The precise, nationally coordinated campaigns of Covid-19 testing and contact isolation that helped South Korea and Singapore avoid broad lockdowns are conspicuously absent in the United States.
The federal government has not been able to rapidly and effectively institute Covid-19 testing, from actively blocking early efforts to providing false reassurance on testing availability. In the absence of national leadership, states and counties are left to their own judgments, to procure their own essential supplies, and to set their own policies, making large-scale coordinated testing even more challenging. And the county-level public health institutions we defer to for policymaking do not control the financial or health care delivery resources required to implement the testing and contact tracing we need today and the vaccinations we will need tomorrow.
I believe that American employers will be our fastest path to establishing the framework for, or alternative to, the national public health system we do not have. Employers already provide health care coverage to 49% of Americans. Extending the reach of American employers to take the lead on broad testing for disease among their workforces and their affiliates, certifying who is clear to return to work, and eventually verifying vaccination will be essential to beating the pandemic and getting Americans back to work.
Testing and certification of non-infection
Covid-19 testing organized and sponsored by employers to confirm that workers are either not infected with SARS-CoV-2 or are immune due to prior infection may be the most effective tool to gradually relax social distancing measures and get the country back to work. Employers could enable broad and frequent testing of their employees and require certification that they are not currently infected before they come back into the workplace.
Employers have a powerful financial incentive to test their full- and part-time employees, contractors, temporary workers, and gig workers: They want to bring them back to work and restart their businesses, which have slowed or stopped on a scale we have never seen before. These employers also have a social and legal obligation to ensure the safety of their employees and their customers, students, and patients.
The cadence of testing would need to be determined by the disease trajectory in a given region, and by the risk exposures of the population. Health care workers, for example, might initially require daily testing, while others might initially require weekly testing. As the spread of disease slows, the testing frequency could be relaxed.
Test results could come from multiple testing sources, from lab-based PCR tests that look for viral RNA to consumer antibody tests that look for immunoglobulins. Test results identifying people as either not being actively infected or immune from prior infection would qualify for a “certificate of non-infection.” These certificates would expire based on the testing protocols, which themselves would vary by the risks based on geography and type of work, informed by published testing protocols grounded in science and epidemiology. Employers, and the testing companies they work with, would be required to report Covid-19 results to local public health authorities, benefiting everyone in the areas where employers require testing and certification.
Employer-led testing has potential risks that must be anticipated and addressed: Employers, acting alone, may be susceptible to making decisions based on non-validated tests that make dubious claims. Employers, especially those with a national reach, may not have the infrastructure to share data with local public health authorities, organized at the county level. And employers would need to develop a set of certification protocols informed by epidemiology that could be rapidly changing. This is on top of the perhaps obvious compliance requirements associated with collecting health information that varies across the U.S. These risks could lead to a failure in translating Covid-19 testing into coherent action that can bring life back to normal.
As unpalatable as employer-based coronavirus testing may be to many, it is preferable to not having an employer at all. As we write this, more than 16 million Americans have filed for unemployment. We can bring America back to work with broad and regular testing facilitated by employers.
Changing the role of the employer in public health
Employers were the first to institute large-scale stay-at-home orders, opening the way for local and state governments and public health agencies to follow suit. In California, the first state to institute a stay-at-home order, major employers and universities had already asked their employees and students to stay home before government orders were put in place. This voluntary and independent action was essential to clearing the path for the decisive government action that is proving effective.
Employers can play a similar role in requiring a process of testing and certification in order to return to work and, in the future, requiring and verifying vaccination.
Only states can mandate vaccination; the federal government cannot because of a 1905 Supreme Court case on smallpox vaccination. That means any employer with a national footprint should expect to encounter state-to-state variation in vaccination requirements.
There is precedent for employers to require vaccination, however, and not wait for state requirements. Health care workers are already accustomed to mandatory influenza vaccination, required and audited by their employers. This is justified since not being vaccinated is a workplace hazard to oneself and to others. The same justification may be used by many employers to require vaccination against Covid-19 when a vaccine becomes available.
As the federal government has struggled to enact critical services and plans for the next phase of this pandemic, employers have begun assuming some of the leadership we traditionally ascribe to government.
The leadership of every employer in the U.S. are focused on protecting the health of their teams and ensuring they can get back to work. Creating a consensus on testing and certification, driven by employers willing and able to take early action, will accelerate America’s return to work. No employer in America can afford to just sit and wait.
Rajaie Batniji, M.D. is co-founder and chief health officer at Collective Health.