Covid-19 testing in the US improved dramatically over the first half of 2020, but things now appear to be breaking down once more as coronavirus cases rise and outstrip capacity — to the point that the mayor of a major American city can’t get testing quickly enough to potentially avoid spreading the virus.

“We FINALLY received our test results taken 8 days before,” Atlanta Mayor Keisha Lance Bottoms tweeted on July 8. “One person in my house was positive then. By the time we tested again, 1 week later, 3 of us had COVID. If we had known sooner, we would have immediately quarantined. Perhaps the National Guard can help with testing too.”

Anecdotally, I’ve heard of similar delays across the country — people waiting days or even weeks for their Covid-19 test results after standing in lines for hours to get tested. Labs have warned about problems: Quest Diagnostics, one of the biggest lab companies in the US, said wait times for test results are now averaging between four and six days for most people.

“Basically, two things are happening,” Ashish Jha, faculty director of the Harvard Global Health Institute (HGHI), told me. “One is the outbreaks are getting much bigger, so the amount of testing we need to get our arms around the outbreak is going up. And second, what we did [before] was some tweaking on capacity issues to get ourselves up to 500,000 to 600,000 tests a day, but didn’t fundamentally address the supply chain problems.”

He added, “This was supposed to be the job of the White House. … But they just never have prioritized really building up a robust testing infrastructure for the country.”

The problems have become more localized than in previous months. New York and Connecticut’s testing capacity seems to be holding up pretty well, largely because their Covid-19 outbreaks seem to be under control for now. States where epidemics are raging, such as Arizona, Florida, and Texas, are where testing problems seem to be spiraling.

As Bottoms’s story conveys, this is a big problem for getting the coronavirus outbreak under control: Testing is crucial for controlling disease outbreaks because they let officials and individuals see when further action, such as isolation and contact tracing, is necessary. But if testing is slow or insufficient, it can’t show people they’re infected and need to take action until it’s likely too late. That’s especially true with Covid-19 because people can have the virus and spread it without showing any symptoms.

“This is the same story we heard in the earlier days of the outbreak,” Jennifer Kates, vice president and director of the Global Health and HIV Policy Program at the Kaiser Family Foundation, told me. “But it’s much worse because everyone felt like the US was a little caught off guard at the beginning. … What we’re learning now is that none of the things that should’ve happened in the interim [during lockdowns] happened.”

So as America faces a surge of new coronavirus cases, the testing delays threaten to make the pandemic even worse.

America improved its testing capacity — to a point

America made huge improvements in Covid-19 testing capacity over the past few months, largely due to local, state, and private action as President Donald Trump’s administration delegated the issue downward and said the federal government would act merely as a “supplier of last resort.”

Nonetheless, the improvements were substantive and real. The US went from testing hundreds of people a day (at most) in late February and early March to consistently hitting 500,000 to 700,000 tests a day in June and now July.

The benchmark of 500,000 tests per day was particularly important, as it was the minimum experts had long called for in order to get the pandemic in the US under control.

But as the country neared that benchmark, attention to testing seemed to plummet. The Trump administration, which had already delegated testing down to lower levels of government and private actors, especially appeared to lose interest: The country’s “testing czar,” Brett Giroir, stood down and went back to his regular job at the Department of Health and Human Services. Trump falsely claimed in May that “America leads the world in testing”; at his Tulsa rally in June, he said he told his people to “slow the testing down” because the rising case count made him look bad. (He later asserted that his statement at the rally was not a joke, despite White House officials insisting it was.)

As all this happened, many of the underlying problems with testing capacity remained.

For one, there’s still a lot of variation between states. While most states, as of July 8, had 150 new tests per 100,000 people per day — the equivalent to 500,000 daily tests nationwide — 18 states still didn’t.

The state-by-state situation looks worse through another metric: the test positive rate, or the percentage of tests that come back positive. If a place tests widely enough, allowing it to catch even the people who show few symptoms but could still spread the virus, it should have a low positive rate — typically below 5 percent, though some experts now argue for less than 3 percent. A high positive rate indicates only people with obvious symptoms are getting tested, so there’s not quite enough testing to measure the scope of an outbreak.

As of July 8, most states in the US had a positive rate above 5 percent, suggesting their testing capacity isn’t keeping up with the scale of their outbreaks.

The consequence is delays in testing results as the demand for tests outmatches the supply. So people can’t get their test results quickly enough to act on a positive report, preventing tests from achieving the exact goal they’re supposed to accomplish.

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Testing was always supposed to scale with larger outbreaks

The diversion between many states hitting 150 daily tests per 100,000 people and still having positive rates that are too high exposes another problem: The call for 500,000 tests a day nationwide was supposed to be only the minimum. Experts always warned that if the Covid-19 outbreak got much worse, there would likely need to be even more testing to keep up with the rise in new potential patients and cases.

“There’s the testing capacity you need to get to the place of opening up, then there’s the testing capacity you need to be open,” the Kaiser Family Foundation’s Kates said. “Once economies start to open again, people start moving and returning to the public sphere, and there are outbreaks. If there’s not enough testing, and testing hasn’t been built along with contact tracing, you’re going to have this explosion that we’re seeing, and the testing is not going to catch up with it.”

Jha, from the HGHI — which was one of the more vocal advocates for the threshold of 500,000 tests — said he worries something got lost in his communications to journalists and government officials.

