Billions of dollars have been poured into telehealth during the pandemic: Insurers loosened the purse strings on virtual appointments, digital health companies pulled in astronomical investments, and the public markets minted multiple unicorns.
But while virtual care’s proponents are fighting to cement its future, many Americans still can’t sign on at all.
Nearly a quarter of adults in the U.S. don’t have broadband at home, network speeds are insufficient for video calls in much of rural America, and 15% struggle to pay for internet. It’s a persistent issue that threatens to hamper the lofty promises made by telehealth startups and policymakers — that virtual care can chip away at long-running inequities in health care, especially those that impact low-income, rural, and Black and Hispanic patients, who are also less likely to have broadband. And while the value and effectiveness of telehealth is still being determined, it’s clear that the gaping disparities in access to health care will only grow wider if the problem isn’t fixed.
“All of the potential good things that come from this move to virtual care are put at risk if we don’t solve this broadband problem,” said Abner Mason, founder and CEO of SameSky Health, a Medicare and Medicaid navigation company formerly known as ConsejoSano.
Payers are starting to pay attention. Federal and state health programs are exploring new ways to cover not just telehealth visits, but the internet access that makes them possible.
“If care is going to be provided virtually and people can’t get it, then instead of increasing access it’s just going to reinforce existing health inequities,” Mason said. But health plans, he added, “are in a position to play a lead role. They’re funded in a way that allows them to benefit from addressing social determinants of health.”
In one move, some Medicaid plans are making sure their members know they’re eligible for the Affordable Connectivity Program, an extension of a pandemic broadband benefit. Signed into law in November as part of the Infrastructure Investment and Jobs Act, it provides $30 internet subsidies for the poorest households, plus a $100 one-time credit for a connected device — but people have to opt-in through a complex, counterintuitively online application process. Health plans can be a go-between to help reach the patients who need it most.
A small number of payers are going further, with several private Medicare Advantage plans offering lower-cost broadband as a benefit. “I think plans will be more willing to say they will sacrifice the government paying for it to create a better member experience that will actually encourage utilization and ultimately benefit their health care,” said Sara Ratner, senior vice president of government markets and strategic initiatives at Icario Health.
“All of the potential good things that come from this move to virtual care are put at risk if we don’t solve this broadband problem.”
Abner Mason, founder and CEO of SameSky Health
In 2021, for example, two Humana plans offered a benefit that paid for members’ data plans, up to $1,000 over a year. This year, members of one Wellcare plan can receive debit cards with up to $125 a month that can be used for utilities, including the internet; Healthfirst of New York has a similar benefit for its dual-eligible Medicare Advantage plans. Three plans from Devoted Health add connected devices or WiFi and data bills to the list of reimbursable expenses, up to a maximum of $300.
For Medicare, this has only been a realistic option since 2020. That’s when the Centers for Medicare and Medicaid Services began a new program that allowed a subset of Medicare Advantage plans to offer benefits not primarily related to health, like air conditioning units or pest control, under the category of Special Supplemental Benefits for the Chronically Ill. That includes “general supports for living” benefits that CMS suggests could include subsidies for utilities like gas, electric, and water — and, potentially, the internet.
“We’re seeing this shift towards [broadband access] becoming a medical benefit,” said Ratner. “Is it analogous to, for example, putting a ramp into somebody’s house so they can get into their house and get access? Well, this is a virtual ramp to be able to access telehealth.”
Consider the example of health plans paying for transportation to and from doctors’ appointments — an upfront investment that can improve health care outcomes and decrease costs in the long run. “A lot of plans today understand that one of the biggest barriers to care is transportation, and they provide transportation many times a year for certain patients,” said Mason. An internet subsidy could play a similar role — and, Mason argues, for less than a payer or patient might spend on physical transportation. “It’s going to be clearly a strong return on investment for the plans,” he said.
Neil Wagle, chief medical officer of Devoted Health, said that if a digital connection to a doctor can help a member avoid a hospitalization, that could save the plan $10,000 or $20,000. “The calculus is can we dramatically improve someone’s life with a benefit, and is that dramatic improvement going to lead to better health, better happiness, and lower costs?” he said. “How many WiFi bills can we pay with that savings?”
One concern is that unfettered coverage for virtual care — and perhaps internet access to enable it — could drive up overall health care costs by encouraging unnecessary or low-value appointments. As policymakers debate legislation to extend pandemic-era reimbursement rates for telehealth, the potential for overuse is a prime point of debate.
But for individual plans, increased utilization isn’t necessarily a problem. “If I can get the member to do more virtual care, it is a win on cost, it’s a win on access, it’s a win on the ability of and the willingness of the member to engage,” said Mason. “They’re going to see that it’s almost a no-brainer to invest and include internet in the plan.”
For now, that number is still low. Despite the fact that more than a quarter of Medicare beneficiaries don’t have a computer with high-speed internet at home or a smartphone with a data plan, the number of plans offering telehealth coverage far outstrips those with provisions to support access to broadband. An analysis from Milliman suggests over 94% of Medicare Advantage plans will offer additional telehealth benefits, up from about 58% in 2020.
There are many barriers for plans that might consider a broadband benefit. Currently, no-questions-asked subsidies are only available for special Medicare Advantage plans targeted at members with chronic illnesses like diabetes, certain cardiovascular disorders, or dementia. Medicare may cover a connected device as a supplemental benefit for other plans, but they’re only authorized to use premium dollars to pay for explicitly clinical use, so a covered smartphone or tablet can only be unlocked during a televisit and can’t be used for any other purposes. More broadly, if internet bills aren’t able to be filed as a medical expense, they could cut into the plans’ medical loss ratios, which are mandated to stay above a certain percentage.
And broadband subsidies can’t change the fact that high-speed connections simply don’t reach enough Americans. More than $40 billion in funding from the infrastructure law will go to state and territory grants to build affordable networks into broadband deserts — but building that infrastructure will take years.
In the meantime, health plans can still do a lot to improve access. “There’s a three-legged stool around digital access,” said Ratner. “One is having equipment, two is having broadband access, and the third is literacy.”
Tackling all three simultaneously will be an enormous challenge for health plans in the years ahead. “The scope of our digital equity strategy, which is in its early stage of development, goes beyond bridging the gaps for those who cannot engage fully in the digital world, but also includes addressing barriers for those who can engage, but currently choose not to because they are uncomfortable for a variety of reasons,” said Kaiser Permanente’s senior vice president and chief health officer Bechara Choucair.
Indeed, it has become increasingly clear that internet access is not clinically valuable simply as an on-ramp to telehealth. Its impacts on health — including how it intersects with employment, education, and access to essential services — are wide-ranging. That is, digital access is a social determinant of health, as the American Medical Association codified last year: a basic need like food, housing, and transportation necessary to build a strong foundation for physical and mental wellness.
“There are so many benefits that this could bring,” said Ratner. “One is opening up telehealth access. The second is the halo effect that it creates for members viewing their plan as providing a real tangible solution that can help solve some of their everyday issues.”