California Dreamin'

June 9, 2020

Photo via Pixabay

Early in the pandemic, California was conducting just 2,000 coronavirus tests a day. Now the state is up to 60,000. How did they ramp up testing so quickly?

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Dan Gorenstein: In late March, Bob Kocher’s phone flooded with calls. 

Hospitals panicked, coronavirus infections were sweeping across California, but labs, doctors and nurses had a problem: The swabs, vials, kits — the supplies they needed to test patients — had run out.

Then Bob got a call. It was Kaiser Permanente, the health care giant that cares for 12 million people, the provider with 39 hospitals and more than $80 billion in annual revenue.

Bob Kocher: Hello, we’re Kaiser. You may have heard of us. We can’t run any tests.

DG: The story of what California did to dig itself out of this COVID testing hole.  

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

DG: It’s March 19. 

Gov. Gavin Newsom: Thank you, everybody.

DG: California Gov. Gavin Newsom just declared an emergency stay-at-home order. 

Newsom: That directive goes into force and effect this evening, and we are confident that the people of the state of California will abide by it. 

DG: With coronavirus cases multiplying across the state, hospitals, health departments and labs scrambled to diagnose and track the virus.

At that point, California barely managed to process 2,000 tests a day in a state of 40 million people.

The situation, says Bob Kocher, was bleak. 

BK: What we discovered was that nearly every lab in California was missing one of the essential ingredients to do a test. The challenge is that we have hundreds of labs in California. And they were calling the companies saying, “Send me more stuff.” And the company said, “Well, we’re out of everything. The whole world wants these things. We’re allocating them in a super secret way. We don’t have any for you.”

DG: Bob leads health care investments at the venture capital firm Venrock.

He also served in the Obama administration as a senior health care advisor.

In February, state health officials recruited Bob to help California improve testing access. 

In those early days, Bob went to manufacturers hat in hand. 

BK: Because we were the governor’s office calling, we could initially lean on their mission orientation and guilt to have them then bring some special supplies.

DG: Bob, along with Charity Dean — assistant director of the California Department of Public Health — knew that was a stop gap. 

Without enough supplies to scale up testing, the state had no compass to guide public health decisions — when to lift stay at home orders or where virus hotspots were brewing — if Charity couldn’t answer the most basic question. Who is infected?

Charity Dean: Looking down the long road of how will we get there, we knew that in order to get there, we’d have to have a really strategic approach. We’d have to measure ourselves with data.

DG: In late March, Newsom formally created a Testing Task Force to be co-chaired by Charity and Bob. 

To hit their first goal — 25,000 tests a day within four weeks — they needed to deal with the supply chain bottleneck. 

Paul Markovich — the president of Blue Shield of California — became the third co-chair. 

Paul Markovich: We put together a group of people who called all of the labs and documented the supplies that they ha, the manufacturers that they were using, and the capacity that they had. And so we had an entire inventory across the state of all the labs. And we were updating it daily. 

DG: The task force worked with California-based medical supply company Hardy Diagnostics who sourced 22 million swabs in China and began manufacturing other supplies. 

That led to 22 million testing kits. 

But many people in that moment weren’t eligible to get tested. 

CD: The CDC guidance did not advise testing people who are asymptomatic. Of course, as a state public health department, we want to be lock-step with the CDC and with our federal partners. But we also have to acknowledge what was happening on the ground. And we have to respond to that.

DG: In early April, based on CDC guidance, all states limited tests to high risk people with symptoms. 

A microbiologist by training, Charity studied the scientific research from China showing that people with no signs of the virus were actively spreading the disease —significantly driving numbers up. 

To test 25,000 people a day and to get a hold of the pandemic, Charity decided the state had to expand who could get tested. 

She called it a game changing moment. 

CD: Rewriting that guidance, quite frankly, was a bold move. But it was absolutely based on public health concepts that are hundreds of years old and sound scientific data.

PM: Charity really stuck her neck out. Step outside the federal source for guidance and it blows up in your face, that’s a pretty good way to lose your job.

DG: A few weeks later, California officially announced asymptomatic health care workers and people living in residential homes could now get tested.  

The trio waited, nervously, for a federal backlash.

BK: We’re dependent upon support from FEMA to provide supplies to our state. We depend on CDC supporting our efforts. We’re dependent upon the White House working with us. The risk Charity took was that if the CDC said this was crazy and we think that California is out to lunch here, or if there was an angry tweet from the White House, we would have had a lot of challenges.

