COVID-19 adds a new health care gap: internet disparity

Novel coronavirus (COVID-19) targets older ethnic and racial minorities with lethal precision, establishing irrefutable evidence that inequality kills. Nearly one-third of those who have died from COVID are Black, while Blacks represent about 14% of the population in the areas analyzed. In Chicago, 78.6% of COVID-related deaths were age 60 or more. While ethnic and racial minorities represent 59% of the population, they made up the majority of all Chicago COVID-related deaths; 76.9%.

The rapid transition to telehealthcare magnifies socioeconomic barriers interfering with access to care. Older ethnic and racial minorities are more likely to experience multiple comorbid medical conditions and less apt to have access to the technology required for telehealth.

The 2010 U.S. Census identified approximately 36% of the population as racial or ethnic minorities.   Even as life expectancy has improved, economic status, race, and even gender impair some older adults from this gain.   Higher levels of disability and mortality due to cardiovascular disease, respiratory illness, diabetes, and cancer contribute to this disparity in minority groups. Not surprisingly,  low socioeconomic status and educational level negatively impact an older adult’s access to technology.

According to the Pew Research Center,  one-third of adults ages 65 and older never use the internet, and roughly half (49%) say they do not have home broadband services. The proportion of older adults with smartphones is 42% lower than those ages 18 to 64.  The combination of older age, racial/ethnic minority status, and lower socioeconomic status significantly reduces the odds of internet use. The patients who need the most care are least likely to access care through telehealth, which presents new challenges for both patient and clinician.

The transformation of health care to online platforms thus intensifies health care disparities for older adults who are also racial/ethnic minorities. The COVID -19 pandemic triggered the rapid adoption of telehealth services to deliver medical care for patients quarantined at home.  We witnessed the easy acceptance of telehealth by younger cohorts, while older adults struggled with the technology and access to internet. The discrepancy raised significant concerns for the fiscal viability of telehealth services for the older adult. Successful video visits for older adults required extensive coaching and behind the scenes support from family members or office staff.

Until April 30, when the Centers for Medicare and Medicaid Services announced equal reimbursement for audio-only and video visits, reimbursement for a telephone visit was at one-half the rate of a video or face to face visit. Lower reimbursement created a challenge for the physician held to stringent productivity standards emphasizing higher payment yielding activities. This challenge for the physician may result in an additional barrier for the older adult seeking care.

Older adults confront multiple barriers to accessing health care, including lack of transportation and limited numbers of physicians accepting Medicare and Medicaid. Limited access to telehealth is one more barrier for the older adult to overcome in accessing health care. Telehealth access decreases with age. For those over 85 years old, less than 50% have access to the internet. The older adult depending on telephone contact with their health care clinician is unlikely to successfully address all of the concerns raised in a face to face or video appointment.  Increased use may be possible only with improved access to affordable technology and additional training. Just as many advocate for a universal healthcare system as a human right, universal access to the internet must become a fundamental right.

To adequately address the healthcare inequities facing racial and ethnic older adults, several interventions are required. Healthcare systems must invest in the development of user-friendly technology platforms, which are easy to use, even for those with limited technology experience. Communities must prioritize technology education for older adults. Until these interventions make a significant impact, the Centers for Medicare and Medicaid Services must continue providing equal reimbursement for telephone and video visits. These concerns are as relevant for urban areas as for rural communities with limited access to the internet and health care professionals. As the population ages, the numbers comfortable and familiar with technology will expand, reducing the need for technology education. Yet, even as the middle-aged tech-savvy adult ages, the socioeconomic barriers will remain. Internet access will continue to be a privilege for the few until we make it a right for all. As a society, we must ensure universal access to internet services.

Sandra Swantek and Magdalena Bednarczyk are geriatricians.

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