Coronavirus Spread in Tennessee, Despite State Paying for Covid-19 Testing

WASHINGTON — As the United States struggled with coronavirus testing this spring, Tennessee was the rare state that lived up to President Trump’s promise that “anybody that wants a test can get a test.” Governor Bill Lee announced in mid-April that any Tennessean could get tested — regardless of symptoms — and that the state would pay for it.

“Testing may be the most important thing in addressing the unknown,” Mr. Lee, a Republican, said in an interview in early June. Decisions, he said, should be based on “real information.”

But that real information is now telling the state’s leadership a story it most likely did not want to hear: As in much of the South and West, Tennessee is awash in confirmed cases, and testing has proved no match for the coronavirus once it overwhelms local governments’ abilities to trace an infected person’s contacts and forces those who were exposed to self-quarantine.

Tennessee is far from the only state to discover that despite Mr. Trump’s hype — he boasted on Monday on Twitter: “our great testing program continues to lead the World, by FAR!” — coronavirus testing is not a miracle path to a safe reopening. As the nation faces a new shortage of tests, Tennessee’s experiences offer a cautionary tale about the limits of testing.

In Georgia, Gov. Brian Kemp, a Republican, expanded testing in early May and urged all residents to make appointments; in Oklahoma, Gov. Kevin Stitt, a Republican, did much the same thing. In Ohio, Gov. Mike DeWine announced on June 11 that any Ohioan could get a test; he and his wife, Fran DeWine, along with the state’s lieutenant governor, Jon Husted, took tests at a news conference as a way of encouraging others to do so. Each state has since had a sharp increase in confirmed infections.

“This was just as predictable as buying snow tires in June for your car in Minnesota,” said Dr. Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “You know December is coming.”

The Trump administration announced on Tuesday that it would start offering free coronavirus testing in three cities — Jacksonville, Fla.; Baton Rouge, La.; and Edinburg, Texas — as part of a new “surge testing” program to support communities identified as hot spots.

But even as he made the announcement, Adm. Brett P. Giroir, the assistant secretary of health, sounded a note of caution, warning that testing without other public health interventions — contact tracing, isolating the sick, social distancing and wearing masks — would be of little use.

“We cannot test our way out of this,” he told reporters, adding, “Testing alone is almost never the answer.”

To be sure, some states that have carried out aggressive testing programs are faring well. Rhode Island has been a national leader, testing 236 out of every 1,000 people — far more than any other state, according to the Kaiser Family Foundation. Its positivity rate — the share of tests coming back positive, a key indicator of whether a state is doing enough testing to keep the virus in check — is 1.8 percent, well below the target of 5 percent or less set by public health experts.

In Tennessee, where 132 out of every 1,000 people have been tested, daily confirmed infections nearly quadrupled between early June and early July, though they have dropped somewhat in recent days. The positivity rate shot up to nearly 8 percent from 5 percent. Last week, the mayor of Nashville, the state’s largest city, rolled back its reopening.

“I’m proud of what we’ve done for the most part, but I’m getting worried,” Dr. Alex Jahangir, the chairman of Nashville’s Board of Health and the leader of the city’s coronavirus task force, said in an interview last week. “Normally, in an ideal world, if you test more your positivity rate is going to go down. It blows my mind, but our positivity rate has gone up. That’s really alarming.”

There are some obvious explanations for Tennessee’s travails. The state was among the first to reopen its economy, and many people abandoned social distancing and masks. A country music star, Chase Rice, performed in late June in front of 1,000 people — most not wearing masks — at an outdoor venue in eastern Tennessee and was eventually shamed into delivering what critics called a nonapology

Young people jammed into Nashville’s famed honky-tonks and bars; Dr. Jahangir said the biggest growth in cases in the city was among people ages 25 to 34. In a city whose economy thrives on music and drinking, tensions have erupted between businesspeople and public health officials.

