The Telehealth Divide: Digital Inequity in Rural Health Care Deserts

Introduction

In rural communities where limited access to health care remains a significant barrier to the wellbeing of low-income households, can telehealth bridge the gaps in service? In this Partners Update, we assess the urban-rural digital divide as a barrier to telehealth access for rural populations and conclude that without addressing the digital divide in the communities of highest need, telehealth's potential to close health care gaps can only be limited.

We address three primary questions in this article. First, where do health care deserts exist in the Southeast (Alabama, Florida, Georgia, Louisiana, Mississippi, and Tennessee)?¹ Second, what is the level of digital accessibility in terms of broadband subscription and device access in health care deserts across the Southeast and United States overall? Third, do these measures of digital accessibility differ by rurality? Our main findings indicate that, on average, rural health care deserts have lower household broadband subscription rates compared to both the Southeast and the United States overall. In addition to low subscription rates, we find that households in rural health care deserts are less likely to own digital devices, such as tablets, laptops, and smartphones.

Though this analysis does not explore socioeconomic or other factors that could impact digital access, prior research has found indicators associated with constrained health systems and low broadband subscription rates in a county-level context.² Additional research has found high internet latency in health care deserts in a global context,³ while prior Atlanta Fed research describes digital access and its association with socioeconomic indicators in the Southeast, like poverty and labor market attachment.⁴

Background on Telehealth

Telehealth encompasses a wide array of both clinical services (such as treatment, diagnostic consultation, and remote monitoring) and non-clinical services (such as provider training, electronic information sharing, and administrative services) that may offer opportunities to bridge gaps in health care access through telecommunications technology.

Research finds that patients living in rural communities (nonmetropolitan counties) experience considerable barriers to health care access in general, with fewer health care services⁵ and individual insurance offerings⁶ compared to individuals living in urban settings (metropolitan counties). Telehealth offers a promising solution to reduce the total costs of the health care system, especially benefitting individuals living in places where transportation increases the cost of care and appointment wait times are high.⁷ Both are prevalent challenges in health care deserts. However, it is important to note that telehealth cannot completely bridge the gap in health care, specifically for patients who require in-person consultation. Nor can telehealth itself completely address the underlying issues related to the shortage of health care workers in rural areas and the scale of health care operations in health care deserts.

Although telehealth has existed for decades, the COVID-19 pandemic increased the need for the service as a safe and efficient form of patient care.⁸ Recent data confirm that telehealth insurance claims grew markedly, from 0.17 percent of all medical claims in March 2019 to 7.52 percent in March 2020.⁹ Subsequently, the use of telehealth decreased to 4.82 percent of all medical claims as of May 2024, although usage remains elevated relative to pre-pandemic estimates.¹⁰

Sufficient broadband access¹¹ and availability of digital devices¹² are prerequisites for accessing telehealth services. Researchers found disparities in patient access to telehealth service during the pandemic, especially for rural communities which also tend to lack access to broadband. Research shows that during the pandemic, adults living in rural areas were 42 percent less likely to use telemedicine than their counterparts in metropolitan areas.¹³ A pandemic-era study of Medicare beneficiaries found that broadband availability was associated with higher telehealth use, and that living in a rural county was associated with lower usage.¹⁴

The following data analysis seeks to understand whether rural gaps in access to broadband might impede the use of telehealth, a service that could help close health care access disparities found in rural regions.

Mapping Health Care Deserts

Map 1 shows health care deserts, or high needs health professional shortage areas (hereafter, "high needs areas"), in the Southeast and their rural status, as designated by the Health Resources and Services Administration.¹⁵

Map 1: High Needs Health Professional Shortage Areas in the Southeast by Rural Status

Source: Health Resources and Services Administration high needs health professional shortage area primary care component boundaries.

