As our country attempts to flatten the curve of coronavirus disease 2019 (COVID-19) and reserve healthcare resources for patients experiencing the most severe symptoms, health systems are quickly shoring up a known but, in many cases, neglected resource for primary and specialty care: Telehealth. The expansion of telehealth services is a pandemic response that reinforces necessary social distancing while, in theory, preserving access to care—particularly among patients whose existing health conditions increase their vulnerability to COVID-19. Up until recently, widespread use of telehealth has been impeded by state licensing variabilities, payment policies, provider and patient comfort with technology, and access to high-speed internet.
Telehealth integration barriers
In a direct response to the pandemic, the federal government enacted Waiver 1135 to incentivize healthcare systems to integrate telehealth services into daily practice.1 Waiver 1135 facilitates telehealth services by allowing visits to occur in patients' homes and also improves reimbursement. While the tenets of Waiver 1135 apply to Medicare beneficiaries, historically, private insurers follow the guidelines established by the Centers for Medicare and Medicaid Services, thus resolving one of the major barriers to widespread use. This federal policy solution has been bolstered in a number of states by license liberalizations to distribute workforce in response to the pandemic.
However, another barrier—a lack of broadband access—has not yet been resolved by these public policy solutions. The uneven distribution in access to internet services between high- and low-income individuals is often referred to as the digital divide. The digital divide impacts the same populations that experience health disparities. We must ask ourselves: Is the migration to telehealth furthering health inequalities? A prime example of this potential injustice lies in America's rural communities, which face health disparities including poor access to care and high disease burden.
The CDC reports that rates for the five leading causes of death are higher in rural communities.2 High disease burden is related in part to workforce shortages, as 128 rural hospitals have closed since 2010, many of which were Critical Access Hospitals, and many rural communities are designated as Health Professional Shortage Areas. These same communities lack access to high-speed internet with the Federal Communications Commission (FCC) reporting that 25% of rural citizens lack broadband access.3 The shift to telehealth services in areas that experience workforce shortages coupled with a lack of broadband access highlights an existing health services inequity and creates a conundrum during an already challenging time.
On March 3, 2020, the day that the US surpassed 100 confirmed cases of COVID-19, the US House of Representatives unanimously passed S.1822, joining the Senate in requiring the FCC to collect and share accurate data about broadband distribution. Although this legislation is an important step to holding broadband providers accountable regarding equitable access, it failed to address essential support for widening distribution, including funding for broadband expansion that could also create much-needed jobs. In this regard, 31 states and Puerto Rico were much more successful during 2019 legislative sessions, enacting measures to stoke infrastructure expansion, municipal-run broadband networks, and stronger oversight.
NP advocacy: Closing the digital divide
As NPs, we are all too familiar with policies that impede access to care, such as nurse practice acts that restrict NP scope of practice. A call to action for nurses is to support legislation that prioritizes funding broadband infrastructure to overcome the digital divide. Access to high-speed internet in modern times is not a luxury but rather a necessity. Federal policy that was introduced in 2019 (but has not yet passed) includes providing matching funds to states to extend broadband services to households lacking access to high-speed internet (S.2018 - American Broadband Buildout Act of 2019), creating a federal office to oversee high-speed internet expansion and equity (H.R.1328 - ACCESS BROADBAND Act), and targeted efforts to stoke rural broadband expansion (H.R.2929 - Rural Broadband Network Advancement Act of 2019).
In fact, broadband legislation in at least 15 states failed to pass during the 2019 or 2020 sessions, indicating missed opportunities to strengthen telehealth when it is most needed.
The future of telehealth
The future of telehealth services after the COVID-19 pandemic is unknown. Some experts believe Waiver 1135 will expire, while others see this moment as an opportunity to bring about permanent change to the digital delivery of healthcare services. Now is the time to make your voice heard by contacting your state, local, and national representatives about the future of telehealth and the broadband that makes it possible—hopefully for all, rather than just for some.
1. Centers for Medicare & Medicaid Services. COVID-19 emergency declaration blanket waivers for health care providers. 2020. www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf
2. US Centers for Disease Control and Prevention. Leading causes of death in rural America. 2019. www.cdc.gov/ruralhealth/cause-of-death.html