Ensuring The Growth Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care

Telehealth’s moment has come. In an effort to limit the spread of COVID-19, Medicare is now compensating for most virtual visits, insurers are waiving virtual visit copayments, and physician organizations are urging their doctors to transition to telehealth. Telehealth increases convenience for both the doctor and patient and decreases everyone’s risk of exposure to COVID-19. But telehealth also has limitations, the most obvious of which are that it does not allow for physical exams or lab tests. Less obvious though, is the potential of telehealth to exacerbate health disparities.

Patients face three overlapping barriers to accessing telehealth: the absence of technology, digital literacy, and reliable internet coverage. Together, these barriers comprise the digital divide, which disproportionately affects older people of color and those with low socioeconomic status. These obstacles are even more insurmountable at a time when doctors are closing their outpatient clinics and delivering care exclusively from their homes, using computers or smartphones to contact their patients through video or phone calls. And along with the digital divide, data increasingly shows that older people and communities of color are at higher risk for health complications due to COVID-19.

Barriers To Telehealth: Digital Technology, Literacy, And Coverage

More than one in three US 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. While family members or caregivers can help, one in five Americans older than age 50 suffer from social isolation. Access to technology is also a barrier in other ages and minority groups. Children in low-income households are much less likely to have a computer at home than their wealthier classmates. More than 30 percent of Hispanic or black children do not have a computer at home, as compared to 14 percent of white children.

But just as access to health insurance does not equal access to health care, access to a computer does not equal access to telehealth. Even with access to a computer, 52 million Americans do not know how to use it properly. Those who lack digital literacy tend to be older, less educated, and black or Hispanic. Furthermore, older and black patients are much less likely to use their patient portal—websites where patients and physicians can communicate—than younger and white patients. Challenges in patient digital literacy during the COVID-19 pandemic have already been highlighted by the American Academy of Family Physicians.

Lack of broadband internet is associated with fewer telehealth visits and hampered patient portal use. Problems with poor coverage are most pronounced in states with a high percentage of rural residents. For example, people in Montana have the slowest average internet speed with roughly one-third of residents without reliable broadband coverage. In the face of COVID-19, deficits in coverage are already concerning people in Utah, where one in seven people do not have an internet subscription, and in Louisiana, a COVID-19 hotspot where one in four residents report the same.

Improving Telehealth Access Through Multiple Stakeholders

Digital technology, literacy, and coverage are crucial for everyday tasks such as banking and shopping, but now they have become critically important for one’s health given the massive transition to telehealth. We must not forget about our vulnerable populations who suffer from the effects of their digital divide. Policy makers, public health officials, and other community leaders should work together to ensure that health care access is not compromised because of the shift to virtual care.

Access To Digital Technology

At the national level, the Federal Communications Commission (FCC) should direct part of its $200 million dollar telemedicine investment included in the recently passed stimulus bill to improve computer ownership in rural and low-income communities. They can work with states to identify communities in need and then distribute computers accordingly. A program similar to the FCCs National PC Donation and Recycling Drive that calls for computer donations can also be implemented by federal, state, and local municipalities to collect and redistribute used technology. Similarly, the federal government can build from its past campaigns that provide free cell phones to those in need.

States can also play a key role in addressing the digital divide. Utah’s legislature recently introduced a bill that creates an office for strategy and public-private partnerships to improve telehealth participation. Through this platform, they aim to address digital technology, literacy, and coverage in their underserved populations. Another approach is to develop or support a “digital health equity” team composed of policy makers, public health experts, community leaders, and students, similar to that created by the Greenlining Institute in California.

These efforts do not have to be health focused. Our education system can improve access to digital technology and thereby improve both educational access and health access. Children across the country are being sent home under the premise that they will learn virtually; however, many children in low-income families do not have a computer at home. For instance, Los Angeles recently reported that 15,000 of their students were not attending virtual classes. K-12 schools should use funds appropriated to them via the $13 billion dollars from the Coronavirus Aid Package or tap into their local resources to provide their students with computers. Boston public schools, even before the passing of the Coronavirus Aid Package, provided 10,000 laptops to students without a computer at home. Empowering one student with a computer at home creates an opportunity for the entire household to engage with technology and also access health.

Access To Digital Literacy Training

To improve digital literacy, the Department of Education should reinstate the Community Technology Centers (CTC) program that functioned to create and expand spaces that provide disadvantaged residents from economically distressed urban and rural communities with access to information technology and the training to use it. Implementing these spaces today is impossible given the need for social distancing, but one mitigation strategy includes a partnership between health systems and the Department of Education in which CTC funds are momentarily funneled to the use of community health workers. Health systems can identify high-risk patients with low digital literacy and use community health workers to help them with the basics of using a computer or smartphone device. Both parties would need to be deemed low-risk of harboring COVID-19. CTCs can then revert to their normal use as mass teaching sites after social distancing is no longer recommended by health professionals. Alternatively, hospitals can screen hospitalized patients for low digital literacy at the point of discharge and quickly orient them to the fundamentals of digital competency.

Access To Internet Broadband Coverage

Numerous efforts at the federal and state level are ongoing to expand broadband availability. While expanding access to broadband is unlikely to be completed in the short term of the COVID-19 pandemic, it is key to do so for the next public health emergency. For now, states should place pressure on internet and phone service providers to sign onto the FCCs Keep Americans Connected Initiative to ensure that Americans do not lose their broadband or telephone connectivity as a result of COVID-19s economic impact. Furthermore, the government should ensure that internet service providers are offering low-cost basic internet plans for the portion of the population unable to afford their services. Such a mandate could be supported by the Defense Production Act, which includes “health resources” under its purview. Access to the internet should qualify as a health resource when traditional in-person health care is not an option.

In A Time Of Urgency...

In a time of urgency, it is easy to forget the people far removed from our technological society. Having a computer at home might appear trivial to those of us who use this technology daily, but it is one of irreplaceable value to many Americans, and one of dire need in a nation that must strive for equitable access to health care. The ability to use technology is equally vital. Federal, state, and local leaders, in addition to health and community systems, should push for health equity by addressing digital technology, literacy, and coverage. Their actions could ensure that the most vulnerable people are not left out during this critical time.