Overwhelmingly, high needs areas are rural (80 percent of high needs area households) and concentrated in South Georgia, South Alabama, northern Louisiana, and Mississippi. High needs areas are composed of counties, census tracts, and county subdivisions and highlight places with a shortage of primary care health care professionals.¹⁶ Designation as a high needs area occurs if a geography's health care workforce relative to its population has a ratio of at least 3,000:1. Across the Southeast, the ratio among high needs areas varies from 3,035:1 in Dallas County, Alabama, to 123,740:1 in Dooly County, Georgia. Furthermore, all high needs areas exhibit additional signs of distress related to health outcomes and health care facility use and capacity, distinguishing these places as geographies of greatest need. To be considered a high needs area one of the following criteria must be met: over 20 percent of its population live below the federal poverty line; more than 100 births per year for every 1,000 women aged 15 to 44; over 20 infant deaths per 1,000 live births; or insufficient health care facility capacity. Insufficient capacity is defined by the area demonstrating two of the four following indicators: excessive caseloads for primary care providers; long waits for appointments; excessive use of emergency room facilities for routine primary care; over two thirds of physicians not accepting new patients; or low usage of health services overall.¹⁷

Digital Access Disparities in Health Care Deserts in the Southeast

Figure 1 compares broadband access within high needs areas in the Southeast and the regional average, and high needs areas nationally and the national average. The chart illustrates how a lack of broadband access could pose a significant barrier to telehealth access in those high needs areas.

Figure 1: Broadband Subscription Rates in High Needs Health Professional Shortage Areas

Source: Author's calculations using 2022 American Community Survey five-year estimates and the Health Resources and Services Administration high needs health professional shortage area primary care component boundaries.

On average, across the Southeast 71 percent of households subscribe to a broadband connection such as cable, fiber optic, or digital subscriber line (DSL). In high needs areas, household broadband subscription rates are lower compared to the Southeast overall and nationwide. In the Southeast, just 46 percent of households in high needs areas subscribe to broadband compared with a nationwide rate of 53 percent.

In this report we focus on fixed wireline connections because they are considered faster and more reliable forms of broadband compared to other options (such as cellular and satellite), according to the Federal Communications Commission.¹⁸ However, the same analysis was completed using all forms of broadband and found similar patterns.¹⁹

Figure 2 demonstrates that rural health care deserts, both in the Southeast and nationally, have even lower broadband subscription rates relative to their urban and partially rural counterparts.

Figure 2: Broadband Subscription Rates in High Needs Health Professional Shortage Areas by Rural Status.

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

Rural high needs areas in the Southeast have the lowest subscription rate of any category at 43 percent. For comparison, 60 percent of households in urban high needs areas subscribe to broadband in both the Southeast and the United States.

The digital divide found in rural high needs areas can be compounded by a lack of access to devices, such as electronic tablets, laptops, and smartphones. Figure 3 shows that across each device category households in rural high needs areas are less likely to own tablets, laptops, and smartphones relative to all households in the Southeast.

Figure 3: Device Access in High Needs Health Professional Shortage Areas

Source: Author's calculations using 2022 American Community Survey five-year estimates and the Health Resources and Services Administration high needs health professional shortage area primary care component boundaries.

For example, although smartphones tend to be widely available to households across the Southeast (88 percent), there is a gap of 10 percentage points in smartphone ownership for rural high needs areas (78 percent). Moreover, only 56 percent of rural high needs households own or use a laptop and 44 percent have access to a tablet. Without such devices, remotely connecting with a health care provider for a telehealth appointment is essentially unfeasible.

Conclusion

We show that the digital divide is disproportionately experienced in rural health care deserts and, therefore, presents a fundamental barrier to telehealth access in those areas. In addition to poor health outcomes and low health care capacity, rural high needs areas have lower incomes, labor force participation, and educational attainment, as well as higher adult disability and poverty rates relative to both the Southeast and the United States.²⁰ We highlight these disparities to show that rural high needs areas have additional barriers to accessing in-person health care providers beyond limited availability of services.

Our analysis implies that policy actions targeted at increasing broadband subscription and device access in rural health care deserts may help its residents access health care services. More research and evaluation are needed, however, to assess how telehealth access can improve health care outcomes, lower costs for taxpayers, and better the quality of life for low-income households. The Affordable Connectivity Program (ACP), which operated from 2022 through 2024 through the Infrastructure Investment and Jobs Act, addressed the cost barrier to broadband subscription and device access through means-tested subsidies. Academic analysis of the program empirically demonstrated it was successful in increasing broadband subscription and personal computer adoption in low-income counties²¹ and that economic distress²² was a significant predictor of ACP enrollment in an area. Additional opportunities to address this issue are possible through existing funding opportunities like State and Local Fiscal Recovery Funds (SLRF), which must be obligated by December 2024, or through provisions in the 1977 Community Reinvestment Act. Moreover, SLRF and the CRA²³ can be utilized for investments related to both public health and broadband infrastructure.

