Digital Access Deficiencies in Rural Health Care Deserts: Identifying a Role for Telehealth

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Introduction

Telehealth, defined as digital access to health care services, has become increasingly used by American patients since the COVID-19 pandemic. Given that many rural communities in the United States face lower access to health care relative to urban communities, telehealth offers a potential opportunity to support health care access in these underserved areas. In particular, telehealth can partly help offset fewer hospitals and health care professionals per capita in rural areas compared to their metropolitan counterparts. However, the digital divide in access to broadband and digital devices between urban and rural communities means that telehealth access has not been equally enjoyed across space.

In this post, we identify where health care deserts are located within the Fifth District. Additionally, we measure how broadband and digital device access (defined as the use of a tablet, laptop or smartphone) differs between these areas, the rest of the Fifth District, and the nation. The coexisting deficiencies in both health care and broadband access suggest that bridging the digital divide in these mostly rural health care deserts may offer the potential to expand health care options for residents through telehealth.

What Is Telehealth?

Telehealth comprises a number of digitally accessible health care resources, including clinical (e.g., treatment, consultation) and nonclinical services (e.g., administrative services). Telehealth has existed since at least the 1960s, and 76 percent of U.S. hospital systems have offered some sort of clinical services through telecommunications technology since 2018. However, its usage ramped up considerably during the COVID-19 pandemic, as patients sought medical care amid widespread social distancing to prevent the spread of the virus. A study of private insurance claims found that telemedicine interactions went from comprising 0.3 percent of all ambulatory care in spring 2019 to 24 percent in 2020.

As of June, telehealth comprised nearly 5 percent of all medical claims in the United States. Most telehealth diagnoses are related to mental health conditions, such as generalized anxiety disorder, major depressive disorder, or adjustment disorders.

Since access to broadband and a digital device is necessary to use telehealth, disconnected areas are less likely to benefit from these services. Research suggests that broadband availability is a predictor of telehealth use and that adults living in rural counties were 42 percent less likely to use the services compared to urban dwellers.

Where Are the Fifth District's Health Care Deserts?

Patients in rural communities tend to experience higher barriers to health care access, as the number of health care providers and hospitals per capita tends to be lower than in metropolitan areas. These conditions can require patients to travel long distances and suffer long wait times which increase the burden of care per patient.

To illustrate the disparity in health care access, Figure 1 below maps geographic high needs health professional shortage areas (HPSAs) for primary care services in the Fifth District by rural status according to the Health Resources and Services Administration (henceforth referred to as "high needs areas.") In this post, we use high needs areas as a proxy for health care deserts because they lack a sizable primary care workforce and exhibit signs of adverse health outcomes. However, we recognize that high needs geographic HPSAs are an imperfect metric for all health care deserts because they are a subset of areas that experience a lack of care. Indeed, there are other forms of HPSAs that do not have "high needs" and encompass populations within geographies that are systematically underserved, which are not included in Figure 1. Given the geographic nature of broadband infrastructure dispersion and its relation to rural areas, we focus on geographic areas designated as HPSAs rather than specific populations. Moreover, while dental and mental health geographic HPSAs exist, we only focus on primary care HPSAs in this post for brevity. Therefore, we encourage readers to refer to the Health Resources and Services Administration for a full description of HPSAs and their coverage across the Fifth District.

Most high needs areas are rural and within southern Virginia and South Carolina. There are only two urban high needs areas in the Fifth District (Fairfield County, S.C., and West Central Baltimore, Md.) and one partially rural (Somerset County, Md.). High needs areas comprise geographies (counties, census tracts, and county subdivisions) that have a shortage of primary care health care professionals and exhibit stress related to health outcomes. The high needs status is attained when the ratio of health care workers to the population is 3,000:1 or greater and if it exhibits one of the following related to health outcomes: over 20 percent of its population living below the federal poverty line, more than 100 births per year for every 1,000 women ages 15 to 44, over 20 infant deaths per 1,000 live births, or insufficient health care facility capacity.

Figure 1: Geographic High Needs HPSAs in the Fifth District by Rural Status

Source: Health Resources and Services Administration high needs HPSA primary care component boundaries.

Digital Access Disparities

Figure 2 below shows that high needs areas not only suffer from a shortage of health professionals, but also tend to exhibit much lower access to broadband. Across the Fifth District, 73 percent of households subscribe to a fixed wireline broadband connection such as cable, fiber optic, or digital subscriber line (the same as the national average). However, only 51 percent of households in Fifth District high needs areas subscribe to fixed wireline broadband (slightly lower than the national rate of 53 percent). The results for "Any Broadband" extend the definition to less reliable forms of services (e.g., cellular and satellite) and show similar disparities.

Figure 2: Broadband Subscription Rates in Geographic High Needs HPSAs

Source: Author's calculations using 2022 American Community Survey 5-year estimates and the Health Resources and Services Administration high needs HPSA primary care component boundaries.

Figure 3 below indicates that device access serves as an additional barrier for households in high needs areas. Households in high needs areas own tablets, laptops, and smartphones at lower rates than the Fifth District average. In the Fifth District, although 88 percent of households own a smartphone, only 76 percent of high needs households own a smartphone. The device ownership gaps between high needs households and the average Fifth District household are even larger for tablet (48 percent versus 63 percent) and laptop (60 percent versus 79 percent).

Figure 3: Device Access in Geographic High Needs HPSAs

Source: Author's calculations using 2022 American Community Survey 5-year estimates and the Health Resources and Services Administration high needs HPSA primary care component boundaries.

Takeaways

Although American patients have increasingly used telehealth since 2020, rural households have been less likely to use these services. We identify health care deserts across the Fifth District that suffer from a lack of access to health care providers as well as adverse economic and health outcomes. We show that these areas tend to also be underserved with broadband service and digital device access, which may further exacerbate the gap in health care access between these predominantly rural areas and their metropolitan counterparts through decreased telehealth access.

Given that the digital divide serves as a barrier to Fifth District households located in health deserts, policy actions that are targeted toward improving subscription rates and increasing digital equity education have the potential to improve the well-being of these disconnected households. Research from the National Telecommunications and Information Administration suggests that a primary reason people do not subscribe to broadband is they have no reason or need for it, which may indicate an outreach opportunity to educate people on uses such as telehealth.

Views expressed are those of the author(s) and do not necessarily reflect those of the Federal Reserve Bank of Richmond or the Federal Reserve System.