Exploring America’s broadband problem & what it means for telehealth

Even as telehealth adoption and utilization soared amid the in-person care restrictions of the COVID-19 pandemic, it quickly became apparent that expanding telehealth access equitably is easier said than done.

The public health emergency (PHE) threw into sharp relief the disparities in the digital healthcare arena, from income and housing insecurity to race and age-related barriers. As researchers delved into the various social determinants of health (SDOH) hurdles hindering virtual care, a particularly trenchant one emerged: lack of broadband access.

Broadband, or high-speed internet, allows people to access the internet at significantly higher speeds than dial-up services, according to the Federal Communications Commission (FCC). The high speed is facilitated through various digital transmission technologies that move text, images, and sound as “bits” of data. These include digital subscriber lines (DSL), cable modems, fiber, wireless, and satellite technologies.  

Access to fast, reliable, and secure broadband is critical for the delivery and receipt of digital healthcare, including telehealth. Here, mHealthIntelligence will detail the broadband access challenges in the United States and how they affect telehealth services.

UNDERSTANDING THE BROADBAND PROBLEM

Though the FCC has taken a glass-half-full approach to progress made in broadband availability over the last few years, independent research shows that the problem is more widespread than FCC reports show.

For instance, the agency’s 2021 Broadband Deployment Report noted that 14.5 million Americans lacked access to 25/3 Mbps broadband service at the end of 2019, down from 18.1 million at the end of 2018. Additionally, the report states that the gap between urban and rural Americans with access to 25/3 Mbps fixed broadband service fell from 30 percentage points at the end of 2016 to 16 percentage points at the end of 2019.

However, the independent research organization BroadbandNow estimates that in 2021, at least 42 million Americans lacked access to terrestrial broadband internet.

The organization further notes that every state over-reports its broadband availability. Though Texas has the most Americans without broadband, with 1.8 million lacking access to a 25/3 connection, Rhode Island over-reports state broadband availability the most. Rhode Island reports that 8,653 residents are without broadband internet; according to BroadbandNow estimates, that figure is 13,227, 52.8 percent higher than the state reporting.

This lack of broadband availability is driven by numerous factors, including roadblocks to municipal broadband operations, according to BroadbandNow. Four states do not have municipal broadband networks, and 16 have laws hindering them.

Another critical barrier is cost. Survey data from the National Telecommunications and Information Administration reveals that 18 percent of Americans say they can’t afford home internet services.

During the PHE, the FCC and other federal agencies took numerous steps to expand broadband availability and access. These included pouring millions into projects to alleviate broadband cost burdens and supporting broadband providers in expanding their services.

One of the most consequential FCC efforts to increase broadband access during the PHE was the Affordable Connectivity Program (ACP). Launched in December 2021, the $14.2 billion program offered eligible households a discount on their monthly internet bill and a one-time discount on technologies like laptops, desktop computers, or tablets.

An FCC factsheet released in February 2024 showed that over 23 million households were enrolled in the ACP. Most of these households (68 percent) said they had inconsistent or zero connectivity prior to ACP, with 80 percent citing affordability as the primary reason for the inadequate connectivity. A majority of households (72 percent) also noted that they use their ACP internet service to schedule or attend healthcare appointments.

However, the funding for the ACP has since dried up, resulting in the program ending on June 1, 2024. As a result, the 23 million households enrolled no longer receive the ACP discount.

While other options are available to help with internet and technology-related costs, like the FCC Lifeline program and various Department of Veterans Affairs (VA) programs, the loss of the ACP is expected to hit Americans hard, especially vulnerable populations. The White House estimated that nearly half of the households benefitting from ACP are military families, one in four are Black households, and one in four are Latino.

HOW DOES BROADBAND ACCESS AFFECT TELEHEALTH USAGE?

The lack of broadband access significantly curbs virtual care utilization, primarily because if Americans cannot access broadband, they cannot use online services. Research has well-documented the connection between broadband access and telehealth access.

A survey conducted by the Bipartisan Policy Center in 2021 revealed that a lack of broadband connectivity is a significant barrier to telehealth access. The survey polled 1,766 adults ages 18 or older.

