The Digital Divide Is a SDOH for the Underserved-The HSB Blog 4/19/22

Our Take:

While digital health/telehealth platforms during COVID-19 have been a favorable mode of receiving care for many, it can be considered a social determinant of health for individuals that have limited internet access. During the initial wave of COVID-19, inadequate housing, financial insecurities, and employment status continued to negatively impact racial and ethnically diverse populations. However, our reliance on digital platforms in all aspects of our lives has exacerbated socioeconomic factors that impact an individual’s ability to acquire adequate internet access and therfore limit their ability to avail themselves of health and wellness checks via telehealth or virtual appointments.

Key Takeaways:

Approximately 37% of Americans who have smartphones do not have high-speed internet connection within their homes.
Approximately 63% of Americans that reside in tribal or rural areas lack sufficient broadband connection in their homes.
Less than 1% of the funding from the Federal Communications Commission (FCC) is spent on expanding broadband connections for tribal or accompanying rural areas.
The likelihood of experiencing poor health outcomes increases within households that do not have a broadband connection and internet access.

The Problem:

As the COVID pandemic put the world into lockdown our main source of communication relied heavily on internet access and technological devices to interact and engage with our peers, fulfill work commitments and as in-person health care facilities shut down, there was a shift to digital platforms and/or the phone.However, the lack of high-speed internet access or the difficulty of accessing broadband connections at all within underserved communities was rarely taken into account. Underserved communities already have a preponderance of racial and ethnically diverse populations that struggle to receive quality healthcare, as a result moving healthcare online only compounded the problem where inaccessibility to internet connectivity and lack of broadband were already issues. In addition, of those who had internet access via smartphones many were constrained by limited data plans or data rates which were quickly throttled down beyond a certain usage point. Thus, what many viewed as the great equalizer was in fact adding another barrier to care.

The Backdrop:

While prior to the COVID pandemic electronic health records (EHR) and patient portals had become common mobile health applications that were broadly used, the lack of internet access or patient mobile usage demonstrated a significant gap in access amongst elderly groups and individuals who had resided in poor, rural, and tribal areas. According to “Digital inclusion as a social determinant of health,” “nearly 30% of older adults and 30% of those earning less than $30,000 own a smartphone and many low-income households share devices, raising both access and privacy issues.” In addition, elderly populations often need assistance to develop the technical fluency to do even the most basic things such as create emails and profiles to access patient portals. Moreover, barriers to understanding the technical or medical jargon can intimidate patients leading to inadvertent or unwanted logoffs from systems.

However, expanding broadband access generally and the improvement of health via digitally inclusive platforms relies heavily on governmental funding to promote broadband connection within neighborhoods that currently lack access. For example, although the Federal Communications Commission (FCC) Lifeline program subsidizes the costs of smartphone devices and internet services, the qualification process varies per state and a lack of consumer awareness appears to be to blame for the limited success to date of the program. Similarly, the Pandemic has also demonstrated that lack of access to broadband connection impacts not just healthcare but also the ability of individuals to find work from home or attend virtual school. For example, a study by the The Economic Policy Institute found that only 20% of African American populations and 16% of Hispanic/LatinX populations were able to work remotely due to connectivity issued. Moreover, a report entitled “Digital Disenfranchisement and COVID-19: Broadband Internet Access as a Social Determinant of Health”, found that “In Washington State, for example, some districts reported 50% or more students and families do not have access to the internet at home (Equity in Education Coalition, 2020)”.

Internet service providers (ISPs) are not the only onesto blame for the inconsistent or poor provision of broadband service that exists in many urban low-income and rural neighborhoods. It is the Federal government that regulates the delivery of internet as a regulated resource and they are taking too much of a hands off approach to this regulation. Perhaps the provision of internet should in fact be a regulated monopoly or duopoly like electric power or land-line phone service. Currently, the Federal government continues to try a nuanced approach by providing $7.171 billion to reimburse schools and libraries for providing free broadband service in the recent American Rescue Plan Act and $65 billion to expand broadband, create more low-cost broadband service options, and subsidize the cost of service for low-income households in the recent Bipartisan Infrastructure Deal. This is likely not enough.

Implications:

While moving healthcare delivery online has been shown to be a benefit to many in underserved communities in terms of convenience, reduced travel time, decreased time away from work and lower costs, this is only true for those who have consistent broadband access. Otherwise, the move to telehealth and other digital tools actually ends up exacerbating or worsening disparities that already exist. As a result, policymakers, providers, and payers need to consider this when integrating digital services into systems and care planning. For example, as noted in the AMA 2021 Telehealth Survey Report “The digital divide remains the No. 1 barrier to telehealth access for patients. Limited patient access to technology, limited digital literacy in patient mix, and limited patient access to broadband internet were the top three barriers cited by physicians.” In addition, a majority of physicians in the survey “said they use audio-only modalities to offer telehealth services” which would be one way to overcome some of the issues noted above, according to a recent survey conducted by the American Medical Association.

In addition, all of the parties noted above need to realize that once the public health emergency (PHE) is declared over a number of crucial supports for many patients will cease and many deficiencies in the system will reappear. Language barriers, lack of digital literacy, unaffordability of internet access plans or continued lack of coverage post-COVID will all remain problems. For example, a 2020 JAMA study noted approximately 13M elderly adults have trouble accessing telemedicine services, and approximately ½ of those people may not be capable of having a telephone call with a physician due to problems with hearing, communications, dementia, or eyesight, including 71% of elderly Latinx people and 60% of elderly Black people. As a result, clinicians need to make sure that when attempting to use these tools patients have the technology to access them, the capability to use them and the wherewithal to get the maximum benefit from them, otherwise they need to sit down and take corrective action so that proper care can be delivered.

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