Healthcare Access and Equity Amidst the Rise of Telehealth
Discussions about healthcare–what services should be provided, who should receive them, and who should pay for them–have been brought to the social and political forefront of the American zeitgeist. Regardless of viewpoint, the crux of the conversation is if and how best to achieve equity in access and quality of care in the U.S. healthcare system.
First Things First: What is Health Equity?
Health Equity is an ideal to which many healthcare reform advocates aspire; It is achieved when all members of society enjoy a fair and just opportunity to be as healthy as possible. In other words, the aim of Health Equity is to create space for individuals to receive affordable and efficacious healthcare regardless of race, gender, sexuality, religion, or socioeconomic status.
It is important to note that equity and equality are not the same concept, and “the implementation of one versus the other can lead to dramatically different outcomes for marginalized people.” Under the notion of equality, every person gets the exact same access to the exact same resources. While on its face this system may appear fair, theories of equality seldom consider the inherent advantages and disadvantages between people.
The notion of equity compensates for that lacking element by providing everyone with the support they need. Under this system, allocation of resources is based upon what each individual needs, providing some with more than others in order to achieve a just outcome for all.
Unfortunately, despite standing out as a frontrunner in medical innovation, healthcare in the U.S. is far from equitable, as evidenced by the systemic disparities in healthcare quality and access for minority groups. For example, mortality rates among African American infants are 2.5 times higher than white infants; diabetes rates are roughly 30% higher in Native American and Latinx populations than their white counterparts; and the life expectancies for Black men and women are roughly 10 years shorter than those of white adults.
Most recently, racial and ethnic disparities in COVID-19 related deaths exposed the insidious nature of these differences.
How Does a Lack of Equity Impact Ethnic and Racial Minority Groups?
An article from the American Clinical and Climatological Journal reported that data shows clear disparities in rates of health insurance coverage among Black and Latinx population groups. Being uninsured is empirically linked to use of fewer preventive services, poorer health outcomes, higher mortality and disability rates, lower annual earnings because of sickness and disease, and later stage discovery of illnesses (when diagnosed).
These disparities do not exist in a vacuum; in fact, they are the direct result of structural and systemic inequality dating back to the Emancipation Proclamation. Jim Crow employment laws in the 19th and 20th centuries were designed to provide protections for white workers, while leaving racial and ethnic minorities at a disadvantage.
A National Institute of Health study in the Du Bois Review analogizes structural racism as an iceberg: “The tip of the iceberg represents acts of racism, such as cross-burnings, that are easily seen and individually mediated. The portion of the iceberg that lies below the water represents structural racism; it is more dangerous and harder to eliminate. Policies and interventions that change the iceberg’s tip may do little to change its base, resulting in structural inequalities that remain intact, though less detectable.”
The simile is apt, particularly when considering that insidious institutions like segregation—abolished almost sixty years ago—had a direct, albeit not overtly recognized, impact on modern-day minority health outcomes. This is most clearly evidenced by seemingly racially-based socioeconomic disparities amongst residential areas resulting in an increased risk of contracting illnesses for ethnic minorities. The NIH study noted that “residential segregation remains pervasive and may influence health by concentrating poverty, environmental pollutants, infectious agents, and other adverse conditions.”
This history of disenfranchisement has aggregated up to now, where the rate of ethnic and racial minorities contracting and dying from COVID-19 is far higher than rates of white Americans. In fact, according to the CDC, “[d]ata on race and ethnicity for more than 90% of people who died from COVID-19 reveal that the percent of Hispanic or Latino, non-Hispanic Black, and non-Hispanic American Indian or Alaska Native people who have died from COVID-19 is higher than the percent of these racial and ethnic groups among the total U.S. population.”
Amidst this backdrop of racial and economic disparities in healthcare, the COVID-19 pandemic brought with it a myriad of drastic changes to American healthcare. One of the most prominent of these changes is the increasing rate of telehealth and telemedicine services offered nationwide.
What are Telehealth and Telemedicine?
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telehealth encompasses remote non-clinical services – such as provider training, administrative meetings, and continuing medical education – in addition to clinical services.
Telehealth services are broader in scope than the more specified telemedicine, which refers exclusively to remote clinical services.
There are three types of telehealth offerings: individual teletherapy, group teletherapy, and telehealth treatment for substance use disorder. These services can be delivered in a number of ways: synchronous (a physician communicates with patients in real-time via phone or computer), asynchronous (data, images, or messages are recorded to share with the physician later), or remote patient monitoring (measurements such as weight or blood pressure are sent to the health care provider. Telehealth services can either be offered through federal or state programs like Medicare and Medicaid or through private health insurance.
Telehealth is not new, but its prevalence, as well as several peripheral offerings, have expanded and many believe they are here to stay. An article by U.S. News opines that “the pandemic has also fostered the rise of innovative medical services, everything from getting prescriptions by mail to drive-through virus testing and pharmacy-based vaccinations.”
