This is my last newsletter of 2021, thank you all for taking the time to open these emails! I’m taking the next two weeks to read and write—see you in 2022 with fresh content. (And, as always, let me know if there’s something you think I should be covering.)
When I originally started this newsletter, I wrote a lot about the logistics of vaccine production and distribution. It was interesting to me because I find joy in learning about logistics and transportation (don’t @ me, you’re reading this newsletter).
What isn’t particularly interesting is all the complicated details of FDA approval—which is why I haven’t written about COVID testing yet. But then, early last week, I came down with a fever and waited more than 90 minutes to get a PCR test in Brooklyn. Two years into the pandemic and it’s taking more than an hour to get a test? Something’s askew.
Why is PCR testing so messed up?
PCR testing is recognized as the “gold standard” of COVID tests, a more accurate option that requires more time and manpower than a rapid test to perform. PCR tests have been around more or less since the beginning of the pandemic (although achieving widespread testing took too long, thanks to some early errors by the CDC). Now, PCR tests are widely available, at drugstore locations, drive-through sites, and pop-up tents.
Despite this availability, there are still a few problems. As Dhruv Vasishtha pointed out on Twitter, many health systems have deprioritized their testing programs, urgent cares have monetized as much as possible, and only local clinics are regularly prioritizing both testing programs and offering tests for free.
The monetization strategies of certain providers have done real harm to the U.S.’s testing strategy. The Families First Coronavirus Response Act, passed in 2020, required COVID testing be free to the patient. But some providers have found ways to charge anyway, making testing far more expensive than it needs to be, and making it more difficult to find a truly free test.
Some providers, like Lenox Hill Hospital, as reported by the New York Times, bill for a moderately complex emergency room visit as part of the test experience. This rate (which implies care that the patients didn’t receive) can add up to more than $3,000, all for a simple COVID test.
This has happened and continues to happen across the country.
With pricing in flux and the occasional surprise bill getting through to the patient, not to mention variable wait times before getting results, it’s not shocking that the public hasn't figured out a way to rely on PCR tests. That’s why rapid testing could be such an important part of the testing system.
What about rapid testing?
Rapid testing is less accurate than PCR but faster. The diminished accuracy of rapid tests might even be a benefit; as Michael Mina, an advocate for greater usage of rapid testing, has argued, rapid testing catches infectiousness (rather than any infection at all), which is really what people need to know before congregating.
But finding rapid tests is difficult in times of limited spread and impossible during outbreaks. The FDA has only provided an emergency use authorization (EUA) to a few companies for their tests, limiting the number on the market.
(Dr. Tim Stenzel, the Director of the Office of In Vitro Diagnostics and Radiological Health at the FDA—the office that authorizes COVID tests—previously worked for both Abbott and Quidel, the two companies with the most EUAs for their tests. Quidel only got into testing, per a video found by ProPublica, after receiving a call from a government insider, later confirmed to be Stenzel. ProPublica found no financial reason for Stenzel to favor Abbott and Quidel, but it’s still a bad look. My former organization put out a letter asking HHS to investigate Stenzel, but no word on whether HHS will follow through. You can read more from my former colleague Matt Stoller in his newsletter.)
Abbott’s Binax test comprises approximately 75% of the tests sold on the market, which means it’s vulnerable to any supply shocks. And rather than wait for supply shocks to happen, Abbott has caused them itself. Over the summer, as the country focused on vaccination and it seemed less likely that tests would be needed, Abbott slowed production of Binax tests, destroyed inventory, and laid off thousands of employees. (In a statement back in August, Abbott said the destruction was part of its regular inventory management practices.)
All of this has left the U.S. with a patchwork of testing options that cost a variable amount and which fail to add up to a coherent strategy. The White House has started to take some steps to fill in the gaps, but it’s unclear (and unlikely, in my opinion) how and if it will make a difference.
In early December, the Biden administration announced a pathway for people to submit receipts to their insurer for reimbursement (but given how much people hate submitting receipts, this is perhaps the most roundabout, indirect way to expand access to tests).
In recent days, as the omicron variant spreads, the White House announced a commitment to purchasing 500 million tests and shipping them to people that want them. President Biden also spoke about the ongoing use of the Defense Production Act to maximize the production of tests, although it’s unclear the timeframe over which that will happen. Finally, HHS said that FDA would streamline its approval process for more types of tests—although it’s a little too late for that, given that we’re two years into the pandemic.
The pandemic is a black comedy highlighting all the ways our system is absurd. When I developed symptoms last week, I spent two days double-masked, cycling through the drugstores nearest to my apartment. Unfortunately, my symptoms happened at the exact moment that everyone else in Brooklyn got COVID, and the stores were all totally sold out.
So I bundled up and waited in line for a PCR test, from a reliable pop-up that previously returned results in just a day. This time, with all of New York waiting for their results, it took more than three days.
In the meantime, of course, I lost my sense of taste and smell. So when I received my result, I was surprised to see that it was negative (which…happens an unknown percentage of the time). This is where a rapid test, to confirm or contradict the results, would have come in handy. Instead, my partner and I will be spending the holidays isolated with our puppy. Here’s to 2022; maybe next year I can focus my interest in logistics on something more fun.
This information shouldn’t be taken as investment advice (obviously), and the opinions expressed are entirely my own, not representative of my employer or anyone else.