The use of telehealth technology and services has increased by record levels in 2020, driven by the realities of the COVID-19 pandemic and subsequent telehealth policy flexibilities temporarily implemented by federal, state and private payers.1 Changing attitudes toward coverage, reimbursement and use are all positive trends for the future of telehealth service delivery; however, the “digital divide”—the gap between those who use or have access to telecommunications and information technologies and those who do not—poses a major challenge to realizing the promises of virtual care. The digital divide encompasses three interrelated barriers:2
- Absence of Technology: More than one in three U.S. households headed by a person age 65 or older do not have a desktop or a laptop, and more than half do not have a smartphone device.3
- Digital Literacy: Even with access to a computer, 52 million Americans do not know how to use it properly.4 Exacerbating technology literacy issues, 25 million disproportionately low-income Americans speak little English and may require interpreter or other services to access virtual care.5
- Reliable Internet Coverage: Recent estimates report that the number of Americans who lack access to broadband ranges from 21.3 million to as high as 42 million.6, 7 The Office of the National Coordinator for Health Information Technology (ONC) states that access to broadband internet is a requirement for telehealth programs, for sufficient bandwidth is needed to transmit high-quality audio, visual, text and image data to support patient care.8
Recognition of the digital divide is not new. For example, the American Medical Informatics Association has been advocating for broader recognition of broadband access as a “social determinant of health” or a critical factor that plays an important role in healthcare and public health outcomes since well before the public health emergency.9, 10
Rural patients and providers are disproportionately impacted by the digital divide, a fact that has been highlighted during the COVID-19 public health emergency.11, 12 Rural communities have historically faced healthcare access issues, stemming from acute shortages of healthcare providers and geographic barriers to care, among other obstacles. The delivery of healthcare services remotely through telehealth approaches offers enormous potential to improve access to care in these communities, but telehealth’s promise hinges on access to fast and reliable broadband.13 According to the most recent FCC estimates, 26 percent of rural residents lack access to broadband, and a Pew Trusts report found that 60 percent of healthcare facilities outside metro areas lack broadband access.14, 15 Permanent policy changes, such as lifting telehealth delivery restrictions for federally qualified health centers (FQHCs) and rural health clinics (RHCs), would be a boon for rural patients and providers. Without addressing the digital divide, however, the full potential of these changes cannot be realized.
The digital divide is also a racial equity issue. Racial and ethnic minorities, people living on tribal lands, older adults, and those with lower levels of education and income are less likely to have broadband at home.16 Further, those who lack digital literacy tend to be older, less educated, and black or Hispanic. Older and black patients are much less likely to use their patient portal—a website where patients and physicians can communicate—than are younger and white patients.17
The challenge posed by the digital divide will require a multistakeholder effort to overcome. A number of federal, state and private industry efforts to address the digital divide existed before the COVID-19 public health emergency, and some are emerging to address urgent needs.
Federal agencies such as the FCC, the National Telecommunications and Information Administration (NTIA, in the Department of Commerce) and the Rural Utilities Service (RUS, in the U.S. Department of Agriculture) have existing funding initiatives to narrow the digital divide—primarily by funding broadband infrastructure. For example, the FCC’s two-part Rural Health Care Program supplies eligible healthcare providers with funding for broadband and telecommunications services that support digital and virtual health projects.18 The first component of the program, the Healthcare Connect Fund, provides support for high-capacity broadband connectivity to eligible healthcare providers (HCPs) and encourages the formation of state and regional broadband HCP networks. Under the program, eligible rural HCPs and those nonrural HCPs that are members of a consortium that has a majority of rural HCP sites can receive a 65 percent discount from the fund on all eligible expenses.19 The second component, the Telecommunications Program, ensures that eligible rural HCPs pay no more than their urban counterparts for telecommunications services used for healthcare purposes. The Telecommunications Program supports the difference between urban and rural rates for telecommunications services for eligible rural HCPs.20 There are also federal funding programs to address other aspects of the digital divide, such as digital literacy and inclusion.21
