Why America Can’t Test Like Europe

America’s complicated health-care system means everything is harder—even rapid testing.

A woman testing for the coronavirus using a lateral-flow test
Peter Cade / Getty

Except for maybe pasta and work-life balance, no topic makes liberal Americans wish they were European more than health care. So when President Joe Biden announced a plan earlier this month mandating that private insurers reimburse people for rapid coronavirus tests that they take at home, some commentators cried out that his plan was not enough. The new rule won’t help everyone, and getting reimbursement will still take legwork, critics crowed—and plus, the Europeans have a better solution!

One of the biggest holes in Biden’s new plan is that it doesn’t force Medicare and Medicaid, which together cover a third of Americans, to pay for the tests. For now, only insurance plans that people get through work or the Affordable Care Act exchanges will be required to cover the swabs. To get reimbursed, privately insured Americans will have to go out and buy the tests, then file claims with their insurer. Meanwhile, the United Kingdom is sending people bags of tests for free. At a recent White House press conference, NPR’s Mara Liasson wondered why America can’t do the same.

Biden administration officials note that they have taken several steps they hope will increase testing capacity. The at-home test supply has quadrupled since late summer, in part because the administration used the Defense Production Act to rev up manufacturing. The administration plans to give community clinics 50 million tests for the poor and uninsured, and Americans can also get a free test at a federally supported testing site. And to be fair, many people thought the need for testing would abate after vaccines rolled out: “Once a vaccine for the coronavirus becomes widely available, the market for the tests will diminish, if not disappear entirely” is a sentence I wrote around this time last year.

Now, with the rise of the Omicron variant, the need for testing will clearly be with us for a while. But the Biden administration’s ability to make it rain rapid tests remains hampered by the peculiarities of American health care, which is more complicated and privatized than the systems in the U.K. and many other rich countries. “The sheer, cussed complexity of how we finance health care in this country creates unexpected challenges,” Nicholas Bagley, a health-care expert and law professor at the University of Michigan, told me.

Take Medicaid, America’s bare-bones insurance for poor people. Medicaid is a state-federal partnership, which means that states can make their own rules about what it covers. The Affordable Care Act allowed states to expand Medicaid to cover more people and said the feds would cover most of the bill. But more than a decade later, 12 states still have not taken the deal. In many situations, the federal government has more power over private insurers than it does over states.

What’s more, Medicare and Medicaid are government programs, which means that expanding them requires government funding, which means getting Congress involved. “For the private insurers, they can do it by regulation. For the government programs, they have to come up with funding, because in that case, the federal government is paying for it directly,” Robert Field, a law and health-policy professor at Drexel University, told me.

Finally, Medicare and Medicaid are cantankerous systems under which creating reimbursement processes for new types of services is hard. “Having been there, I don’t think it would be feasible to stand up [a reimbursement system] reliably for a huge national program in a matter of weeks,” says Mark McClellan, the director of the Duke-Margolis Center for Health Policy at Duke University and a former administrator of the Centers for Medicare & Medicaid Services, or CMS. As Bagley put it, “CMS is overstretched, and pushing anything substantial through the bureaucracy takes time.”

Still, the White House’s testing coordinator, Carole Johnson, seemed to imply that the administration is working to expand the types of people who can get reimbursed for the tests. In an interview, Johnson said that “the Medicaid program under the statute does allow—and require—coverage of at-home tests, it’s just that states can put a variety of limitations on it … The announcement we made last week was a step of many steps that we’re taking to continue to expand access, and we’re not done.”I asked Johnson why the government doesn’t just send people free tests, the idea that became a flash point in the recent White House press briefing. The administration seems reluctant to send tests to people who won’t use them. “We want to make sure that we’re getting tests to the people who need them,” Johnson said.

But also, the U.K.’s National Health Service, which does send people tests, is more intertwined in the lives of British citizens than most Americans’ doctors are in theirs. It’s “used to playing more of a public-health function,” Field said. “The NHS basically is your doctor. And people in England are glad to accept that. In this country, there’s a lot more resistance to having the government be your doctor.”

If Americans can’t handle European health care at its most rigid and invasive, apparently, we can’t have it at its most helpful and expedient, either.