DG: And then another call to Bob’s phone.

BK: I was stunned to get a call from Jared Kushner saying thank you for expanding the guidance in California. We want to do this for the country. 

DG: A senior administration official confirmed Bob’s account of his call with Jared Kushner, who is running a COVID response team. 

Simultaneously, the Task Force had begun standing up test sites, with an eye on placing most in underserved areas. 

Those moves helped the team hit its 25,000 tests goal in just 21 days. But nobody was pulling out any Mission Accomplished banners.

A May 4 article from Kaiser Health News described a supply chain still reeling and overwhelmed, testing deserts in underserved areas, a rural community examining raw sewage for traces of coronavirus contamination. 

It painted a picture of a state divided between the “haves” and the “have nots.” 

Paul said they knew there were gaps.

PM: We had done mapping. We had a process for prioritizing which ones would go in which communities based on income, based on ethnicity to try to get it to the neediest population. 

DG: The team identified about 60 new testing sites to improve access for the rural towns and communities of color — the “have nots.” 

By early June, California averaged 60,000 tests a day — or 1.5 tests per 1,000 residents — and others have noticed. 

Bob says eight states, including New York, Michigan and Nevada, have reached out for guidance.

By all accounts, the task force can celebrate real success, increasing testing 30-fold.

But for all the ground they’ve gained, Bob, Paul and Charity have set new goals. 

Charity is focused, in part, on catching hotspots, hard to do, she says, when public health departments must count on slow, old-fashioned data systems.

CD: A lot of the way that data is tracked in public health right now is the same way it was 100 years ago. And we’re still faxing or mailing paper records of test results. And that means the emergency room can’t just log into a system and see all of that patient’s information. So that cripples the ability to be nimble and fast on the ground.

DG: Another priority: affordable, reliable tests companies need to keep workers safe as they return to the office. 

Paul says the majority of tests are really inefficient. 

PM: Having people go to a physical location, sticking a very large swab up their nose and tickling their brain, putting it in a tube with some goop and sending it to a lab and running it all through at $100 a pop is the most accurate gold standard way to have confidence whether someone is infected or not.

DG: The task force says insurers pick up about 90% of the cost of the actual tests. 

The state pays half a million dollars a day to run the 100 testing sites. 

The federal government will pay up to 70% of the state’s cost until the federal emergency declaration is lifted. After that it’s all on California. 

That leaves Bob dreaming of something better. 

BK: I’m imagining a world where we can have testing kits in every pharmacy and convenience store in the state so that the contact tracing team can say, “Just go to the nearest store and grab that sample collection tube, take it right now, mail it and we’ll get your result very quickly.” That does not exist today. 

DG: The upheaval brought by this pandemic and the limitations of testing have inspired even the most data-driven people to hope for a moonshot. 

I’m Dan Gorenstein, this is Tradeoffs.

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Episode Resources

Select News, Analyses, Resources:

Testing In California Still A Frustrating Patchwork Of Haves And Have-Nots (Anna Maria Barry-Jester, Angela Hart and Rachel Bluth; The Kaiser Health News; 5/4/2020)

‘This Is Not the Hunger Games’: National Testing Strategy Draws Concerns (Apoorva Mandavilli and Catie Edmondson; New York Times; 5/26/2020)

Why We Must Test Millions a Day (Divya Siddarth and E. Glen Weyl; Edmond J. Safra Center for Ethics; 4/8/2020)

National COVID-19 Testing Action Plan (The Rockefeller Foundation; 4/21/2020)

In Large Texas Cities, Access To Coronavirus Testing May Depend On Where You Live (Sean McMinn et al; NPR; 5/27/2020)

COVID19.CA.GOV: Testing and treatment ( website)

COVID-19 Testing Sites in California (Map)

COVID Tracking Project (The Atlantic)

Episode Credits


Co-chairs of California’s Coronavirus Testing Task Force

Bob Kocher, MD, partner at the venture capital firm Venrock.

Charity Dean, MD, MPH, assistant director of the California Department of Public Health

Paul Markovich, president and CEO of Blue Shield of California

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode from Checkie Brown, Broke for Free and Blue Dot Sessions.

This episode produced by Victoria Stern. It was mixed by Andrew Parrella.

Additional thanks to:

Ngoc Ly Le, Bonnie Gee, Amy Zhang, Don Campbell, Corinna Albert, the Tradeoffs Advisory Board…

…and our stellar staff!