Originally published in Capital & Main

When the emerging COVID pandemic ended in-person appointments, clinics and patients rapidly shifted to telehealth visits. For Cynthia Gonzalez, a patient at the Venice Family Clinic, being able to talk with her therapist by phone, and later via video, was a lifeline. “If the clinic hadn’t offered [telehealth], it would have had a very negative impact on me and my family,” Gonzalez told Capital & Main through an interpreter.

She plans to continue her therapy sessions via video chat on her phone even when the clinic opens up for in-person behavioral health visits. “I’m a single mom and I work. It’s much better to have [appointments] at home than have to cancel them when I’m too busy.”

Telehealth involves the use of digital information and communications technology, most crucially the internet, to receive health care and services at a distance. It frequently includes virtual visits — visits carried out between the health care provider’s screen and the patient’s, and also can involve the use of smartphones or tablets. Telehealth can make the sharing of test results and other information between provider and patient easier and faster. While in the past it has been used primarily in rural areas and for patients with limited transportation options or for whom moving around is a hardship, telehealth took a huge step forward into the mainstream in the age of COVID.

But for those in need of health care to get the most from the services telehealth provides, they need access to affordable and adequate broadband internet. Gonzalez said she didn’t have any issues with her internet connection, but not everyone in Los Angeles is so fortunate.

Like real estate redlining, “digital redlining” results in unequal access to resources, in this case the internet, either because it’s unaffordable or because internet service is unavailable or subpar. Digital redlining frequently starts with internet service providers (ISPs) that decide not to serve poorer areas because they think it’s not as profitable. The FCC’s 2016 Broadband Access Report concluded that, across the U.S., poorer families have far less access than wealthier ones, with up to half of the lowest income Americans lacking internet speeds adequate for video conferencing (25 Mbps).

A USC-Annenberg study showed systemic discrimination against low income users in how fiber optic service is deployed across Los Angeles County. Poorer neighborhoods, particularly neighborhoods whose majority population is persons of color, are left behind with slower access by the same carriers that serve wealthier neighborhoods with faster broadband. In some parts of Los Angeles County, more than 20% of households don’t have internet access, including neighborhoods in Boyle Heights, East Los Angeles and Bell Gardens, according to a data dashboard maintained by the county. Across L.A. County, 13% of households are without internet access. Lack of reliable broadband — or any internet connection — can have a big impact on Angelenos who need medical care and can’t meet a provider in person.

“In 2021, roughly a third of our members said they’re having issues on site with Wi-Fi and broadband that were causing a barrier to video visits,” said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County, an organization serving 1.7 million patients, nearly two thirds of them below the poverty line. She noted that lower income patients, and the clinics that serve them, are located in the same areas that have been underserved by internet service providers.

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A growing movement to bring digital equity to Los Angeles County by providing free broadband to the most underserved neighborhoods is likely to have a big impact on health care for these residents, advocates say. And it won’t come a minute too soon.

Health care providers serving primarily lower income Angelenos of color said the COVID pandemic shined a light on the benefits of telehealth, with many patients conducting appointments by video for the first time. Lockdowns and restrictions on in-person medical visits caused many patients — at least those with reliable internet access — to switch to telephone and video visits. Now that restrictions have eased, many patients want to continue using telehealth.

Nationally, telehealth came into widespread use during the first round of COVID lockdowns. Close to half of U.S. physicians used virtual visits to treat patients in the pandemic’s first few months. Although telehealth use has declined as health centers have opened up, it remains higher than before the pandemic. More than a third of patients nationally have done virtual visits in 2022, and 36% use telehealth for behavioral health and substance abuse.

While home broadband subscriptions have increased across California in recent years, racial and ethnic gaps persist. In 2020, 80% of Latino households and 83% of Black households had broadband, compared to the statewide average of 85%. And 77% of Californians with broadband share it with others at home, which requires additional bandwidth for reliable access and videoconferencing. In L.A. County, there’s a strong correlation between lack of broadband service and lower median income.

