By Paul Bolin, MD, MPH, Former Member of Minnesota Public Health Corps, Minnesota Department of Health
The COVID-19 pandemic shined a light on the benefits of utilizing telehealth to bring health care provider services to patients in a virtual format. However, according to the Federal Communications Commission, an estimated 14.5 million Americans lack access to broadband internet. This lack of access is not distributed evenly. As of 2020, 22.3% of Americans in rural areas and 27.7% of Americans in tribal lands lack high-speed broadband, compared to only 1.5% of Americans in urban areas. Compounding on this so-called digital divide is the relative lack of health care and public health providers in rural America. While 20% of Americans live in rural areas, only 10% of physicians practice in rural areas, presenting a significant and growing public health concern. Broadband access represents a promising lifeline for Americans in remote areas, with regards not only to telehealth, but also increased postsecondary educational opportunities, access to well-paying jobs through remote employment, and social interaction.
Promoting equitable access to telehealth addresses a social determinant of health (SDOH). According to the World Health Organization, social determinants of health are “the conditions in which people are born, grow, work, live, and age” that influence health outcomes. Some have described broadband access as a “super-determinant of health” as it influences multiple social determinants of health, including education, employment, social connectivity, and, in the case of telehealth, access to health care. In expanding broadband access, we have the opportunity to address multiple determinants at the same time.
Over the past few years since emerging from the pandemic, federal policymakers have begun to recognize the link between physical infrastructure (i.e., broadband) and health care access. Broadband expansion is a centerpiece of the Infrastructure Investment and Jobs Act – commonly referred to as the Bipartisan Infrastructure Law – signed by President Joe Biden in 2021. It invests roughly $65 billion through new and existing government programs to expand access to high-speed internet, including particular emphasis on rural America and tribal lands. This includes nearly $2 billion in loans and grants to fund the costs of construction, improvement, or acquisition of facilities and equipment needed to provide broadband service.
Legislators at the state level are also taking steps to expand broadband access. Alongside federal funding, the state of Minnesota has invested an additional $100 million in broadband as part of a larger agriculture bill signed by Governor Tim Walz in 2023. This funding aims to expand access to over 33,000 homes across the state.
It must be noted that addressing and solving broadband access inequities is not by itself enough to solve inequities in telehealth access. It’s only a necessary foundation. The Federal Communications Commission has identified access to broadband as the first step to achieving desired health outcomes. Beyond the potential for access, it must be ensured that individuals can afford to subscribe to broadband services. Furthermore, those who have subscribed need the knowledge and efficacy to utilize broadband for telehealth and other applications.
The success of expanding and improving telehealth access will depend on many policy and personnel factors which must be addressed by government officials, public health practitioners, and health care workers. This includes funding and sustainability, equitable access to resources, health care staff training, reimbursement policies, as well as legal issues such as malpractice insurance and licensure law reform in some states. This will require cooperation between governmental and private stakeholders. It is no small undertaking. The pandemic has taught us that telehealth is a popular and effective means to address crucial health care delivery issues and may provide solutions to stubborn and long-standing access to care inequities, as well as other social determinants, in the future.