Telehealth is frequently touted as a key strategy for improving access to care, but data often show disparities in its use for certain rural and underserved populations.
A recent federal report found that, despite a 63-fold increase in Medicare telehealth utilization during the pandemic, Black and rural enrollees were less likely to use the service compared with white and urban enrollees, respectively. Other studies found low-income patients were less likely than high-income earners to turn to telehealth.
Reasons for these differences in vary. Many researchers point to lack of broadband as a leading barrier to accessing telehealth, particularly for rural patients. Some patients may also be less inclined to use, or may lack access to, the computer or smartphone technology needed to facilitate the visits.
To permanently incorporate telehealth into health care delivery, and to mitigate the disparities in access and use of the service, policymakers are expanding broadband infrastructure, allowing audio-only telephone visits and assessing site restrictions and reimbursement.
Bolstering Broadband
Millions of consumers lack reliable broadband access, which is often a requisite for telehealth services.
The Federal Communications Commission estimates that, as of December 2019, at least 14.5 million Americans had insufficient broadband speeds, although advocates argue the number is likely higher. Recent federal initiatives, with more coming down the pike, may have made progress toward reducing that number.
The federal Infrastructure Investment and Jobs Act allocated $65 billion for broadband-related projects, including a $42.5 billion grant program for states and the territories to expand broadband infrastructure. The law requires states to prioritize funding for “unserved” areas (those lacking at least 25/3 Megabits per second service), which are predominantly rural. States can then use funds for “underserved” areas (lacking 100/20 Mbps), followed by “anchor institutions” including health centers, schools and libraries.
Every state will receive a minimum of $100 million, though final funding allotments will be determined by the number of unserved and underserved areas in a state based on maps created by the FCC.
State broadband offices, task forces or other authorities will play a primary role for many states in obtaining these funds and deciding how they are used. For example, the Georgia Broadband Program developed its own maps to identify areas without adequate broadband, which the state can compare with FCC maps to determine where to target federal dollars.
The federal infrastructure bill included other funding opportunities for states and territories, such as $2.75 billion to help fund digital equity and inclusion efforts. Additionally, at least 25 states and America Samoa have allocated American Rescue Plan Act funding toward broadband projects.
Taking to the Telephone
Before the pandemic, most states heavily restricted or prohibited audio-only telephone consultations. Since then, however, several states have expanded access to audio-only to better ensure access for certain patients, especially those with limited broadband or access to live video.
At least 29 states enacted legislation in 2021 related to audio-only telephone visits. Some states specified audio-only telephone coverage for Medicaid or private insurers or both. Many states simply lifted previous restrictions on these visits.
Some legislation maintains limitations on audio-only visits. Tennessee limited audio-only to telebehavioral health visits—and only if the patient lacks access to live video or other telehealth modalities. Washington required Medicaid and private insurers to reimburse for audio-only at the same rate as in-person care, referred to as payment parity. However, a provider must have an established relationship with the patient—or another provider with an established patient relationship must have referred the patient to the current provider.
Assessing Site Restrictions and Reimbursement
Some researchers identified site restrictions—requirements affecting where telehealth can be used—as another barrier to virtual services, particularly for low-income patients. In response, several states permanently lifted restrictions on where patients can be located when receiving telehealth services (the “originating site”) and where providers can be located when delivering services (“distant site”).
Minnesota and Oklahoma broadly defined the originating site to be where the patient is located when receiving care. Arkansas clarified originating site as a patient’s home. And Colorado, Mississippi and Texas authorized certain facilities, including federally qualified health centers and rural health clinics, to be both originating and distant sites for Medicaid reimbursement.
Lastly, many states are bolstering reimbursement requirements for telehealth, which proponents argue is critical for providers in underserved communities. At least 22 states require payment parity for private insurers. Other states—Iowa, Massachusetts, Nebraska and Rhode Island—limit parity to specific services, including mental and behavioral health. Maryland and New Hampshire implemented payment parity for their Medicaid programs in recent legislative sessions.
These represent just some of the strategies states are using to ensure equitable access to telehealth. Between allocating federal broadband dollars and assessing telehealth regulations, states will continue playing a primary role in shaping the role of telehealth beyond the pandemic, particularly for rural and underserved communities.
Jack Pitsor is a policy associate in the health program.
This resource is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services as part of an award totaling $767,749, with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. government.