A Center for Disease Control study, conducted at the height of the pandemic, analyzed data from four of the largest U.S. telehealth providers that offer services in all states. Data showed that during the first quarter of 2020, the number of telehealth visits increased by 50% compared to the same period in 2019. Another study on the use of telehealth during the pandemic revealed that, among insured patients, those with employment and post-high school education were more likely to utilize telehealth services.
Another CDC study, analyzing the utilization of telehealth services between June and November of 2020, showed that almost 30% of medical visits during that time frame were conducted via telehealth; indicating that this development is here to stay. However, a Harvard Law article cautions that while telehealth may be, in many ways, a panacea for access to healthcare, particularly in COVID times, we should be concerned that patients of color may be left behind.
Issues of Equity in Telemedicine
Over 28 million low-income or uninsured Americans are serviced by ambulatory care, such as community health centers, which have fallen behind in terms of having the resources or the infrastructure to keep up with the ever-increasing pace of telehealth. Medical research has demonstrated that minority groups are often at increased risk of underlying chronic health conditions, and without adequate telehealth capacity and support, many community health centers will be left without means of providing the continuous preventive and chronic disease care that can keep communities healthy and out of the hospital.
A study by the American Diabetes Association analyzed the rate of individuals over 18 diagnosed with diabetes, hypertension, or both, who had access to internet health resources and by extension, telemedicine. Results showed that minority groups (Blacks and Hispanics) often reported lower rates of healthcare literacy and resources such as telehealth. Another study analyzing telehealth use among California residents with limited English speaking proficiency found that patients with limited English proficiency utilized telehealth roughly 30% less than primarily English speaking patients.
Penn Medicine News released a study report showing inequity in telehealth across English proficiency, race and ethnicity, ability, and age demographics. Patients over 55 were 25% less likely to successfully participate in a telemedicine visit, patients with Medicaid insurance were slightly less likely than other patients to successfully use telemedicine, and non-English speaking patients were 16% less likely to engage in successful telemedicine use.
More often than not, this lack of successful telehealth usage is attributable not just to limited digital literacy but also to limited digital access. An article in the Milbank Quarterly: A Multidisciplinary Journal of Population Health and Health Policy states that homes headed by a person 65 years or older, children of any race in low-income households, and minority children are all less likely to have a computer in their household than other Americans.
All of the aforementioned data sets demonstrate that many healthcare patients are not yet equipped to take place in the rapidly increasing prevalence of telemedicine in the modern age. As stated by an article in the Karger Publishers Public Health Emergency Collection, “telemedicine shifts prevention, treatment, care, and support from clinics to homes and mobile devices, which permits uninterrupted care of clients. Hence, it is urgent to identify barriers to telemedicine to inform the development of treatment delivery in order to address health disparities and manage COVID-19 impact in this challenging time.”
How Do We Bridge the Gap?
Interestingly, the groups most disenfranchised by the expanse of telehealth also report being the most interested in the concept of telehealth services. An AARP study conducted in 2020 found that African American and Latinx individuals expressed higher interest in telehealth use than their white counterparts. The National Health Law program provides recommendations for increasing equitable access to telehealth:
- Broadband (high-speed internet) must be available and affordable to every individual
- Low-income populations should have access to devices that enable a telehealth interaction
- Extensive public outreach to increase digital literacy should be provided for low-income and elderly groups
- Access to language interpreters or multilingual telehealth offerings should be offered for non-English speaking patients
The Department of Health and Human Services posits that one of the most significant ways to ensure equal access to telehealth services is to reduce the challenges that impede disadvantaged individuals from accessing those services.
Interestingly, many scholars and healthcare professionals are aware of the potential issues at play, and some even offer suggestions to mitigate the systemic hindrances to quality care:
(1) proactively explore potential disparities in telemedicine access,
(2) develop solutions to mitigate barriers to digital literacy and the resources needed for engagement in video visits,
(3) remove health system–created barriers to accessing video visits, and
(4) advocate for policies and infrastructure that facilitate equitable telemedicine access.
The federal Office for the Advancement of Telehealth provides several programs designed to promote the usage of telehealth. These include:
- Telehealth Network Grant Program – use telehealth networks to improve health services for medically underserved people (e.g. urban, rural, and frontier communities)
- Evidence-Based Tele-Behavioral Health Network Program – evaluate programs to establish an evidence-based for assessing the effectiveness of telehealth
- Telehealth Technology-Enable Learning Program – aims to connect specialists at academic medical centers with primary care providers in rural and underserved areas
- Licensure Portability Grant Program – provides support for state professional licensing boards to carry out programs under which licensing boards of various states cooperate to develop and implement
- Telehealth Broadband Pilot Program – will assess broadband capacity in selected test pilot state
Of course, policy decisions may end up being the ultimate indicia of systemic healthcare change. According to policy researcher Lori Uscher-Pines, “what ultimately happens with telemedicine really depends on how the policy environment evolves . . . there is a lot of action going on at both the state and federal level right now on telemedicine policy.”
The proposed solutions are in no way simple or straightforward to achieve, however, they do provide an overarching framework for the necessary restructuring that needs to be made in the ways in which healthcare is provided in this country in order to ensure that equitable access is available to all.