Make rapid tests actually free, not kinda-sorta free.
Biden’s plan to expand at-home Covid-19 tests is a step forward, but it’s needlessly complicated.
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Rapid at-home Covid-19 tests should be free. And by free, I mean actually free. Free at the point of sale. Free like water from the fountain in a park. Free like bus fare for toddlers. Not free if you do a bunch of paperwork and later get reimbursed after paying marked up retail prices.
As part of its response to the emerging Omicron variant, the Biden administration announced yesterday that it would expand free rapid at-home coronavirus tests for Americans this winter.
That’s good. I support widespread use of rapid tests and have for over a year. But I’m not convinced the word “free” is an accurate representation of the new policy. Under the plan, insurance companies will be required to reimburse their customers for rapid tests. That means people will still have to pay for rapid tests wherever they are for sale, and insurance companies will then have to reimburse them, if and when the required paperwork and receipts are correctly submitted. And it’s likely that those who are the most apt to do the paperwork are also the ones least likely to need free tests.
For those without private insurance, Medicare, or Medicaid (which add up to around 55% of US residents) rapid tests will have to be obtained from community centers and other distribution centers. (The White House said that it is aiming to make 50 million rapid tests available in neighborhood sites, doubling its previous commitments, including to more rural sites.)
There’s a word for all of this: sludge.
All of this means those with insurance will have to jump through hoops for their rapid tests to be genuinely free. Not to mention, insurance companies have been known to deny legitimate claims for arbitrary reasons. What’s to stop them from making reimbursements difficult to obtain? Meanwhile, those without insurance will have to search for tests in community sites which, unlike many pharmacies, are likely to be open during business hours only.
There’s a word for all of this: sludge. Sludge is the busywork that stands between a person and a goal. Filling out long forms, having to print those forms, and having to send them by US mail when the same result could have been achieved with one simple online form? That’s sludge.
As my Harvard colleague and occasional collaborator Cass Sunstein has written, by its very nature, Sludge is meant to slow things down. Sometimes sludge has a genuine purpose, functioning as a kind of quality control. But mostly, soul-crushing sludge is designed to obstruct and impede progress. A majority of sludge is ultimately pointless, other than to dissuade some desired action.
One underestimated aspect of sludge is an implied value judgement that accompanies it. Before the pandemic, Cass and I wrote about this in an essay about the opioid epidemic. We noted that because physicians must enroll in and endure hours and hours of special training to be permitted to prescribe buprenorphine—a long-acting opioid replacement medication also known as Suboxone—many physicians continue to internalize an archaic and harmful message that there is something “bad” about this approach to treating opioid use disorder.
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Why would the government want to enact a policy that puts sludge between the general public and free, rapid, at-home Covid-19 tests? It’s counterproductive. Rebates, in essence what the Biden plan amounts to, are a marketing tool, not a public health one. They’re meant to give the appearance of a lower price. But savvy businesses know that most people won’t bother with the sludge it takes to get that rebate. They know that they’ll rarely have to reimburse their customers, as they promised they would. If only 1 in 10 buyers completes the required steps for a 10% rebate, the company only feels a 1% cut in the price. As long as the rebate attracted a few more customers, the marketing succeeded.
Rebates, in essence what the Biden plan amounts to, are a marketing tool, not a public health one.
What possible upside could sludge around our Covid-19 policies have? The government’s Covid-19 response should not have any associated sludge. Too much is on the line. In fact, our governments should be doing the opposite; they should not merely be removing sludge but also providing nudges on actions that will help everyone. In essence, that’s how vaccine mandates have functioned, for most people. It appears that a majority of unvaccinated people mandated by their employers to get vaccinated were actually willing to do so, given a deadline (if not the direct ultimatum).
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Every month, I get a text message from the city of Cambridge reminding me that street cleaning is the next day and that I should not park in my usual spot, lest my car get ticketed and towed. If I didn’t get this friendly text and I occasionally failed to remember the street cleaning schedule, I’m sure the city would profit off of the transactions. But they’ve determined it is not worth it.
By analogy, our governments should be making it easy to get rapid Covid-19 tests for free. No friction. The federal government has the infrastructure for this in place. It could be handing out rapid Covid-19 tests for free at post offices—there’s one in every ZIP code.
But even that would be a form of sludge, wouldn’t it? People who wanted the tests would have to haul over to the post office and hope there were enough tests available that day. If only the post office employed people who could deliver free rapid tests to every American household….
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