Expanding Equitable Telehealth Access: Federal Funding Opportunities to Support Universal Broadband
Zoe Barnard and Michelle Savuto, Manatt Health
States are awash in federal funding opportunities as a result of the COVID-19 pandemic to assist states in responding to or mitigating impacts of problems generated by the federal public health emergency (PHE). Two recent federal funding initiatives, through the American Rescue Plan Act (ARP) and the Infrastructure Investment and Jobs Act (IIJA), offer open opportunities for state officials to expand access to care through broadband infrastructure and connectivity projects.
The COVID-19 pandemic spurred a dramatic increase in the adoption of telehealth and other virtual care modalities. The rise has been driven by need for social distancing in healthcare delivery as well as a wide range of telehealth policy flexibilities implemented at the federal and state levels, though some of these flexibilities are due to expire at the end of the PHE. Despite the important role of telehealth in enabling access to care during the PHE, there is growing recognition that a “digital divide”—the gap between individuals who use or have access to telecommunications and information technologies and those who do not—is a social determinant of health that exacerbates existing disparities in healthcare access and outcomes.
The Federal Communications Commission (FCC) estimates that nearly 14.5 million Americans do not have access to broadband internet with adequate upload and download speeds to support telehealth or other virtual care modalities. Individuals living in rural and Tribal communities disproportionately lack access to adequate internet connectivity compared to people in urban areas, and also experience chronic healthcare workforce shortages (particularly for behavioral health services). Research shows that individuals in rural areas have an equal, or perhaps greater need, for mental health services but are less likely to receive any mental health service when compared to individuals residing in urban and suburban settings. Even within urban areas, broadband adoption gaps remain among older, lower-income, and less educated groups, as well as communities of color. Further, the boost in telehealth offerings during the PHE generally favored higher-income, metropolitan-dwelling adults, further compounding these disparities. Notably, the same communities and demographic groups that are experiencing disparities in access to telehealth are already experiencing disparities in healthcare access and health outcomes.
In recognition of these issues, the Biden administration and Congress have committed historic amounts of funding to: (1) build infrastructure in support of universal broadband access; and (2) launch planning, mapping, equity, and adoption projects that address the digital divide. This expert perspective describes recent federal funding initiatives and outlines considerations for state policymakers as they consider how to direct funding toward healthcare priorities. In particular, there is a key upcoming deadline for states to submit plans to the Treasury for ARP’s Capital Projects Fund on September 24, 2022.
Federal Funding Initiatives Supporting Expanded Broadband Access
Though some deadlines to apply for federal funds that support broadband expansion have passed [for funding allocated in the Coronavirus Aid, Relief, and Economic Security Act (CARES), for instance], there are still opportunities to incorporate healthcare priorities into planning for funds distributed through ARP and IIJA, described below.
ARP Coronavirus Capital Projects Fund (CPF)
ARP created the CPF in 2021, which made available almost $10 billion to help states, territories, and Tribal governments carry out critical broadband infrastructure and digital connectivity technology projects. These projects must support work, education, and health monitoring in order to be considered for funding. States may also fund other capital projects, such as multi-purpose community facilities that enable work, education, and healthcare monitoring, including remote options. The program encourages recipients to focus on economically distressed areas, support community empowerment, and adopt strong labor practices. To date, the CPF has awarded more than $915 million to 8 states (Kansas, Louisiana, Maine, Maryland, Minnesota, New Hampshire, Virginia and West Virginia) and Tribal governments that will be invested in high-speed internet infrastructure. All states have used CPF funding to launch broadband infrastructure projects in areas that lack adequate service and require internet service providers to participate in the Affordable Connectivity Program to provide subsidies for broadband service and connected devices.,
States interested in receiving CPF funds have until September 24, 2022 to submit their grant plans for funding through the Treasury Submission Portal; and they must provide additional detail by December 31, 2024.
Additional Funding Opportunities
The IIJA, enacted in November 2021, made $42.5 billion available for broadband deployment through the Broadband Equity, Access and Deployment (BEAD) program, with $100 million allocated to each state initially and the remainder of the funds to be distributed via formula grants that favor “underserved locations.” States that submitted plans for initial planning funds (that were due August 15, 2022) are now required to develop and submit a five-year action plan within 270 days of receipt of initial planning funds. Additionally, states must develop and submit initial and final proposals in 2023 and 2024, respectively, to trigger release of the remaining funds.