Survey results show that 45 percent said access to technology, including broadband and computers, is a barrier to telehealth. More than one-third of rural residents reported that high-speed internet and technology access were obstacles to using telehealth, and nearly half (42 percent) of adults over 65 cited broadband connectivity as the main obstacle to using telehealth.

Additionally, broadband availability has been linked to video visit use. According to a study published in 2022, patients from the Veterans Health Administration (VHA) who engaged in video-based telehealth the most frequently experienced the highest levels of broadband availability and had the lowest area deprivation index (ADI).

For the study, researchers gathered administrative data on primary care from the VHA before (Oct. 1, 2016, to Feb. 8, 2020) and during (March 1, 2020, to June 30, 2021) the COVID-19 pandemic. They found that veterans with optimal broadband availability participated in 16 additional video visits per 100 patients per quarter compared to those with inadequate broadband.

Research also shows that broadband availability directly influences telehealth use. For a study published in 2023, researchers merged county-level data on broadband capacity, telehealth utilization among Medicare Fee-for-Service beneficiaries from January through September 2020, and county-level socioeconomic characteristics.

They found that of 3,107 counties studied, those with the most significant broadband availability had 47 percent higher telehealth utilization than counties with the least. Not only that but rural county designation was also associated with decreased telehealth utilization.

Research further highlights that underserved communities typically experience more extensive broadband and internet access challenges, widening the digital divide in healthcare.

A 2020 Peterson-KFF Health System Tracker analysis showed that more Hispanic and Black Americans did not have internet access at home in 2019 than White Americans. About 18 percent of seniors did not have internet access at home, including 28 percent of Black seniors and 24 percent of Hispanic seniors.

Data released in 2024 shows that these trends have persisted over time. The Pew Research Center released a factsheet showing that though 80 percent of US adults said they subscribed to home broadband in 2021, White Americans subscribed to home broadband at higher rates (83 percent) compared to Hispanic Americans (75 percent) and Black Americans (68 percent). Similarly, 87 percent of 30-49 year olds subscribed to home broadband in 2021, compared with only 70 percent of those 65 and older.

Broadband availability differs not only by race but also by location. A county-level analysis published by the University of Cincinnati last year identified disparities in healthcare and high-speed internet access in the US. While counties with the highest broadband access also had the lowest barriers to healthcare access, counties with fewer healthcare resources had the lowest broadband access.

There is also research showing that, on the flip side, expanded broadband access boosts rural healthcare delivery.   

A 2023 report by the Southern Rural Black Women's Initiative for Economic and Social Justice revealed that expanding broadband infrastructure in rural areas could save millions in healthcare costs.

The researchers examined the most common health issues in 10 counties in rural Alabama, Georgia, and Mississippi, including diabetes, chronic respiratory diseases, heart disease and heart failure, and cancer.

Overall, healthcare cost savings from expanded broadband and, therefore, telehealth access could total almost $43 million annually, according to the report.

Not only is broadband availability stratified by race, age, and location but also by income. Pew Research Center data reveals that 92 percent of people with an annual household income of $75,000 or more subscribed to home broadband in 2021 versus 57 percent of those with an annual household income of less than $30,000.

This data highlights the widening care gaps between Americans with and without reliable broadband connectivity. But there are gradients even among those who have access to high-speed internet.

Americans with unreliable or spotty internet connections could experience dropped calls or bad connections that deepen their distrust and frustration with the healthcare system, the Department of Health and Human Services notes.

This disruption could especially stymie telemental healthcare delivery, with dropped calls or spotty connections making virtual therapy sessions less effective. Telemental healthcare has maintained its popularity as a telehealth use case even as in-person care resumed. Telehealth may have dropped nearly 25 percentage points from peak usage in 2020, but 37 percent of mental health visits were still occurring virtually in 2023, according to data from Epic Research.

As federal and state governments work to expand broadband availability nationwide, telehealth providers must work around the existing barriers to broadband access to ensure that telehealth benefits reach the most vulnerable Americans.