Path to Zero: Utilizing Interstate Compacts to Unleash Testing Capacity 

Severe testing shortages and processing delays are hampering the COVID-19 response. Here is how to rapidly build the arsenal of timely tests we need to suppress and defeat the coronavirus 

As coronavirus cases soar across the United States, viral testing has become a bottleneck. People are standing in line for hours in some hotspot states to get tested, and many wait over a week or longer for their results. Containment of the virus is impossible in such conditions – slower than 48 hour turnaround times for test results makes contact tracing ineffective. We cannot break the chain of transmission if the virus outpaces us at every step. 

This is the second time the nation faces severe testing shortages as case counts rise. Yet this time, innovators and labs are ready to unleash millions more tests. The reason they haven’t done so already is that these entrepreneurs need to know there is a market for the tests, that someone will buy them -- while the state leaders wanting to buy these tests need to know they can afford them.  

What both the innovators and the state leaders need is a framework to quickly settle this supply-and-demand problem. In the absence of a national strategy to procure tests and distribute to states as needed based on outbreak size, states are currently asked to figure this out on their own. But with the exception of California, no state alone needs the large number of tests that would make it worthwhile for a biotech or other company to build or switch production to COVID-19 testing.  

“Next-generation genome sequencing labs, for instance, could process 1 million samples a day,” explains Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.  “But no single state needs that many.” 

By buying and bargaining as regional groups, however, states can overcome these obstacles and get the number of tests they need at an affordable price. 

Empowering States

“There is a solution: Congress can activate and fund regional interstate compacts that would have the express job of investing in the testing capacity we have not yet activated,” says Allen.“Interstate compacts are valuable tools for addressing problems that are complex, require scale to solve, and also require state leadership because of on-the-ground variation. They are tools for empowering states.”

Interstate compacts are legally binding agreements between states, territories, and/or tribal nations that allow them to take collective action to solve shared problems or enact a common agenda. The Port Authority of New York and New Jersey is such a compact, as is the Emergency Management Assistance Compact, which enables states to deploy personnel across state lines to help in times of crisis, such as wildfires or hurricanes.

The Compacts Clause of the U.S. Constitution grants states the right to create interstate compacts for their common benefit. The text of the Compacts Clause requires congressional consent to these agreements. Compacts that receive congressional approval have the force of federal law and therefore supersede state laws. 

Activating ALL Labs That Could Test For Coronavirus

"States have been left to compete for PPE, as well as testing supplies and capacity, which has resulted in bidding wars, allocation inefficiencies, and testing delays," says Ben Linville-Engler of the Massachusetts Manufacturing Emergency Response Team and a director at MIT's System Design and Management Program. "We need a mechanism that enables states to collaborate with each other as opposed to compete with each other.  Interstate compacts can achieve this."

By working together, states could activate several lab types that could but aren’t currently doing any coronavirus testing: The U.S. has six categories of labs — state public health labs, clinical commercial labs (for instance, Quest Diagnostics and Lab Corp), hospital labs, academic research labs, commercial nonclinical labs (for instance, 23andMe and other labs running genome sequencers), and veterinary labs. But to date only commercial and state labs are fully activated, while hospital labs are partially activated, and all the other labs are used only very sporadically or not at all.

More Certainty in Testing Markets

“Compacts would have the scale and market power to make guaranteed off-take contracts for a million tests. On the supply side, these contracts would bring certainty and eliminate demand volatility for test suppliers, giving existing firms an incentive to expand production and new firms an incentive to enter the marketplace and compete on price,” says Puja Ohlhaver, chief executive of ClearPath Surgical.  “On the demand side, these contracts would turn test suppliers from price-makers into price-takers.”

Harvard’s Edmond J. Safra Center for Ethics and the Harvard Global Health Institute are working with experts and political leaders across the country to brief governors and congress on the way forward that interstate compacts provide. For details on compacts, and how they fit into the TTSI COVID-19 suppression framework, please explore our documents below. 

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