In response to COVID-19, the FCC has relaxed certain recertification, eligibility and enrollment requirements for Lifeline, a federal program that provides subsidized phone and/or internet service to low-income households (enrollment in Medicaid, among other programs, makes one eligible for the program).22 The commission released a Report and Order establishing the COVID-19 Telehealth Program in April. The program will distribute the $200 million appropriation from Congress under the Coronavirus Aid, Relief, and Economic Security (CARES) Act in order to help healthcare providers provide telehealth services to patients in response to the COVID-19 emergency and include investments in telecommunications and broadband connectivity services.23
Before the pandemic, a growing number of states created dedicated offices and full-time staff positions to work on broadband availability and accessibility, as well as other issues of digital inclusion.24 For example, Maine’s program to enable universal availability of high-quality internet, ConnectME, was founded in 2006 and is powered primarily by a small fee related to landlines and some broadband connections. North Carolina’s Broadband Infrastructure Office created a Broadband Community Playbook, which has driven county-level improvements in digital access.25
In response to the pandemic, several states have started new initiatives to address the digital divide, both temporarily and in advance of future telehealth policy changes. New Mexico amended Appendix K during the pandemic to allow its Medicaid 1915(c) Home and Community-based Waiver participants up to $500 to ensure they have access to a computer, tablet or other smart device necessary for remote videoconferencing, training and monitoring by clinicians.26
In March, three states introduced new bills aimed at broadband access:
- California introduced AB 2163, which would require state agencies to work together to develop a grant program to support broadband and telecommunications infrastructure.27
- New York introduced S5996, which requires the Public Service Commission to review the status of broadband and fiber optic services within the state and to construct those services in communities in which such services are absent.28
- Utah introduced House Bill 385, which proposes to create a Division of Digital Access and Opportunity that would implement programs and policies to address digital equity by promoting digital access, literacy and safety.29
Several state Medicaid programs are addressing telehealth accessibility barriers during the pandemic. This is particularly notable because Medicaid has traditionally focused on social determinants such as food and housing insecurity.30, 31 Massachusetts and New York have issued resources to provide Medicaid beneficiaries with information about options for accessing technology required for telehealth.32, 33, 34 The Office of Inspector General (OIG) has notified providers that they may reduce or waive cost-sharing obligations beneficiaries owe for services delivered via telehealth without being subject to OIG administrative sanctions. As of mid-June, 18 states have broadly waived cost-sharing charges in their Medicaid programs and 20 have issued guidance to waive or lower telehealth copayments specifically (note that some states did not charge cost sharing for any or all services prior to the pandemic).35
Private healthcare organizations and technology companies have also launched initiatives in the past few years to address the divide:
- Driving Real Innovation for a Vibrant Economy (DRIVE), an economic development council of local governments in Pennsylvania, and Geisinger health system partnered in 2018 to bring expanded internet access to Montour County, Pennsylvania.36
- Facebook is building orbital lasers and satellites to increase rural access to the internet.37
- Google’s parent company, Alphabet, recently received approval to deploy internet balloons in Kenya.38
- SpaceX’s Starlink project proposes to deliver high-speed broadband internet to “locations where access has been unreliable, expensive or completely unavailable” and targets service in the northern United States in 2021.39
- Microsoft’s Airband is leveraging unused spectrum between TV stations to deliver internet connectivity to underserved communities.40 For example, the company partnered with rural technology operator RTO Wireless in 2018 to enable broadband access for almost 300,000 people living in rural areas of New York and Maine.41 In 2019, Microsoft and Watch Communications brought broadband internet access to rural areas of Ohio, Indiana and Illinois.42
Historic levels of telehealth adoption and service delivery have prompted increased awareness of the challenge the digital divide poses to the expansion of telehealth. With the prospect of a more flexible coverage environment and reimbursement parity for many telehealth services after the public health emergency, the last hurdle will be ensuring that providers can reliably reach their patients. Further investment in and support for patient access to telehealth are critical to ensure the sustainability of these services in the medium to long term for practices that incorporate new telehealth offerings. Additionally, the pandemic has only made health disparities—and the structural discrimination they are rooted in—more apparent.43 Thus, digital equity will continue to be a necessary consideration as telehealth becomes a more common method of delivering care.