Promoting Health Equity Through State Orders for COVID-19 Testing

July 22, 2020 | Andy Baker-White

In order to contain and mitigate the COVID-19 pandemic, widespread, rapid testing is key. Rampant and efficient testing determines who has the virus and who may be at risk of transmitting it, and allows for effective management of isolation and quarantine activities for the infected or exposed. While testing has increased over the past months across the country—by mid-July the number of tests reached between 700,000 to 800,000 per day, double the number of daily tests performed in May. However, that number is still well below the estimated 1.2 million daily tests needed to contain the outbreak and 4.3 million tests per day that would suppress the virus.

To reach the level of testing needed to mitigate and suppress COVID-19, it’s essential that there’s more capacity and funding for producing, delivering, administering, and analyzing tests. Greater and easier access to the tests is also important, especially for those who are uninsured, underinsured, undocumented, or can’t see a healthcare provider. The need to conduct COVID-19 testing in a way that addresses health disparities and that is equitable is also necessary because evidence shows the virus is having a disparate impact on racial and ethnic minorities, those with underlying medical conditions, essential workers, and people who live and work in congregate settings.

To help meet the need for wider testing, several state health departments have issued standing orders authorizing COVID-19 tests be administered to individuals who meet certain criteria. A few of the standing orders address health equity needs by explicitly authorizing testing populations that are suffering a disparate health impact from COVID-19.

In North Carolina, the standing order authorizes testing sites to administer a coronavirus test to individuals recommended under state guidance, which includes anyone with COVID-19 symptoms, close contacts of positive cases, and people who are at higher risk of exposure or disease severity including:  historically marginalized populations; essential workers; healthcare workers; first responders; people with high risk of severe illness; people who have attended mass gatherings; rallies or protests; and people who live in or have regular contact with congregate living settings like long-term care facilities, homeless shelters, correctional facilities, and migrant farmworker camps. The order also requires the testing site to provide information on control measures to follow while waiting for the test results, what to expect from the contact tracer who will follow up a positive test result, necessary medical care if symptoms develop, and social resources needed to adhere to the control measures. If they test positive, individuals will be expected to give data about household members and close contacts to help with any necessary contact tracing. Finally, the testing site is directed to collect the name and contact information of the individual’s primary care provider, if available, and provide the test result to the provider.

Maine’s statewide standing order authorizes any healthcare provider or other trained personnel at a healthcare facility or testing site to test anyone who meets certain eligibility criteria. Eligible individuals must be at least 12 months old and fall into one of three categories:

• People who have known or suspected exposure to COVID-19 within the incubation period with or without symptoms, a close contact (within 6 feet for at least 15 minutes) with a positive case, a healthcare worker or first responder, or a resident or staff of a congregate living setting.
• Those who are not symptomatic or have no known exposure to COVID-19 but have an elevated risk of exposure, like: seasonal and migrant agricultural workers; employees of lodging facilities; employees of businesses who have direct, daily contact with members of the public; people arriving from states with a higher prevalence of COVID-19 than Maine; people participating in large gatherings; or other individuals who may be at increased risk of COVID-19 based on the duration and density of their recent, potential exposures.
• Finally, populations identified by the state health department in need of population-based sentinel testing. Testing sites must also provide educational information including written information on the steps to take following testing, information on how to obtain follow-up medical care, answers to questions about a positive diagnosis for COVID-19, and for those who test positive, the requirement for self-isolation.

New Jersey’s standing order authorizes any healthcare provider, licensed pharmacist, or trained personnel at a healthcare facility or testing site to collect and submit laboratory analysis of coronavirus tests from eligible patients. To be eligible a person must: reside in the state; be 12 months of age or older; within the COVID-19 incubation period; had close contact with someone who tests positive for the virus; be a healthcare worker or first responder; reside or work in a congregate living setting; have COVID-19 symptoms; be part of a population identified by the state health agency for needed surveillance; or other prioritized groups, including those experiencing homelessness and seasonal farm workers.

Statewide standing orders in Arizona and Nevada authorizes any medical provider or trained personnel at a medically-supervised COVID-19 testing site to collect and submit laboratory analysis of a test from any individual concerned about being exposed to and infected with COVID-19 and who signs a consent and voluntary isolation agreement. In Indiana, the statewide standing order allows providers at COVID-19 testing sites to test individuals with COVID-19 symptoms as well as close contacts of COVID-19 positive patients who have to keep working and/or have close contact with at risk populations. Others who may be tested under the standing order include healthcare workers treating vulnerable populations; first responders; essential workers; anyone 60 or older, individuals who are immunocompromised; and residents and staff of congregate living settings.

In Kentucky, a statewide public health order authorizes coronavirus testing without a licensed clinician’s order, and prohibits insurers from requiring a precondition from a licensed clinician’s order before covering the cost of testing. It also reminds insurers that the ‘Families First Coronavirus Response Act’ passed by Congress prohibits cost sharing requirements and prior authorization for coronavirus testing.

Under a standing order in Vermont, nurses and other healthcare providers working for the state health department may administer coronavirus testing on anyone over the age of 12 months who have been identified by the health department as needing a test for COVID-19. A Wisconsin standing order authorizes testing for anyone five and older with have symptoms of COVID-19, or anyone five and older who is referred for testing as part of a public health investigation.

State and territorial health agencies are key to increasing the level of COVID-19 testing to mitigate and suppress the coronavirus. They can also play a role in the equitable access to COVID-19 testing by using standing orders. As more jurisdictions consider these measures, ASTHO will continue to monitor their efforts.