As daily life has become digitally dependent, socioeconomic inclusion is tied to broadband access and device use. Therefore, the digital divide is a barrier to socioeconomic inclusion, and the potential of telehealth to expand care in health care deserts is limited until digital inequity is addressed.

By Pearse Haley, CED senior analyst, Sofia Tenorio Martinez, manager of evaluation and data for Strong4Life at Children's Healthcare of Atlanta, Alvaro Sanchez, CED senior analyst,and Adam Scavette, regional economist at the Federal Reserve Bank of Richmond. The views expressed here are the authors' and not necessarily those of the Federal Reserve Bank of Atlanta or the Federal Reserve System. Any remaining errors are the authors' responsibility.

¹ We define health care deserts as primary health provider shortage areas, as designated by the Health Resources and Services Administration. See https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation.

² Diego F. Cuadros, Claudia M. Moreno, F. DeWolfe Miller, Ryosuke Omori, and Neil J. MacKinnon, "Assessing Access to Digital Services in Health Care-Underserved Communities in the United States: A Cross-Sectional Study," Mayo Clinic Proceedings: Digital Health 1, no. 3 (2023): 217-225, https://doi.org/10.1016/j.mcpdig.2023.04.004.

³ Pradeeban Kathiravelu, Dalibor Fonović, Tihana Galinac Grbac, Zachary Zaiman, Luís Veiga, Judy Wawira Gichoya, Saptarshi Purkayastha, and Babak Mahmoudi, "The Telehealth Dilemma-Health-Care Deserts Meet the Internet's Remote Regions," Computer 56, no. 9 (2023): 39-49, https://doi.ieeecomputersociety.org/10.1109/MC.2023.3252945.

⁴ Alvaro Sánchez, "Connecting to Economic Opportunity: The Digital Divide in the Southeast," Federal Reserve Bank of Atlanta Partners Update (August 2023), https://www.atlantafed.org/community-development/about-us/staff/sanchez-alvaro.

⁵ Gina Turrini, D. Keith Branham, Lucy Chen, Ann B. Conmy, Andre R. Chappel, Nancy De Lew, and Benjamin D. Sommers, "Access to affordable Care in Rural America: Current trends and key challenges," Assistant Secretary for Planning and Evaluation Office of Health Policy: Research Report (2021), https://aspe.hhs.gov/sites/default/files/documents/09e40880648376a13756c59028a56bb4/rural-health-rr.pdf.

⁶ Jean Marie Abraham, "Individual market volatility and vulnerability, 2015 to 2019," RSF: The Russell Sage Foundation Journal of the Social Sciences 6, no. 2 (2020): 206-222, https://doi.org/10.7758/RSF.2020.6.2.09.

⁷ Xiaoli Wang, Zhiyong Zhang, Jun Zhao, and Yongqiang Shi, "Impact of telemedicine on health care service system considering patients' choice," Discrete Dynamics in Nature and Society 2019, no. 1 (2019): 7642176.

⁸ US Department of Health and Human Services, "Why Use Telehealth?," https://telehealth.hhs.gov/patients/why-use-telehealth#what-is-telehealth.

⁹ FAIR Health, "The Evolution of Telehealth during the COVID-19 Pandemic," (June 2022), https://s3.amazonaws.com/media2.fairhealth.org/brief/asset/The%20Evolution%20of%20Telehealth%20during%20the%20COVID-19%20Pandemic-A%20FAIR%20Health%20Brief.pdf.

¹⁰ FAIR Health Monthly Telehealth Regional Tracker: https://www.fairhealth.org/fh-trackers/telehealth.

