Adoption of virtual care1 has skyrocketed during the COVID-19 pandemic; however, the “digital divide”—the gap between individuals who use or have access to telecommunications and information technologies and those who do not—poses a barrier for expanding patient access services.i, ii The digital divide encompasses three interrelated barriers: broadband access and affordability, technology device access and affordability, and digital literacy.iii
These barriers may exacerbate existing disparities in overall health care access and outcomes.iv For example, the boost in virtual care offerings was experienced disproportionately in higher-income counties—about 48 visits per 10,000 people, compared with 15 per 10,000 people in high-poverty areas. Additionally, patients living in metro areas averaged 50 visits per 10,000 versus 31 visits per 10,000 in rural areas.v This experience, combined with the disproportionate health and economic impacts of the COVID-19 pandemic, has created a burning platform for states to develop and implement a variety of strategies to address the digital divide.
As states develop post-pandemic virtual care coverage and reimbursement policies,vi several actions can help enable equitable patient access to virtual care and bridge the digital divide:
Achieve universal broadband access.
The Federal Communications Commission (FCC) estimates that nearly 30 million Americans do not have access to broadband internet. In particular, only 65% of Americans living in rural areas have access and, on Tribal lands, only 60% have access to high-speed internet.vii
All 50 states have created either a task force, commission or authority to coordinate broadband expansion. Some states have created programs to identify underserved and unserved areas through public mapping websites, while others have established initiatives to provide input on the development of a statewide broadband framework. At least 26 states have enacted these active/current initiatives and authorities through legislation.viii
Many states are accelerating efforts to eliminate gaps in broadband access as a result of the COVID-19 pandemic, supported by federal stimulus funding and grant programs.ix, x For example, the North Carolina Broadband Infrastructure Office issued $12 million in grants in August 2020 to support expansion of high-speed internet service in 11 rural counties.xi Similarly, Kansas, which established its Office of Broadband Development in late 2020, created the Broadband Acceleration Grant Program, which has worked quickly to disperse $10 million in its initial year as part of the ten-year, $85 million investment.xii
States are likely to have substantially more funding available if the Biden Administration passes the American Jobs Plan, which proposes to invest about $100 billion in broadband expansion over the next decade. The President’s plan prioritizes building “future proof” broadband infrastructure in unserved and underserved areas to reach 100% high-speed broadband coverage.xiii
Ensure internet access is affordable.
Increasing the availability of internet services alone is not sufficient to ensure access to virtual care. The price of internet services varies widely across the country and many consumers struggle to determine total cost due to poor transparency, highly complex pricing structures and confusing itemized billing. In addition, the high average cost of internet service is unaffordable for many U.S. consumers.xiv According to a recent study of 6 million U.S. households with annual incomes under $25,000, 51% didn’t have home internet because it was too expensive.xv
States have a role to play in enabling affordable access to the internet. To address affordability challenges, New York Governor Andrew Cuomo announced plans in January 2021 to enact comprehensive telehealth reform to help residents mitigate high costs associated with accessing virtual technologies. Under the Governor’s proposal, all internet providers would be required to offer affordable service at $15 per month to low-income households. To combat practices that limit consumer choice and increase the cost of internet services, the proposal directs the New York State Department of Public Service to require adherence to a universal “broadband disclosure” that explains all charges, such as device, termination, activation and equipment fees, in plain and easy-to-understand language so consumers will no longer get hit with unexpected charges. Additionally, the proposal includes plans to launch a website to help New Yorkers find the affordable plan in their area and report on coverage gaps and consumer experiences.xvi
Legislation modeled after the proposal, the Affordable Broadband Act, was signed by the Governor in April 2021. The Governor also launched the Affordable Broadband Portal to help New Yorkers find the affordable broadband programs in their area.xvii
Require coverage of select, clinically appropriate audio-only services.
