RALEIGH — Vice President Mike Pence told governors on May 11 that all nursing home residents and staff should be tested for the coronavirus in the following two weeks.
In North Carolina, more than six weeks later, that still hasn't happened. And state officials haven't said how or when it will.
The delay is "unconscionable," said Charlene Harrington, professor emerita in the School of Nursing at University of California San Francisco, in an email. The professor, one of the country's top experts on nursing-home policy, said the testing "is essential to save lives."
"We know that large numbers of staff and residents are asymptomatic, and without testing they cannot be identified," she wrote. "The state should be giving NHs (nursing homes) deadlines with penalties for failure to act."
It's been evident since at least February, when an outbreak at a Washington nursing home made national headlines, that the coronavirus would have devastating effects in nursing homes, where residents live close together, often two to a room, and have underlying health conditions that can make infection with the virus particularly deadly.
While testing was extremely limited in the early days of the pandemic due to a bungled federal response, state officials now say anyone who needs a test can get one. Still, the North Carolinians most vulnerable to COVID-19, the disease caused by the virus, have not all received the baseline test recommended by the U.S. Centers for Disease Control and Prevention, let alone the repeat testing that some experts, including Harrington, say is necessary to stop the spread of the virus.
Although nursing-home residents make up less than 1% of the state's population, they account for more than half of the deaths attributed to COVID-19. In some nursing homes with current outbreaks, more than 1 in 4 residents who tested positive for the virus have died, state data show.
Lauren Zingraff, the executive director of Friends of Residents in Long-Term Care, an advocacy group based in Raleigh, is frustrated by the state's response.
She said the continued lack of universal testing is exacerbating another crisis — loneliness, which researchers have found is correlated with cognitive decline and early death. Regulators have barred visitors from nursing homes in most circumstances for months.
"Literally — I say this without any facetiousness or sarcasm — literally, people are dying from the depression and the loneliness and the isolation and the sadness," Zingraff said in an interview with The News & Observer. "This idea that everyone has a tablet to Zoom with their family member or FaceTime with their family member is a fallacy."
Shortages in hardware and internet bandwidth have been problems, and people with cognitive deficits can find the technology confusing to use, Zingraff said.
Pat Weaver's husband has a neurodegenerative disorder that makes communication, especially using technology, difficult. So she was relieved when her husband, along with the rest of the residents and staff at his nursing home, were tested earlier this month.
"I saw it as a step in the direction of being able to visit again," she said.
Friends of Residents has been calling for widespread testing in nursing homes, especially those with low quality ratings, since April.
Compared to other states, Zingraff said, "We are so behind the curve."
Virginia, for example, released detailed reopening guidelines for nursing homes last week, and West Virginia, Tennessee and Maryland are allowing some in-person visitation.
In those states, the initial round of testing is complete.
What we know about N.C.'s testing plan
As early as May 14, state health officials said they planned to test all residents and staff members in North Carolina's more than 400 nursing homes, according to a newsletter sent to members of the N.C. Health Care Facilities Association, a trade group.
Yet the details of North Carolina's testing plan remain opaque more than a month later.
Universal testing in nursing homes is recommended, but not required, said Amy Adams Ellis, a spokeswoman for the N.C. Department of Health and Human Services, in an email to The News & Observer.
Officials have not revealed the extent of testing so far, but say they have completed tests of all staff and residents in state-run facilities.
A funding plan is still being worked out. Insurance will cover the cost of most tests, Adams Ellis wrote, and the department is "working to identify a vendor to support facilities that need additional support."
While most residents have insurance, usually through Medicare and Medicaid, many staff members do not, and some private insurers have balked at paying for screening tests, The New York Times has reported.
About 78% of direct care workers in North Carolina nursing homes have health insurance, the most recent American Community Survey data show.
Industry groups have been calling attention to testing costs, as well as capacity problems, for months.
The American Health Care Association and National Center of Assisted Living estimated the cost of one round of universal testing in North Carolina would cost more than $12 million, but the group did not account for insurance payments and assumed tests cost $150.
North Carolina nursing homes have received both federal stimulus money and increased Medicaid payments intended to offset costs associated with COVID-19.
But that may not be enough, said Don Taylor, a professor of public policy at Duke University who studies long-term care.
The White House's testing prescription "might be the mother of all unfunded mandates," he said. It was reinforced June 13 in CDC guidance that recommended, on top of baseline tests for residents, weekly tests for workers, with some room for adjustment based on local virus prevalence.
In Taylor's view, the underlying problem is the lack of a national testing strategy with funding to match.
Problems with the availability of tests and personal protective equipment have still not been completely resolved, he said, and there hasn't been enough research to determine what the right frequency of testing should be.
North Carolina's decision to recommend universal testing rather than to mandate it, Taylor said, reflects those uncertainties.
What's happening in other states
West Virginia was the first state to order mass testing in all its nursing homes. The governor issued the executive order April 17, calling on the help of the National Guard.
By the end of May, some states were finishing up the first round of testing. Each state's approach varied. Some sent test kits to facilities. Others encouraged partnerships with private labs.
Several states have ordered additional rounds of tests.
Maryland, for example, requires nursing home staff to be tested once a week. Executive orders in New York and Texas say staff must be tested twice as often.
While there are still questions about testing intervals, researchers agree that widespread testing is key to preventing so many more unnecessary deaths in elder-care facilities.
"There is no way to stop the spread of the virus unless universal testing is done for all staff and residents on a regular basis," Harrington said.