One of the city’s best-known establishments — Kid Rock’s Big Ass Honky Tonk & Rock ’N’ Roll Steakhouse — lost its permit to serve beer for five days after opening its bar in violation of a city public health emergency order that limited alcohol to tables and booths. Photographs on social media showed a packed house of maskless patrons standing shoulder to shoulder. On Monday, Kid Rock’s was among several bars whose owners sought a temporary restraining order against city and state health officials.

“We did well, but then stuff started opening up, and there’s not national leadership. I don’t care if you quote me on that, because I’m tired of being P.C. about that,” Dr. Jahangir said, referring to political correctness. “There’s not national leadership, and there’s a lot of pressure to open up the economy.”

Public health experts say they saw this coming and have been warning for months that the country was too focused on testing and not enough on other measures, like contact tracing, that must be paired with it.

“I feel like we’ve got attention deficit disorder — we can only focus on one thing: a travel ban, stay at home, testing,” Dr. Thomas R. Frieden, a former director of the Centers for Disease Control and Prevention, recently told reporters. “None of those things are going to work in isolation.”

Dr. Osterholm said he, too, had been trying to send the message that “the testing, testing and testing mantra was not going to save us, or even materially change the course of the pandemic.” He said he saw offering tests to anyone, regardless of symptoms, as a waste of precious resources.

In May, he and his colleagues published an article calling for a national blue-ribbon panel to devise a “smart testing” strategy.

But the Trump administration has resisted a national testing strategy, insisting that it be left to the states. And Mr. Trump’s mixed messages about testing are only complicating matters. His claim in April that the United States had “tested more than every country combined” was rated “‘pants on fire’ wrong” by Kaiser Health News.

Now, the president has taken to blaming the rising caseloads on an increase in testing — an assertion that is also false, given that the percentage of tests coming back positive is also rising. The sharp increase in confirmed infections has created more demand for testing, leaving some governors back where they started: scrambling for scarce supplies.

“Although we have greatly expanded the amount of testing we have done in the United States, the virus has outpaced those efforts,” said Dr. Jennifer Nuzzo, the lead epidemiologist for Johns Hopkins University’s Covid-19 Testing Insights Initiative.

Throughout the spring, administration officials and public health experts said states needed to ramp up testing and contact tracing to reopen. But very few were doing enough to stay on top of potential outbreaks. Tennessee’s expansive approach stood out, according to a report in May by Kaiser Health News, which wrote that it was ”rare for a community to encourage such broad symptom-free testing.”

Building capacity took time. The state’s health commissioner, Dr. Lisa Piercey, said in an interview that she initially relied on national laboratory vendors, who were slow, before turning to private labs based in Tennessee.

It was a win-win situation, she said: By guaranteeing payment, the state created a ready market for the local laboratories, which were able to purchase new equipment, scale up and deliver test results quickly. Facing outbreaks in prisons and nursing homes, the state also did targeted testing.

Tennessee’s governor “made two very important decisions that I wish could have been a national model,” said Dr. James E.K. Hildreth, the president of Meharry Medical College in Nashville. “He made testing available to anyone who wanted a test, and he also decided to test nursing homes and prisons.”

But not everyone has such high praise. Dr. William Schaffner, a professor of preventive medicine and infectious disease Vanderbilt University in Nashville, said he gave the governor a B+ for his management of the pandemic. While Mr. Lee had “modeled wearing masks,” Dr. Schaffner said, the governor opened the economy “earlier than the medical community wanted, and so that knocks him down a little bit.”

Mr. Lee, a businessman who had never held public office before becoming governor, said the decision to offer free testing grew partly out of his Christian faith; he did faith-based nonprofit work in Haiti, Mexico and Africa, which gave him an appreciation for those confronting disease. Dr. Piercey said they had prayed about it.

“Our key success factor is you will never pay for a test,” she said in late May, when daily confirmed infections were declining and the positivity rate was about 5 percent. “We couldn’t think of a better way to use our resources than on widespread testing.”