Alejandra Felix, a housecleaner and grandmother from Richmond, Calif., had a cough and a sore throat. So she did the responsible thing in COVID times and called in sick.
Her symptoms were mild, but she wanted to get tested for COVID before she went back to work, so as not to spread the virus. She works for herself, and wants to keep her clients' trust.
"First I need to know that I've taken all the precautions. I need to be sure it's only a flu," she says.
Felix had spent all morning driving around to pharmacies in Richmond and surrounding cities, looking for rapid antigen tests. There were none to be found.
The COVID testing site at her neighborhood clinic, Lifelong Medical Center, was fully booked. She called and called but waited so long on hold that she got discouraged and hung up.
For Felix, a week with no work means losing up to $800 dollars in income.
"That's a lot because I need it to pay the bills," she says with a nervous laugh. "I feel desperate because I have to cancel all my work this week. If they give me an appointment it'll be tomorrow or the next day, so I have to cancel everything."
Across the country, the spread of omicron has people scrambling to get tested for COVID. The lines are long, appointments get scooped up fast, and rapid antigen tests are hard to find. This problem is hitting essential workers – often people of color – particularly hard. Unlike many office workers, they can't work from home, and their companies haven't stockpiled tests. The result is lost wages or risking infecting coworkers or family members.
Renna Khuner-Haber, who coordinates Lifelong Medical's testing sites, says the people who most need convenient home tests can't get them. The disparity is glaring, especially in the Bay Area, where tech companies send boxes of rapid antigen tests to workers who have the option to work from home in a surge.
"Rapid tests — they're not cheap. If you have a family of 10 people and everyone needs a rapid test and they're each $10, that's $100 right there. To test everyone twice, that adds up," she says.
Community testing sites try to fill the gaps
One solution that's filling in the gaps are small neighborhood clinics like Lifelong Medical, which specifically serve low-income communities, including Medicaid patients, Spanish-speaking immigrants, and essential workers who risk COVID exposure at their jobs.
Since the beginning of the year, the demand for testing at this neighborhood clinic in the working class city of Richmond has ballooned.
Lifelong runs three testing sites in the Bay Area. Its COVID hotline is getting about a thousand COVID calls daily, up from about 250 in the fall.
José Castro is one of their patients. His whole family had the sniffles, so he brought his wife and three children, ages 3, 5, and 14, to get tested. He works as a house painter and spent the previous day driving all the way to San Francisco the previous day trying to find a test.
"I waited about an hour or 90 minutes on the phone [with Lifelong] and finally got through to get an appointment. I need to have a negative test to be confident that I'm not positive so I don't transmit it to anyone at the job site," he says, in Spanish. "Also my oldest son needs a test to go back to school."
Another Lifelong patient, Victoria Martín works as a dental hygienist and worried about being exposed after someone tested positive at work. She was frustrated to have caught a cold – hopefully not COVID – even after she cancelled holiday plans.
"It's very scary. I came here yesterday and made an appointment for today," she says. "You try to stay safe by staying in a close circle and not going out, and then someone in your bubble gets it and what can you do?"
Reaching vulnerable communities and struggling to scale up
Lifelong's Richmond site can only test 60 people daily and can't scale up. Compare that to a county site a 15-minute drive away in Berkeley run by a private lab, which can do up to a thousand tests per day.
During the surge, these smaller clinics have been swamped, struggling to keep up with demand. Yet public health officials say the small scale is by design, a feature not a flaw.
"It's not always about quantity. But if we're reaching those who have no other way to access testing resources, then we're achieving our goal," says Dr. Jocelyn Freeman Garrick, who leads COVID testing for Alameda County's public health department.
With demand up 400% at county testing locations, Freeman Garrick says these smaller sites do what larger ones can't – serve vulnerable neighborhoods.
"We found at those smaller sites, their percent positivity rate was much higher than the general population so the number [of tests] may be small, but that's a pivotal role," in serving people whose jobs and living situations put them at risk, Freeman Garrick says.
