Rural-urban telehealth divide evident among privately insured Americans

Though telehealth use skyrocketed among United States adults with private health insurance during the COVID-19 pandemic, new research reveals that rural residents utilized telehealth less than their urban peers.

The research, published by the AARP Public Policy Institute last week, examined changes in telehealth use from 2019 to 2021 among people younger than 65 enrolled in private, employer-sponsored health insurance plans.

During the COVID-19 public health emergency (PHE), the government implemented numerous regulatory waivers, easing telehealth adoption and utilization. Following the end of the PHE last May, the future of these waivers is uncertain, with most slated to expire at the end of the year.

Thus, researchers from AARP and NORC at the University of Chicago investigated how Americans with private insurance used telehealth in the first two years of the pandemic and how the usage differed based on demographic factors. The report also includes a discussion of the findings’ policy implications.

They used a national sample of commercial insurance claims from individuals with private, employer-sponsored insurance, which covers nearly two-thirds of Americans under age 65. They found that telehealth use jumped among this population from 0.7 percent in 2019 to 19.6 percent in 2020. That figure declined slightly to 16.2 percent in 2021.

In 2020, adults between the ages of 55 and 64 were the top telehealth users among all age groups, with 25 percent using telehealth. However, utilization among this age group fell the most among all age groups, dropping 6.6 percentage points to 18.4 percent in 2021. On the other hand, telehealth use among adults aged 35 to 44 and 18 to 24 declined by only 3 and 1.7 percentage points, respectively, between 2020 and 2021.

The data also reveals disparities in telehealth use based on geography. In 2020, 20.6 percent of individuals with private insurance living in urban areas used telehealth compared to only 13.3 percent of those living in rural areas. The gap between the groups narrowed slightly from 7 percentage points in 2020 to 6 percentage points in 2021 when urban telehealth use dropped to 17.1 percent and rural telehealth use to 10.5 percent.

However, telehealth claims per user increased in 2021 in rural and urban areas despite the decline in the proportion of privately insured individuals who used telehealth. This indicated that people in both rural and urban areas who used telehealth in 2020 were more likely to use it again in 2021.

Still, urban residents used it more frequently, with an average of 4.5 encounters in 2021, compared to 3.3 telehealth encounters among rural residents in the same year.

Further, the report shows that adults with private insurance living in areas with higher median household incomes had higher rates of telehealth use in 2021 (20 percent) versus those living in zip codes in the lowest income quartile areas (12 percent).

Telehealth was primarily used to access mental healthcare services, with 41.2 percent of telehealth claims reflecting mental health conditions in 2020. This figure rose to 52.3 percent in 2021.

As lawmakers consider policy changes in the aftermath of the PHE, the researchers emphasize that changes should focus on health equity. They suggest that new policies focus on increasing access to broadband by improving both broadband availability and affordability, expanding the coverage and affordability of telehealth through regulations such as payment parity, and allowing existing healthcare providers to expand their scope of practice through telehealth.

However, the researchers noted that “telehealth should complement, not supplant, in-person care.” They cautioned against telehealth-only plans that do not fall under federal group health regulations and allowing health insurers to count telehealth services toward meeting network adequacy requirements.