This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

One silver lining of the COVID-19 pandemic is that the expansion of telehealth has kept Michiganders safely, virtually connected to their health providers – but that service is not equally accessible to all. Michiganders who are older, live in rural areas, or have income challenges may have trouble navigating, accessing, or affording the technology they need to keep their telehealth appointments.  

“Many people may have trouble with internet connection, especially in rural areas, or when storms cause power outages. It’s very difficult,” says Pam Werner, manager at the Michigan Department of Health and Human Services Recovery Oriented Systems of Care. “... Individuals living with severe disabilities, the developmentally disabled or those with physical disabilities, often do not have accommodations to facilitate telehealth.”

By May 2020, in light of social distancing mandates, many Michigan providers had made a successful transition to telehealth. Blue Cross Blue Shield of Michigan saw the number of providers offering telehealth rise from 10% to 82%. Grand Rapids-based federally qualified health center (FQHC) Cherry Health was conducting more than 800 virtual visits a day. Auburn Hills-based Easterseals Michigan increased staffing for its behavioral telehealth programs from 20 to 300. And Grand Rapids-based Arbor Circle’s mental health providers were handling 80% of their 4,000 open cases via phone and videoconference. 

While telehealth use has decreased since the early days of the pandemic, many providers and patients have continued using it. They find it convenient and effective for a wide range of health care concerns. Most likely, telehealth will become the standard for many health care issues post-pandemic.

As a member of the Michigan Coronavirus Task Force on Racial Disparities telehealth workgroup, Jametta Lilly, CEO of the Detroit Parent Network, says addressing the digital divide is key as that transition continues. Using data provided by the Michigan Health Information Technology Commission, the workgroup was able to pinpoint Michigan’s levels of internet access and adoption down to the zip code level.
Jametta Lilly.
“Most of that kind of mapping is still a 10,000-feet view. In dense areas like Detroit and places like Flint and Grand Rapids, there are still significant parts of communities where African-Americans, Latinx, and First Nations people live that don’t have [internet access],” Lilly says. “There may in fact be broadband coverage offered, but that doesn’t mean the internet is accessible, because it’s not affordable.”

Digital divide wallops elders and rural residents

The recent National Poll on Healthy Aging conducted by the University of Michigan found that 25% of older Americans had a virtual medical visit in the first three months of the COVID-19 pandemic, most often by video. In 2019, only 4% of people over 50 had used telehealth. 

However, lack of experience with the technology, and lack of access to internet and devices, were noted as ongoing barriers for many older adults. While 72% of the older adults surveyed expressed interest in using telehealth to connect with their providers, 24% had concerns about privacy and 25% were concerned about having difficulties seeing or hearing their provider.

For many Michiganders in rural areas that lack high-speed internet access, telehealth is not a viable option even though their higher incidence of chronic illness such as diabetes, hypertension and obesity would make it a useful modality. Building infrastructure required for broadband in sparsely populated rural areas does not yield the profits that it does in urban areas. Where broadband is available, it may be unaffordable for many rural residents.

Check it out

Kent District Library (KDL) had already recognized the need to increase internet access to Kent County residents before the pandemic. KDL's hotspot lending program lets library patrons check out Verizon Jetpack mobile internet hotspots, which boost connectivity for up to six devices. Joyanne Huston-Swanson, community engagement at KDL, references a 2017 Kent County study that found that 25,000 families in the county were without internet access.
A wi-fi hotspot available for checkout at the Kent District Library.
“It’s a budgetary choice, or they live in rural communities where companies haven’t invested in that infrastructure,” Huston-Swanson says. “It became clear to KDL that we could literally help our patrons and community members remain connected during the [COVID-19] shutdowns and restrictions. We purchased about 700 more hotspots, so we have about 1,000 in our collection right now.”

KDL surveys found that before the pandemic, patrons used the hotspots for work or to stay connected while on vacation. During the pandemic, families with children became the number one borrowers, as children needed to complete schoolwork online. Huston-Swanson notes that the hotspots have also helped library patrons keep their telehealth appointments. She shares the story of a cancer patient whose depressed immune system made her unable to go to her doctor’s office.
Joyanne Huston-Swanson holds a wi-fi hotspot.
“Being able to connect remotely using the hotspots was essential to her care,” Huston-Swanson says. “If people can’t access the internet, it’s very difficult for them to have the information they need, especially during the pandemic when information has been fast and furious. In any health crisis, the internet is essential to connect with your doctor’s office or the health department or state services like unemployment. Not being able to do that will severely hamper your families’ success, finances, and being able to provide food and care. We just didn’t want lack of internet to be an obstacle.”

Guidelines for telehealth needed

While some health care systems and providers have done a stellar job of making telehealth easier for their patients, others have dropped the ball. Lilly gives the example of one clinic that angered patients who came in expecting a face-to-face office visit and instead were handed a tablet in the lobby for a telehealth consultation.

“They left quite disgusted. They pulled back. One of the goals of our workgroup was to ask how we can ensure we can equip a system that works for everybody. There are no specific guidelines for telehealth,” Lilly says. 

She says the state's telehealth workgroup on racial disparities is "on the precipice" of winning funding for a survey of both patients and providers.

“We will ask what have been the barriers, what has worked, and what are their recommendations," Lilly says. "We need that information ... for the purposes of policy and to make clear recommendations.”

A Wayne County study released in March 2021 did find positive outcomes among providers and patients who had transitioned to telehealth during 2020. Because of telehealth, more contacts were made with patients — and their functioning and symptoms did improve. Many patients surveyed hoped to be able to continue using telehealth after the pandemic.

To ensure telehealth will be accessible, Lilly would like to see Medicaid and private insurers create a funding pool to cover internet connection and devices for families and individuals without access.

“I would love to see individual physician practices have a digital health plan just like the schools. All of the school districts had to develop a plan on how to ensure that children and families could utilize this technology,” she says. “We don’t have anything like that in health.”

A new social determinant of health

Early on, those in the health care world realized that telehealth could be especially effective in reaching patients with income challenges and those impacted by all social determinants of health. But without access to the internet or devices, that reach is unachievable. Phone and wi-fi access now join the list of social determinants of health that prevent people with income challenges, most often people of color, from achieving not only health equity but also educational equity and employment opportunity. Without a phone or wi-fi, it is more difficult to do nearly everything, from locating new housing or the closest food pantry to arranging transportation and child care.

“COVID has put a spotlight on all the existing disparities. They are blowing up and flaming before us,” Lilly says. “We should be talking about internet for all. How are your children going to be able to do their school, work, complete a job application, or do telehealth visits with your pediatrician? But I am cautiously optimistic. Telehealth is absolutely a viable mechanism to connect more people to the health care they need.”

A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at Estelle.Slootmaker@gmail.com or www.constellations.biz.

Joyanne Huston-Swanson photos by Kristina Bird. Jametta Lilly photos by Nick Hagen.