Another group in San Francisco's Mission District, called Unidos en Salud, also provides COVID testing and vaccinations to undocumented people, essential workers, recent immigrants, and the uninsured, through a partnership with UC-San Francisco and the Latino Task Force.
"These sites are for communities who don't have health care and where people might not trust other sites," says Dr. Carina Marquez, who founded the partnership. Still, she adds: "Size does matter when you're in a surge."
At Unidos' Mission testing site, daily tests rose from about 200 in early December to about 980 in early January as omicron hit and people spilled over from private and county-run sites in better-resourced parts of the city.
Her organization has decided not to require appointments, even though it's a challenge to manage the line that stretches around the block.
At Lifelong, after a lull in demand since late summer, it's been hard to meet the community's testing needs.
"We're in a moment in the surge where demand is through the roof. We don't have staffing and we were never built to do that," Khuner-Haber says. "It's so hard to prioritize. Everyone is coming because they were exposed, symptomatic, or needing to return to work or school. Everybody is top priority."
With some of her employees calling in sick, Khuner-Haber has struggled to stay fully staffed and hire culturally competent, Spanish-speaking staff, who are essential to building trust with patients.
Strapped for resources
Andie Martinez Patterson, a vice president with the California Primary Care Association, says mission-minded health clinics need more resources sothey can hire more staff.
"The point for health centers is that we are open door access for anybody and in particular for vulnerable and underserved disenfranchised populations," she says. "It is the moral imperative in the mission of why community health centers exist."
Martinez Patterson says neighborhood clinics have stepped into testing and vaccination as part of their role as primary care providers.
But because these clinics primarily serve Medicaid recipients, they're not reimbursed at the same rates as other testing centers, many of which negotiated large contracts with county health departments.
"We are not reimbursed anywhere close to what we're reimbursed for in the typical primary care setting. So you, in effect, take staff, you lose money immediately to achieve the moral imperative," she says. If Medi-Cal, California's Medicaid program, reimbursed more, clinics could hire more staff and serve more people.
The state provides tests and vaccines to these sites, but she argues that the current payment structure in a fee-for-service environment means clinics lose money when providing life saving vaccines and COVID tests.
COVID is a chance to restart the policy conversation about how health centers get paid, so they can be part of public health disaster response in the future, Martinez Patterson says.
Easy testing access and follow-up care are critical
There's a big need for easy access to testing in the neighborhoods served by community clinics because the mostly low-income Latino immigrant families who live there are more likely to live in multi-generational households, where one sick family member could expose more vulnerable ones.
That was Alejandra Felix's situation. There are seven people living in her home, including her daughter, and a grandson who's too young to get vaccinated.
"There's a baby in my house. That's why I'm worried. I wear gloves and a mask in my own home, because I want to protect the baby," she says. When she got sick, she stopped cooking for her family and sent her husband to sleep on the living room couch.
"Easy walk-up access to testing is critical. You want a situation where you can bring the whole family down and get tested," says Marquez from Unidos en Salud. "Testing should be low-barrier, easy to access, with no online registration, where people can wait in line, and get results quickly. Then they need to get linked to care."
Unidos also provides follow-up care to people who test positive, offering financial assistance, food, cleaning supplies, and more medical care when appropriate.
"Sometimes people need guidance on how to isolate in crowded households, when they can go back to work and what to do on day five. Vulnerable workers and families want to prevent transmission, but a positive test has so many implications for them," says Marquez.
To improve testing access, Marquez sees potential in the promotora model, where community members are trained to conduct rapid antigen tests and counsel people, then can be called in to help deal with surges. Primary care providers, schools and clinics can also be proactive in distributing at-home tests to their patients.
Meanwhile, staff at small community clinics are just trying to keep up with the surge. At Lifelong Medical, Griselda Ramirez-Escamilla, who runs the clinic's urgent care center, says this surge is taking an emotional toll on her small staff.
"We get tired and we just got to step aside, take a breath. There are times where we cry a little," she said, tearing up from exhaustion. "It's hard! And we show up every morning. We have times where we do break down, but it's just the nature of it. We have to lift our spirits and keep moving."
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