companies to basically send the reagents here.”
The complications with getting to the front of the line have continued: Philip Huang, director of Dallas County Health and Human Services, said the county recently placed an order for testing materials to expand testing at community sites where the local government is partnering with UT Southwestern and Parkland Hospital.
“We’re having to go into a que,” he said. He doesn’t know when or if the order will go through. Asked whether the state had done enough to aid in obtaining testing materials, Huang said: “I think it’s a difficult situation for them to be in because there’s such a limited supply. They’ve been trying to advocate for us. But I think it’s just a difficult situation for everyone. Everyone everywhere is trying to clamor for the same things.”
Abbott’s opinion on the supply chain differs from those who believe that demand still outweighs availability. At a press conference Tuesday he said the state had “clear visibility” regarding the materials necessary to increase Texas’ testing capabilities. “According to information provided to me by the advisers in the White House,” Abbott said, “they believe Texas is going to have all the testing capability we will need.”
One county got way ahead of the state
Some entities in Texas have navigated the competitive testing supply market with greater success. And no area has figured out mass testing — and the mastery of the supply chain and public-private coordination it requires — better than Galveston County, population 342,000. As of April 21, 11,487 tests had been performed there. That was almost the same number as the city of Dallas, population 1.34 million, where 12,211 tests were reported as of April 22. (Huang said he did not know Dallas County’s testing totals and to check the city data.)
About 3.3% of Galveston County’s population has been tested. That’s more than five times the testing rate of Texas. Between April 16 and April 21, about one-eighth of all tests that were recorded in the state were performed in Galveston County.
In March, Galveston County was as far behind as the rest of Texas. Then, on April 9, it entered into a partnership for mass testing with the University of Texas Medical Branch at Galveston, which also runs The Galveston National Laboratory. In December and January, as news about the coronavirus seeped out of China, UTMB began to evaluate its pandemic stock of testing supplies. The day Wuhan was locked down, Jan. 23, UTMB began buying new materials.
The early start allowed it to create tests before thousands of other buyers had entered the market and to build relationships with manufacturers and the dealers that represent manufacturers. “We were a known entity,” said Chris Toomes, VP of supply chain services for UTMB. “From the (sellers’) perspective they’re looking at us like, ‘you’ll order and pay, and everybody else is getting in line.’”
With supplies low in China and Italy, UTMB recently found a German manufacturer to replenish testing materials. “The other part is being in the right place at the right time and having people out there beating the bushes every day looking for it,” Toomes said. “And when it comes available immediately being able to snatch it up.”
The future of Texas testing
A widespread testing program that can lead to the reopening of Texas or any state is going to require an unprecedented effort of communication and planning between state and local governments and private labs, hospitals and universities, according to Becker, executive director of the Association of Public Health Laboratories.
Communities will need supplies to conduct enough diagnostic testing and antibody testing, and local authorities will have to ensure private labs are sharing data and performing accurate tests. The state will have to decide where resources can be used most efficiently.
That may be difficult in Texas, where relationships are tense between urban areas and the state. After Abbott first discussed his plans to reopen, on April 17, U.S. Rep. Joaquin Castro, a San Antonio Democrat, said in a call with reporters:
“Governor Abbott, from the beginning, has followed a ‘see no evil hear no evil’ approach. He started by dumping responsibility of the pandemic on local leaders, even though he was eager to take away their authority to regulate bathrooms, plastic bags, and Uber rides. The response has been slow all around, and the delay has cost people their lives.
“Texas ranks, depending on the day, last or third-to-last in per capita testing, and that’s why I say it’s a ‘see no evil, hear no evil’ approach.”
Abbott has acknowledged Texas needs more testing. At a press conference April 17, he said that by late April or early May Texas would have “a massive amount of testing ability” coming. More capacity has already reached Tarrant County: Fort Worth and Arlington opened free testing sites on Friday as partnerships between the public health department and HSC Fort Worth and UT Southwestern.
Abbott also announced his Strikeforce to Open Texas, which includes a group of medical experts who are working on a comprehensive testing plan, and that the Texas National Guard would mobilize more than 1,200 personnel to help organize testing sites around the state.
Look to Galveston County as example
Abbott has said he wants the state to be at a level where entire communities could be tested, not just people showing symptoms.
A Texas that reaches that benchmark may look similar to Galveston County. The county opened a testing site in mid-April where anyone can get tested for free, regardless of symptoms, age or whether they’re a health care worker. (It was the second site to open in Texas that lets anyone get tested; Houston opened the first days earlier.)
The data from testing sites is quickly turned over to county health officials and made public. And a team of volunteers and TCMB medical students have helped fortify the health department’s contact tracing efforts.
“As best as anyone can tell,” Galveston health authority Philip Keiser told the Galveston Daily News, “we’re positioned as well as anybody in the country.”
This story was originally published April 26, 2020 at 8:00 AM.
