Telehealth Disparities Compound Existing Disparities
In light of the benefits of telehealth, and especially during the pandemic, attention to the adoption of telehealth in underserved communities is of urgent importance. The very populations that most lag in telehealth use (e.g., seniors, people with economic or social vulnerabilities, and those living in rural areas) stand to benefit the most from the convenience it offers. Since populations with low telehealth use already experience higher rates of chronic disease and premature death, the disparity in telehealth use is likely to increase, rather than decrease health disparities.
For example, in the United States, health and life expectancy are strongly associated with race, education and poverty. Black and Hispanic adults are considerably more likely (16.9% and 16.0%) than White adults to say that they are in fair or poor health (10.4%). The same groups are also more than half-again as likely to have diabetes (13.0% for Black and 13.2% for Hispanic adults) than Whites (8.0%).
Healthcare only explains a small fraction of differences in health outcomes. Poverty, education and other social determinants of health, including access to healthy food, safe places for physical activity, transportation, and employment opportunities--are far more influential. Thus, people with a college diploma live nearly 14 years longer than those with less than a high school education. Having a high income adds 10 years to life expectancy for vulnerable populations.
The excess burden of disease experienced by Black and Brown people reflects differences in access to resources and environmental factors. Whereas 29.5% of all white adults have less than a high school education, that is true of 38.4% of Black adults. Black households are twice as likely as white households to be living below the poverty level (25.0 versus 12.2 percent). Additionally, pervasive racism has a marked toll on physiologic and psychological health.
Taken as a whole, we cannot explore solutions to telehealth disparities without also addressing the social determinants of health that exacerbate health disparities.
A reliable broadband connection is essential for telehealth. Lack of broadband and digital skills have been recognized as significant barriers to telehealth adoption. Whereas national statistics on internet access point to gaps especially in rural areas and for seniors, tremendous variability underlies these averages, especially in urban communities. For example, in the U.S., 82.7% of all households in the US had broadband internet subscriptions as of the 2019 American Community Survey 5 year census data. However, tremendous disparities are seen when looking at differences across smaller areas.
Cleveland, Ohio was ranked by the National Digital Inclusion Alliance as the Worst Connected City in 2019. In Cuyahoga County Ohio, home to Cleveland, one can see that at least in about one-fifth of the County’s neighborhoods, fewer than one-half of households have a broadband subscription. Many assume that people without home broadband use smartphones instead. However, many of the neighborhoods with low broadband subscription rates also have the lowest levels of smartphone ownership-- between 37% and 68% of households.
Affordability is a tremendous barrier to internet adoption, but cost does not explain everything. The overlap of digital disconnectivity with segregation is striking. In the neighborhoods with the darkest red, at least 84% of residents are Black whereas in the neighborhoods with the lightest color, 3% or fewer residents are Black. About 80% or more residents in the suburban neighborhoods have broadband subscriptions and/or smartphones.
Highly segregated and impoverished neighborhoods in many cities have missed out on broadband infrastructure investments. As a result, residents do not have the same options for high-speed affordable broadband as their suburban counterparts.
Because internet use is now recognized as a “super social determinant of health,” efforts to close digital barriers to telehealth in rural and urban communities could have an outsized impact on health disparities overall.
In addition to the need for broadband and the tools needed to access it (hardware, affordable financial plans, digital literacy, etc.), real-time virtual visits also require that patients have a range of additional items:
- A device with a camera and software that can accommodate streaming video
- A fast internet connection with minimal lag time
- A data plan that will not make a video visit a costly undertaking
- Digital skills needed to make the appointment, launch the visit, adjust the camera and microphone, ete
- A private, well-lit place to conduct the visit