Fiber optic cables being installed in rural Virginia on the existing electrical grid, which will bring dependable high-speed broadband to the area for the first time. High speed internet is a requirement for reliable telehealth services. (Photo: USDA/Preston Keres)

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Throughout the Covid-19 pandemic, healthcare providers have turned to telehealth as a solution to any number of healthcare problems, especially for those in rural areas.

While telehealth was gaining ground in some areas before the pandemic, it exploded in the months following the start of the pandemic. Since then, all eyes have turned to telehealth visits as a way to solve the problem of dwindling numbers of healthcare workers in rural areas and to bring specialty providers to rural areas.

But some rural officials argue telehealth isn’t much of a solution if rural residents don’t have access to the broadband internet services that their urban counterparts do. While government officials and companies throw equipment and money into telehealth, what’s really needed rural officials say, is roll out of rural broadband infrastructure.

Kyle C. Kopko, Ph.D., the director for The Center for Rural Pennsylvania said the problem is threefold. First, he said, it’s getting access to the technology – like smartphones and tablets. But for rural residents, there’s also the question of having access to consistent broadband internet, and being able to afford to pay for that internet.

Kopko said that while the Federal Communications Commission claims that 98 percent of the country has access to broadband, the measurement of whether or not someone has “access” doesn’t tell the whole story.

In fact, a study on broadband availability in Pennsylvania by researchers at Pennsylvania State University released in 2019 found that while the FCC says that 100 percent of Pennsylvania has access to broadband connectivity, zero counties in the state (yes, zero) had reliable and consistent broadband access for at least half of their residents.

The FCC defines broadband as 25-3, or download speeds of 25 megabits per second with uploads of 3 mbps. In its 2018 report on broadband, the FCC said, “Approximately 98.1% of the country has access to either fixed terrestrial service at 25 Mbps/3 Mbps or mobile LTE at 10 Mbps/3 Mbps, with that number dropping to 89.7% in rural areas.”

For most zoom calls, telehealth visits and work from home situations, a resident would need a minimum of 25/3, Kopko said.

But when researchers tested actual broadband speeds from across the state in 2018, they found that median speeds in most areas of the state do not meet the FCC’s criteria to qualify as broadband. And in the report, rural areas fared much worse than urban ones did.

“At the county level, the 2018 data showed that there were 0 (zero) counties in Pennsylvania where at least 50% of the populace received ‘broadband’ connectivity, as defined by the FCC, (and) connectivity speeds were substantially slower in rural counties (as defined by the Center for Rural PA) than in urban counties,” wrote Sascha D. Meinrath, lead author of the study. “By combining 2018 data with a historical archive of an additional 15 million tests from Pennsylvania residents, the research team identified that, since 2014, the discrepancy between ISP’s self-reported broadband availability in the FCC’s broadband maps and the speed test results collected via the M-Lab platform has grown substantially in rural areas, a trajectory that is not mirrored in urban areas; this may indicate a systematic and growing overstatement of broadband service availability in rural communities.”

In fact, according to a 2019 Pew Research report, as many as 37% of rural residents don’t have access to broadband.

Kopko said legislators in his state are not only looking into how to address the gaps in broadband access, but also how to navigate the issue innovatively. Opening up broadband access to rural electrical co-ops is even being looked at as a solution.

Other roadblocks to getting more widespread broadband access include state laws that prohibit municipalities from operating or installing broadband. According to BroadbandNow, an internet service that helps consumer find and compare Internet service providers, more than 20 states have laws banning municipal broadband.

With the U.S. Department of Health and Human Services (HHS) rolling out its Rural Action Plan last week, there has been much focus on the implementation of telehealth as a solution to rural healthcare.

“The HHS Rural Action Plan represents an important step in our work with rural America. It includes key initiatives we have already taken to align with those goals,” HHS Secretary Alex Azar wrote in the plan. “Through changes to Medicare, we have also expanded access to telehealth services, allowing us to bridge the gaps in care in rural communities. This has been particularly true in response to the Covid-19 pandemic as we made rule changes in Medicare that have allowed clinicians across the country to provide care virtually in response to the public health emergency.”

In the meantime, HHS’s Rural Action Plan would allocate approximately $30 million in HRSA funding to support the expanded use of telehealth in rural communities with a focus on tele-emergency and tele-behavioral health. But it makes no mention of working with other agencies to expand broadband access in rural areas.

Companies have jumped on the bandwagon too. Earlier this month, Samsung Electronics America announced it will be teaming up with a national healthcare company, Centene Corporation, to expand access to telehealth services in rural communities.

The program will provide 13,000 Samsung Galaxy A10e smartphones with 90 days of free wireless service and some Galaxy tablets to healthcare providers. The providers can them give them to patients who might not have otherwise had access to technology that would make telehealth visits possible. The phones and tablets would be directed to approximately 200 federally qualified health centers (FQHCs), other providers and community support organizations within Centene’s markets, with a particular focus on rural and underserved areas.

Centene didn’t return emails asking what happens when the free wireless service ends though, or what happens when the recipient lives outside of a cellphone towers signal area.

Still some healthcare advocates say there may be a work-around to getting broadband so those in rural areas can use telehealth – namely, bringing rural patients to the broadband.

Since the start of the epidemic, some rural hospitals have provided WiFi access to patients in their parking lots in order to provide access to telehealth visits. In Morehead, Ky, Saint Claire Regional Hospital provided patients with an area in its parking lot to access telehealth services. Nurses would come to the patient’s car and provide them with a tablet with which they could have a telehealth visit with their healthcare provider using the hospital’s broadband service.

“Our patients have really embraced that,” said Saint Claire Regional President and CEO Donald Lloyd said in June. “You know many of our patients (in more rural areas) can’t afford to travel to Morehead or they have very limited transportation ability. It is amazing to me how effective this technology and the use of telemedicine has been for us to connect with them now. I think we were all scared that they would just be, forgive the phrase ‘left up in the hollers’ and not have the access that they needed to get to the people that they needed to see. It sounds like they’re coming into the parking lots and accessing it that way.”