Telehealth–the ability for providers to care for patients using computers, tablets, or smartphones–has the potential to expand access to healthcare by allowing people to interact with providers remotely. However, there are disparities in access to the technology that makes it possible to use telehealth. For example, in analyzing Census data on availability of widely used technologies (i.e., computers and internet), there are substantial differences in access to broadband. Inequalities in access to technology exacerbate existing disparities in access to care.
Now, as we prepare for the end of the COVID Public Health Emergency (PHE), providers are considering how telehealth should be incorporated into future models of care, and policymakers are debating which of the PHE telehealth flexibilities should be made permanent. As telehealth policy evolves, identifying which populations still struggle to access and use telehealth can help inform solutions to advance healthcare equity and reduce barriers to accessing care.
Increase in Use of Telehealth in Medicaid During the PHE
Overall, use of telehealth in the Medicaid program increased substantially during the pandemic as people sought to stay in their homes and new, temporary flexibilities were granted to allow more services to be covered. A 2021 report from the Government of Accountability Office (GAO) found a 15-fold increase in the use of telehealth services from 2019 to 2020. Across the 5 states examined by the GAO, approximately 455,000 Medicaid beneficiaries used 2.1 million telehealth services between March 2019 and January 2020 compared to 4.9 million beneficiaries using 32.5 million services between March 2020 and February 2021. However, despite this increase in utilization, there are gaps in access to telehealth care that resemble disparities in access to in-person services. If not addressed, these disparities could exacerbate inequities in the healthcare system.
Ongoing Disparities in Access to Technology Necessary for Telehealth
Often barriers to accessing healthcare disproportionately affect historically underrepresented populations (e.g., individuals with lower socioeconomic status, Medicaid recipients, and minority populations). Our team found evidence those same groups may face more barriers to accessing telehealth services that require an internet connection. Using American Community Survey (ACS) data, we found more limited access to internet in households with lower income, in areas with a higher proportion of Medicaid recipients, and in areas with a higher percentage of minority households. (All results were statistically significant at the 95% confidence level.)
A higher percentage (34%) of lower-income households (incomes less than $20,000 a year) were without a home internet subscription compared to households with higher average incomes (only 6% of households with incomes of $75,000 or greater a year were without internet). Additionally, access to the internet at home was more ubiquitous in areas with a higher proportion of non-Hispanic White households.
In areas with a high proportion of households identifying as non-Hispanic White (>=83%; upper 75th percentile of all households), 10% did not have access to a computer and 15% of households did not have access to internet. In contrast, in areas with a low proportion of households identifying as non-Hispanic White (<35%; lower 25th percentile of all households), 12% were without a computer and 21% lacked internet.
We found that areas with a larger percentage of the population enrolled in Medicaid also had lower computer ownership and less access to internet. In areas with high Medicaid enrollment (>= 29% participation), 14% of the population did not own a computer and 24% had no access to internet, compared to areas with low Medicaid enrollment (< 10% participation), in which 4% did not own a computer and 8% were lacking internet access.
Percentage of Households Lacking Internet Access by Income, Race, and Medicaid Status
Source: Author analysis of American Community Survey data
Traditional Barriers to Care Affect Access to Telehealth
Households with higher income are more often able to reliably access the technology necessary for telehealth. At the same time, access to technology is necessary, but not sufficient, for accessing telehealth. Barriers to in-person care, such as distrust of institutions and unfamiliarity with or fear of healthcare services, still resonate in the world of remote care.
A study published in the July 2022 issue of Medical Care focused on the Florida Medicaid population found that telehealth use was highest among those with chronic conditions who were already higher users of in-person care. Telehealth use was lower for Medicaid recipients in rural areas and health professional shortage areas where there may already have been barriers to in-person care.
While telehealth can help overcome some traditional barriers to access, such as distance to providers and access to translators for non-native English speakers, it can also introduce new barriers through lack of access or familiarity with technology.
The Future
More people across the country are gaining access to telehealth services through expansion of PHE-related flexibilities, new allowances through commercial plans, and state laws to support expanded services. Despite policies aimed at reimbursement parity and coverage for new services, use of telehealth requires access to the internet and comfort using technology. While disparities in accessing technology exist, advancing equity in telehealth will require more than ubiquitous internet access. Many of the same barriers to seeking in-person care are also relevant for telehealth. Truly expanding future access to healthcare will require reaching out to vulnerable populations to both provide technological support and understand, and breakdown, long-entrenched barriers to care.
Emily Gillen