Will telehealth survive after the pandemic?

Telehealth revolutionized how Amy Suto uses health care. The 27-year-old Los Angeles-based writer and podcast producer was diagnosed with rheumatoid arthritis in January 2021. Immunocompromised and not yet vaccinated, Suto left town with a pandemic bubble of close friends during LA’s COVID-19 spike. But she worried that being away might be a health care nightmare.

“In reality, it was beyond ideal,” Suto said.

 Zoom, phone, and email kept Suto connected with her health care providers. She picked up prescriptions and had blood drawn locally with the help of her providers back home. Getting the care she needed was possible because she had unlimited remote access to her primary care provider and because telehealth coverage expanded during the pandemic, including for Covered California plans like hers.

But as the pandemic enters a new phase, some health insurers — including Aetna and Anthem — have begun tightening access to telehealth. Others are set to follow when the federal public health emergency ends, according to America’s Health Insurance Plans (AHIP). The emergency declaration has been renewed four times since it was issued January 31, 2020. It is set to expire later this month if it is not extended again.

What happens next will determine whether telehealth fulfills its promise to expand access to health care or becomes yet another service for which consumers have to fight. 

Promise versus reality 

When the Trump administration and Congress made it easier to take advantage of telemedicine during the pandemic, usage skyrocketed. Telehealth seemed poised to improve access to care and reduce health disparities. 

With no need to travel to a doctor’s office, pay bus fare or parking fees, arrange child care, or lose wages for time off, telehealth promised to make getting care more convenient and less costly — especially for people who face barriers to in-person care. 

“The pandemic highlighted the opportunity to begin transforming care for underserved communities,” said Dr. Lisa Fitzpatrick, founder and CEO of Grapevine Health. 

In reality, telehealth may be more of a luxury than a great equalizer. It requires access to technology, digital literacy, private space, and trust in the health care provider on the other end of the exchange, some of which may be harder to come by for communities that already struggle to obtain care. In many cases, telehealth also requires English proficiency.

Among Medicaid beneficiaries, telehealth use increased 2,700% in 2020. And nearly half of Medicare beneficiaries had used telehealth in the summer and fall of 2020. Nevertheless, disparities are evident.

According to an analysis by Komodo Health, a health care data company, telehealth utilization during the pandemic has been higher in wealthier communities — 13% in counties with median incomes of $140,000 or more, compared with 9% in counties with median household incomes of $46,000 or less. 

One study conducted during the pandemic showed that Black and Hispanic patients were less likely to use telehealth than to visit the emergency department or a doctor’s office, compared with white and Asian patients.

Technology is a significant obstacle. A JAMA study showed that 41% of Medicare beneficiaries lack a computer with high-speed internet access at home or a smart phone with a wireless data plan. Similarly, lower-income people are less likely to have a computer, tablet, or smart phone than higher-income people, according to Pew Research Center. 

Herein lies a cruel paradox of telehealth: the people who most need better health care access because of systemic barriers may be least equipped to take advantage of telehealth’s potential to reduce those barriers.

Telehealth may not only fail to ease racial and ethnic health disparities, but could make disparities worse if Medicaid beneficiaries don’t have the necessary devices or internet access, said Matt Salo, executive director of the National Association of Medicaid Directors. 

“If the new normal of Medicaid will have more of a telehealth component, and if it’s set up to fail Medicaid because it’s a promise of access that they can’t actually get … then that’s just a cruel joke,” Salo said. 

A simple solution?

Before the pandemic, federal regulations allowed telehealth only through secure platforms, such as a patient portal or onsite at a provider’s office. 

Pandemic rules allowed telehealth via a range of commercially available platforms, from the patient’s home, and on a nearly universal device: the telephone.

Many older and lower-income patients who don’t have access to high-speed internet have been able to consult with their doctors via their cell phones during the pandemic, according to Tim Fraser, vice president of government affairs at Health Center Partners of Southern California (HCP). 

Audio visits are a central component of health equity, Fraser said.

“Beyond the pandemic, it’s crucial that Medicare and Medicaid continue to reimburse telehealth and telephonic visits just as they would an in-person doctor's visit, as both require the same amount of staff time and follow-up care as a traditional in-person visit,” Fraser said.

Fitzpatrick would like to see telehealth coverage include options such as texting, FaceTime, and Facebook Messenger, which many older people may find easier to use than the portals set up by health plans and providers. A 2018 Health Affairs study underscores the point: most patients did not use their provider’s patient portal, with one-quarter citing lack of internet access and 22% citing privacy concerns. 

But rather than expand telehealth options, some health insurers are reintroducing copayments and limiting which providers can provide care. More insurers may follow if — or when — the federal public health emergency expires. Reverting to restrictive telehealth policies may limit health care access for millions of Americans who have come to love it.

According to J.D. Power’s 2021 U.S. Commercial Health Plan Member Study, more than one-third of commercially insured health plan members used telehealth, up from 9% the prior year. That usage contributed to higher member satisfaction. Similar dynamics are at play for Medicare Advantage members, according to another J.D. Power study. 

“It’s overwhelmingly popular,” said James Beem, managing director of global health care intelligence at J.D. Power. Telehealth fulfills more than consumers’ desire for convenience, he added. 

“What they’re really interested in is deeper levels of conversation,” Beem said. Consumers may start using telehealth for simple issues, such as migraine headaches, and then pursue more in-depth care, including mental health services. 

Back in Los Angeles and vaccinated against COVID-19, Suto could safely return to seeing her doctors in person. But she’d rather use telehealth than drive. 

“The traffic here is atrocious,” she said.