The Digital Divide is Real: How Can We Address it Right Now?

Our Take:

National trends in telehealth use show the popularity of telemedicine has not waned since the COVID-19 pandemic. However, inequities in home broadband access disproportionately impact vulnerable communities in need of telehealth access such as older adults, racial and ethnic minorities, low income, and rural communities. These communities share a higher burden of chronic conditions and higher likelihood of mortality from leading causes of death such as cancer and chronic lower respiratory disease. Adequate home broadband access has emerged as a vital social determinant of health, impacting access to high quality healthcare, health information and social services. Broadband access also intersects with other social determinants such as access to education, social support, and employment, further impacting health outcomes and overall wellness. Aspects of inadequate broadband access such as the lack of high-speed internet or smartphone dependence significantly impacts the quality and timeliness of virtual medical care. Despite the promise of additional government investment in broadband under the Infrastructure Investment and Jobs Act, lack of adequate home broadband access will leave historically disenfranchised, and underserved populations with existing health disparities behind as healthcare continues to move toward the virtual model while access is being built out.

Key Takeaways:

More than 25% of the U.S. population lacks adequate home broadband access, with that number rising to 57% for those earning less than $30,000 per year and 73% for those living in tribal and/or rural areas (Pew Research Center)
Counties where patients required the highest level of care and had the highest acuity (as measured by Hierarchical Condition Categories-HCC risk score) had 50% higher telehealth utilization vs. counties with patients who had the lowest acuity (Journal of Telemedicine and Telecare)
28% of Americans in households earning less than $30,000 per year rely on a smartphone for internet access compared to only 4% of individuals in households earning $100,000 or more (Journal of Telemedicine and Telecare)
Rural Americans are more likely than their urban counterparts to die prematurely from the five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke (CDC)

The Problem:

Broadband access in the home has become increasingly important since the COVID-19 pandemic as telehealth services become common practice and even preferred in some populations such as communities where telehealth can decrease transportation costs, and other barriers to healthcare. However, as noted in a recent article in the Journal of Telemedicine and Telecare, high-quality telehealth visits require adequate broadband access with the authors finding that counties with the highest median household income had 35% higher telehealth utilization as compared to the counties with the lowest. Moreover, according to a 2024 Pew Research Center Study entitled, Americans’ Use of Mobile Technology and Home Broadband, 95% of adults having annual household income of at least $100,000 say they have broadband access compared with only 57% of adults in households making less than $30,000 per year.

The Backdrop:

With research indicating that 28% of Americans in households earning less than $30,000 per year rely on a smartphone for internet access compared to only 4% of individuals in households earning $100,000 or more it is clear that the digital divide is real. However these disparities in care and access to care are real. example, counties where patients required the highest level of care and had the highest acuity (as measured by Hierarchical Condition Categories-HCC risk score) also had 50% higher telehealth utilization as compared to the counties with patients who had the lowest acuity according to the above referenced Journal of Telemedicine and Telecare article. Given an HCC risk score predicts how likely chronic health conditions are to affect long-term health outcomes, this suggests that the communities with the highest burden of chronic conditions were also more reliant on telehealth during COVID-19. Similarly, we can conclude that these communities are also more vulnerable to adverse health outcomes when they experience inadequate broadband access.

Implications:

It is generally well established that communities more likely to have poor internet access may also experience a decline in healthcare visits, inconsistent telehealth usage, as well as a decline in the quality of telehealth visits if they use them at all. For example, according to the CDC, rural Americans are more likely than their urban counterparts to die prematurely from the five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease and stroke - all of which are conditions that can be addressed through digital technologies like remote patient monitoring. Perhaps the bigger question is while we wait for these larger infrastructure investments in widespread broadband to occur, what can we do right now?

1) Fixed Wireless: One proposed solution is wider adoption of fixed wireless. As noted by Verizon, fixed wireless access (FWA) has the potential to provide these communities with access to affordable high-speed internet despite the lack of infrastructure. FWA “is a type of 5G or 4G LTE wireless technology that enables fixed broadband access using radio frequencies to send high-speed signals that offer data transfer to and from consumer devices instead of cables.”

2) Coverage of Audio Only Telehealth: Additional support and coverage for audio only telehealth could help bridge the gap. For example, During the COVID-19 pandemic, the Public Health Emergency (PHE) granted broader access to telehealth services including audio-only services for Medicare and Medicaid recipients. An analysis by HHS entitled “ Updated National Survey Trends in Telehealth Utilization and Modality (2021-2022)” showed persistent disparities in accessing video telehealth services by education level, age, race, and ethnicity. Individuals who identified as Hispanic or Latino, Black, and Asian were found to be more likely to use audio-only vs video telehealth services than White respondents. While the Consolidated Appropriations Act, 2023, provided an extension for some flexibilities for providers to bill through December 31, 2024, there is currently no mandate for payment parity for audio-only reimbursement.

3) Public/Private Partnerships and Subsidies: Finally, additional subsidies, perhaps enabled by public private partnerships, should be considered to increase smartphone access. As noted by the 2024 Pew Research Center study, adults ages 65 and older are less likely to even own a smartphone. Consequently, the establishment of state and local programs and partnerships that subsidize the cost of digital devices for individuals/populations that cannot afford these devices can help reduce or eliminate the financial burden of providing individuals with even limited internet access through smartphones. This would be particularly true for those who are most financially burdened such as unhoused individuals and could serve as the hub for enabling a number of other services. While disparities in digital literacy would still impact the quality of telehealth for individuals reliant on their smartphones, they could be combined with training and other services to improve literacy and connectivity. Not only could this education be used to promote equity, payers, providers and care teams could be engaged to connect people with coverage and ensure they were making use of the most appropriate and cost-effective sites of care.

As our healthcare system continues to move toward a more digitized, virtual model of care, currently underserved communities and populations with existing health disparities can be brought into the system in a more effective, convenient, and patient-friendly way that reduces barriers while improving the cost and quality of care.

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