¹¹ The Federal Communications Commission defines sufficient broadband speed requirements for various types of telehealth appointments (for example, remote monitoring, high definition video conferencing, image transferring). See Federal Communications Commission, "Health Care Broadband in America: Early Analysis and Path Forward," OBI Technical Paper No. 5. (August 2010), https://transition.fcc.gov/national-broadband-plan/health-care-broadband-in-america-paper.pdf.

¹² Health Resources and Services Administration, "What do I need to use telehealth?," last updated September 10, 2024. https://telehealth.hhs.gov/patients/what-do-i-need-use-telehealth.

¹³ Jeong-Hui Park, Min Jee Lee, Meng-Han Tsai, Huan-Ju Shih, and Jongwha Chang, "Rural, regional, racial disparities in telemedicine use during the COVID-19 pandemic among US adults: 2021 National Health Interview Survey (NHIS)," Patient preference and adherence (2023): 3477-3487, https://doi.org/10.2147/ppa.s439437.

¹⁴ Pandit, Ambrish A., Ruchira V. Mahashabde, Clare C. Brown, Mahip Acharya, Catherine C. Shoults, Hari Eswaran, and Corey J. Hayes. "Association between broadband capacity and telehealth utilization among Medicare Fee-for-service beneficiaries during the COVID-19 pandemic." Journal of Telemedicine and Telecare (2023): 1357633X231166026, https://doi.org/10.1177/1357633X231166026.

¹⁵ The HRSA uses US Department of Agriculture Rural Urban Continuum Area codes to define rurality. See Health Resources and Services Administration, "Defining Rural Population," https://www.hrsa.gov/rural-health/about-us/what-is-rural#:~:text=How%20Do%20We%20Define%20Rural,a%20UA%20to%20be%20rural.

¹⁶ Health professional shortage areas exist for the following groups: primary care, dental health, and mental health. See US Department of Health and Human Services, "Health Professional Shortage Areas (HPSAs) and medically underserved Areas/Populations (MUA/P) Shortage Designation Types," https://www.hhs.gov/guidance/document/hpsa-and-muap-shortage-designation-types.

¹⁷ Each of the criteria listed for insufficient health care capacity in high needs areas is defined based on specific criteria. See Health Resources and Services Administration, "Shortage Designation Management System (SDMS): Manual for Policies and Procedures," (May 2024), https://programportal.hrsa.gov/docs/pco/Manual-for-Policies-and-Procedures.pdf.

¹⁸ FCC Consumer Guide, "Getting Broadband Q&A," https://www.fcc.gov/sites/default/files/getting_broadband_qa.pdf.

¹⁹ For the sake of brevity, household subscription to cellular and satellite services was not included in this paper. However, readers are welcome to contact the authors for the full results.

²⁰ Rural high needs areas had a median household income of $52,687, a labor force participation rate of 53 percent, a family poverty rate of 20 percent, an adult disability rate of nine percent, and a share of adults without a high school diploma of 16 percent according to 2022 ACS five-year estimates. In comparison, the Southeast had a median household income of $62,292, a labor force participation of 60 percent, a family poverty rate of 18 percent, an adult disability rate of seven percent, and a share of adults without a high school diploma of 11 percent. The United States had a median household income of $75,149, a labor force participation rate of 63 percent, a family poverty rate of 14 percent, an adult disability rate of six percent, and a share of adults without a high school diploma of 11 percent.

²¹ Galperin Hernan and Francois Bar, "Measuring the Effectiveness of Digital Inclusion Approaches (Media) - Phase II," USC Annenberg School for Communication, (May 2024), https://arnicusc.org/wp-content/uploads/2024/05/Deliverable-2-final.pdf.

²² John B. Horrigan, Brian E. Whitacre, and Hernan Galperin, "Understanding uptake in demand-side broadband subsidy programs: The affordable connectivity program case," Telecommunications Policy (2024): 102812, https://doi.org/10.1016/j.telpol.2024.102812.

²³ Department of the Treasury, Office of the Comptroller of the Currency, "Community Reinvestment Act; Interagency Questions and Answers Regarding Community Reinvestment; Guidance," Federal Register, Vol. 81, No. 142. July 25, 2016. https://www.govinfo.gov/content/pkg/FR-2016-07-25/pdf/2016-16693.pdf.

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