States have also pursued other funding opportunities such as the CARES Act of 2020. The CARES Act (1) allocated $25 million to the U.S. Department of Agriculture’s Distance Learning, Telemedicine, and Broadband Program to facilitate distance learning and telemedicine in rural areas; and (2) authorized over $150 billion to states, of which broadband access was an allowable use. Most states took advantage of funding under CARES, initiating programs to deploy broadband and technology, but many of these programs were directed at specific needs, like internet-enabled devices for education or public internet access points. For example, Missouri dedicated approximately $5 million to purchase 12,500 hotspots for community-based providers to support access to telehealth services.
Considerations for States
States have an opportunity to deploy federal funds to begin to remedy the digital divide and enable equitable access to telehealth and other virtual care modalities beyond the PHE. States who have received or are planning to request broadband funding may consider the following activities to elevate healthcare-related priorities:
Facilitating Cross-Agency Collaboration. Authorization to plan and distribute federal broadband-related funds may reside in one or more state agencies or departments. Healthcare agencies, including Medicaid, public health, behavioral health and Marketplace, may not currently be connected to planning efforts. State executive-level leadership has a key role in facilitating connections among state agencies to ensure that healthcare agency officials are involved in decision-making. This may include development of cross-agency workgroups or task forces. Health agency officials may also reach out proactively to state leadership to express interest in participating in planning discussions. Legislators need to be briefed about the role of broadband in mitigating healthcare needs and workforce shortages, particularly for behavioral health, as they play a role in many states in approving project plans and appropriating federal funds.
Conducting Outreach With Providers to Understand Community Needs. Federally qualified health centers, rural health centers, Tribal providers, and other community-based providers have a deep understanding of the neighborhoods and populations disproportionately experiencing the digital divide. Health officials should conduct outreach to and convene meetings with providers to understand root causes and identify solutions. Findings from these discussions should then be shared broadly with other agencies involved in the planning process and can help to build public support for broadband projects with public and legislative bodies.
Leveraging Data to Identify Priority Areas and Populations. During planning discussions, state health officials can contribute robust data to inform the highest value funding targets, including:
- Local broadband deployment data; the FCC acknowledges data gaps in the national Broadband Deployment map and is taking a variety of steps to improve the usability and precision of this resource. States may collect information from local broadband providers and other stakeholders (e.g., Tribal, community-based providers, consumers) to supplement FCC data and demonstrate areas where broadband access is needed to mitigate gaps in healthcare availability.
- Health Resources and Services Administration (HRSA) Area Health Resources Files (AHRF), which include data to show healthcare professional shortage areas.
- State Medicaid/CHIP network adequacy data (e.g., geospatial analyses).
- Claims/administrative data, where available, to understand the geographic distribution of video and audio-only telehealth claims. Audio-only claims are likely to be indicative of poor broadband coverage and though this modality emerged as a lifeline to address critical access needs during the PHE, policymakers, providers, and patients have expressed concerns that audio-only services, as compared with face-to-face encounters, may be less efficacious.
The COVID-19 pandemic has highlighted the urgent need to close the digital divide for Americans that have historically lacked timely and convenient access to healthcare services. State agencies charged with planning and distributing new federal broadband funding are well-positioned to strategically invest in high-value projects, and healthcare agency officials have an important seat at the table in programs that drive equitable access to telehealth and other virtual care modalities.
 The federal PHE is currently in effect through October 12, 2022, but expected to be renewed by the U.S. Department of Health and Human Services (HHS) until January 2023.
 A competing estimate states that 42 million Americans lack access to broadband internet.
 All approved state plans support broadband infrastructure designed, upon project completion, to deliver reliable internet service that meets or exceeds symmetrical download and upload speeds of 100 megabits per second (Mbps), speeds that are needed for a household with multiple users to simultaneously access the internet to telework and access education and health monitoring.
 Each state’s plan also requires all service providers to participate in the FCC’s Affordable Connectivity Program (ACP). The ACP provides a discount of up to $30 per month to households to afford broadband and connected devices.
 The deadline for Tribal governments to submit applications closed on June 1, 2022.
 The IIJA also allocated funding to 1) providing discounted broadband services and connected devices; 2) rural and Tribal broadband programs; 3) middle mile broadband infrastructure (applications are due September 30,2022); and 4) grants for states to develop Digital Equity Plans. Deadlines for these programs have passed unless otherwise noted.