The vast majority of patients served at the South Central Family Health Center, located south of downtown Los Angeles, have household incomes low enough to qualify for discounted broadband according to David Roman, the Center’s director of development and communications. But he says even with the discounts, some patients choose to go without broadband access.

“We don’t ask human beings to make a choice between eating and shelter. Those are both things that they need to live with dignity. We’re at a place right now [where] we’re also saying, well, to live in a society, you need not only telephonic access, but you need access to the internet as well.”

The percentage of behavioral health visits now conducted from “screen to screen” is much higher at SCFHC than the national average, up to 95%, according to Roman. A smartphone is most patients’ device of choice, and many patients have data-limited programs. “So it creates a big challenge,” Roman said. “If I’m in a moment of crisis, experiencing significant depression, anxiety, and this is important for me to allocate that very finite resource to this need that I have, I think it puts our patients in a very tough position.”

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At the Venice Family Clinic, the majority of appointments are done remotely, most by phone, only a small percentage by video. But according to Iliniza Baty, director of the clinic’s behavioral health department, telehealth via video has been a game changer for patients who can use it.

“Many patients have jobs with no paid time off from work, they may take several buses to get here, and they may be caring for children,” Baty told Capital & Main. The clinic didn’t do any video visits before COVID, but the pandemic made it clear that video conferences and appointments by telephone are important alternatives that need to remain available. “People who are bedbound and homebound and sick can reduce their sense of isolation [through telehealth]. Patients have said this saved their lives.” One patient, a blind man on dialysis, expressed gratitude that he could have video sessions instead of making the trek to the clinic. “For patients like him, the impact on stress relief is significant compared to privileged populations,” Baty said.

There are even more patients who would use video for telehealth visits if they had faster internet, Baty said. Even then, they may have multiple children on devices for school and therefore have limited access.

Limited access means limited care. According to McCarthy, the COVID crisis has provided an illuminating look at how less affluent Angelenos access — or don’t access — health care.

“When you look at the map of where COVID cases were the worst, [then] look at the map of where the community health centers are and the communities that they [serve] — it’s not a Venn diagram. It’s a complete overlap.”

Patients who can’t come to a clinic and can’t use video usually make do with telephone calls. Those calls can accomplish a lot, including medication management and behavioral health, McCarthy said. But video is very helpful “for people to be able to show us what medications they have, or being able to look at the space the person’s in and talk about ergonomics, or maybe how they should be arranging things to prevent falls.”

Affordable broadband access and reliable Wi-Fi aren’t just issues for patients but for their health care providers as well, McCarthy said, noting that a third of the member clinics in the Community Clinic Association of Los Angeles County had their own broadband access issues that were barriers to video visits with patients. When telehealth works as it should, staff productivity goes way up because patient no-shows and late arrivals go way down.

“Pre-telehealth we had about 26%-50% no-show rates for in-person care. If half your patients aren’t showing up, how do you plan your day?” McCarthy said. Even late arrivals due to long bus rides, car trouble or traffic can have a ripple effect on a provider’s schedule. Now, for centers that extensively use telehealth, no-show rates have fallen to less than 10% in some cases, she said.

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Immediate and longer term solutions are in the works to bring greater health equity to Angelenos, through greater broadband equity. The L.A. County Board of Supervisors is moving forward with plans for public-private partnerships to build community wireless networks to bring faster cheaper service to seven underserved communities. County officials are currently compiling a short list of companies qualified to build the networks and hope to have at least one operating by the end of the year

It took a pandemic to not only expose the need for telehealth in L.A.’s lowest income areas, but to free up resources to make internet access more affordable. Roman pointed to expanded unemployment benefits, business loans and rent forgiveness as evidence that the government can pitch in when necessary. “[COVID offered] a first glimpse at what our government could do. But we know that those dollars are not here forever, so [we are] making sure that responsible choices, good decisions and good procurement policies are followed by the county. If we don’t do this now, we may not have a second opportunity to make that transformative change in our society that we all deserve.”