At the same time, Jha and the other experts I spoke to were always clear, at least to me, that the 500,000 benchmark was a minimum. In fact, even before the current testing problems, Jha and the HGHI said the number was likely too low to keep up with the US epidemic and called instead for a minimum of 1 million daily tests.

“We were the ones who generated the 500,000-a-day number. We did it based on a particular size of the outbreak,” Jha said. “Clearly, things have gotten much worse since then.” He added, “We’re learning. We’re trying to figure out how to control the virus and where the country should go. And obviously in that we’re going to be updating data as it goes along.”

With the positive rate, it’s a similar story. Thomas Tsai, a health policy expert at Harvard, said the real goal for the positive rate is 0 percent — when the coronavirus is vanquished. So it’s important for states not to get complacent just because they’re now below an “acceptable” maximum of 3 percent or 5 percent. “The tests are a mean to an end,” Tsai said. The metrics “are just signposts along the way to give you directions.”

But as Covid-19 cases dropped and plateaued for the greater part of May and early June, much of the public and officials may have become complacent with the testing situation. They set their attention to other issues, such as the rise of new Black Lives Matter protests. Trump and the rest of the White House stopped focusing on the topic, halting daily press briefings about Covid-19, perhaps as officials realized that the president’s botched response to the crisis had made him look much worse. Meanwhile, there was a push, from Trump in particular, for states to reopen as quickly as possible to boost the economy.

Now it’s clear that problems with Covid-19 testing remain.

Earlier on, the hurdles with testing were linked to supply chain problems: not enough swabs to collect samples, vials to store them, or reagents and kits to run the tests. Over time, those problems were fixed or worked around.

The issue, experts say, is that these kinds of problems were always bound to come back as testing demand increased. Fixing a bottleneck for kits may let the country get to 500,000 tests a day, but that bottleneck can easily come back if, for instance, the nation needs 1 million per day and there are only enough kits for 700,000.

Jha pointed to basic economic concerns as a key problem. “If we decided to tomorrow, do we have the technological capacity to be able to get many millions of tests a day? Absolutely,” he said. But labs aren’t sure that making the massive investment for way more tests is financially sustainable, he explained, especially as Covid-19 outbreaks ebb and flow — and, as a result, occasionally deplete demand for those tests, as well as the number of people who need them.

Ideally, the federal government would be in charge of handling these problems. It’s the one entity that can go to labs across the country, see what the holdups are, then work along the global supply chain to see what can be done to address the issues. It has the funding ability to ensure labs and suppliers remain whole. And it can prioritize limited resources to specific cities, counties, or states that need them most, instead of leaving these supplies to a free-for-all.

This is, in fact, what the federal government does with other issues — such as when it ensures that a manufacturer has all the parts needed for an order of guns, tanks, or jets.

“The military has visibility into the entire supply chain, and the military oversees the entire supply chain,” Jha said. “It may be working with private companies, but the [Department of Defense] doesn’t leave this all up to chance.”

The Trump administration, however, has described the federal government as a “supplier of last resort.” That’s very different from the kind of proactive approach the feds take on other issues to get ahead of supply constraints.

So the problem is left to private actors as well as local and state governments, which often face legal, financial, and practical constraints that hinder their ability to move quickly. And the problem persists, even as Covid-19 cases continue to rise.

Testing always mattered and still matters

It’s been said a countless number of times in recent months, but it’s still true: Testing is key to stopping the Covid-19 pandemic.

When paired with contact tracing, testing lets officials track the scale of an outbreak, isolate the sick, quarantine those with whom the sick came in contact, and deploy community-wide efforts as necessary. Aggressive testing and tracing are how other countries, such as South Korea and Germany, got their outbreaks under control, letting them partly reopen their economies.

This testing problem is solvable in the US. “New York at its peak had people dying in the hallways of hospitals. Test positive rates were routinely above 20 percent,” Tsai said. “Look at it now, with a test positive rate of about 1 percent. In Massachusetts, our positive rate is about 2 percent now. These states show that concerted efforts … can not just mitigate the pandemic, not just flatten the curve, but also contain and suppress the pandemic.”

This only works, however, if officials can move quickly on a test, preferably within 24 to 36 hours. In the time it takes to confirm whether someone either has Covid-19 or came into contact with someone who has it, the person is more likely to continue their typical routine, potentially infecting others in the public or even within their own homes. In this context, every day and hour matters to get people to stop the spread of the coronavirus.

Testing and tracing can’t solve the pandemic all on their own. They have to be paired with precautions such as wearing masks and keeping 6 feet apart in public. In extreme cases, lockdowns can still be warranted if an outbreak is so out of control that a stay-at-home order becomes the only way to reel things back.

Lockdowns, however, were also supposed to buy the nation time to build up its testing system. As Natalie Dean, a biostatistics professor at the University of Florida, previously told me, “The whole point of this social distancing is to buy us time to build up capacity to do the types of public health interventions we know work. If we’re not using this time to scale up testing to the level that we need it to be … we don’t have an exit strategy. And then when we lift things, we’re no better equipped than we were before.”

It’s now clear that the US didn’t take full advantage of the time it bought with lockdowns. While testing did dramatically improve compared to the early days of the pandemic, it’s still not at a point where America can handle the higher demand brought on by another surge in coronavirus cases.

“It’s pathetic. This is not how a first-world country functions,” Jha said. “That people should not expect to access a test to an infectious disease many, many months into a pandemic — I find myself amazed that this is where we are as a country.”