Audio-based telehealth has been instrumental to maintaining access to care during the COVID-19 pandemic, particularly for individuals who lack a computer, smartphone or sufficient data plan to support audio-visual telehealth.xviii, xix Further, there is a small but growing body of literature demonstrating that audio-based telehealth is an appropriate modality for patients receiving certain services that don’t require a physical or visual exam.xx, xxi However, payers may stop reimbursing for most audio-only visits in coming months because of concerns related to cost, quality, and potential for fraud and abuse. These concerns may be alleviated by narrowing audio-only coverage to only a select set of services (e.g., evaluation and management services that don’t require a physical exam, or behavioral health counseling) that they deem can be delivered via audio-only in a clinically appropriate manner. To date, North Carolina, New York and New Hampshire have enabled ongoing Medicaid coverage for audio-only services to enable access for low-income populations who are disproportionately impacted by the digital divide.xxii, xxiii, xxiv Rhode Island is also advancing a bill through its state legislature that expands the definition of telemedicine to include audio-only services and prohibits any payer from imposing specific requirements or limitations.xxv
Provide patient education to improve digital literacy.
Americans fall along a spectrum of readiness when it comes to using digital technologies to engage in virtual care. Nearly 16% of Americans (31.8 million) lack sufficient comfort or competence with technology to use a computer.xxvi In recognition of these gaps among state residents, the Rhode Island Office of Innovation launched an initiative called ConnectRI in 2019 that offers digital literacy courses that are open to the public.xxvii During the COVID-19 pandemic, the program has been instrumental to providing state residents with high-speed, low-cost internet service, computers, and education.
Improve accessibility of services for individuals who require interpreter services and other accommodations.
There are an estimated 25 million people in the United States who speak little English and would require assistance engaging in telehealth services.xxviii At least 15 states had enabled Medicaid and CHIP reimbursement for interpreter services before the COVID-19 pandemic, and more have expanded reimbursement recently.xxix The Oregon Health Authority enabled an add-on payment for interpreter services for Medicaid telehealth visits through June 30, 2021.xxx Massachusetts similarly introduced a bill in the state Senate during the 2021 session that requires reimbursement for interpreter services for patients with limited English proficiency or those who are deaf or hard of hearing.xxxi
There is also a pressing need for states to include individuals with disabilities in policy and program development.xxxii New Jersey introduced a bill in early 2021 that requires telemedicine and telehealth systems to include accessible communication features to facilitate the use of telemedicine and telehealth by individuals with a disability and individuals with a sensory impairment, including, but not limited to, individuals who are deaf, hard of hearing, visually impaired, blind or deaf-blind.xxxiii
Supporting the adoption of school-based telehealth may also increase accessibility to both primary and specialty services for the estimated 8.1 million students who don’t have access to either required technology or broadband at home.xxxiv Even before COVID-19, the use of school-based telehealth was growing rapidly.xxxv Twenty-eight states explicitly allow schools to deliver telehealth services, although restrictions often apply.xxxvi In North Carolina, Atrium Health, funded in part by the state’s Medicaid program, developed a school telehealth network specifically for small schools in areas where poverty and unemployment are high and insurance and access to primary care are scarce.xxxvii
Support provider education to encourage the delivery of patient-centered virtual care.
States are focusing on developing and launching provider-focused trainings to promote sustainable adoption of virtual care and effective deployment of new technologies. In Rhode Island, the Care Transformation Collaborative, convened by the Office of the Health Insurance Commissioner and Medicaid, provides training and infrastructure payments to primary care practices to support delivery of team-based virtual care services.xxxviii The Michigan Department of Health and Human Services leverages an existing partnership with GetSetUp, an education technology company, to offer multiple hours of free online tutorials on using telehealth technology, videoconferencing and managing online appointments. GetSetUp’s interactive video platform is designed to help older adults become more comfortable with technology.xxxix, xl
The COVID-19 pandemic has shone a light on the urgent need to close the digital divide. Continued state investment and policymaking to enable patient access to virtual care is crucial to ensuring its sustainability within the health care delivery system.
1 The definition of virtual care encompasses all forms of remote health care delivery, to include synchronous, audiovisual telehealth, telephone (i.e., audio-only), store and forward, remote patient monitoring, SMS text-messaging, and portal communications.