Flexible Telehealth Policies Bridge the Rural Health Gap

June 18, 2024 | Catherine Murphy

A doctor seated at a desk with a laptop, holding a document, with the text “Federal Health Policy Update” in the lower left.

While telehealth has been used since the 1950s, the practice boomed in 2020 to improve safety and access for patients and providers during the COVID-19 pandemic. The declaration of COVID as a public health emergency allowed new flexibility for telehealth in Medicare, Medicaid, and private insurance. In the time since, it has become clear that these changes are widespread and improve healthcare access. Throughout the last four years, the telehealth landscape has seen considerable change, and, while the overall rate of telehealth use has decreased since its pandemic-era peak, telehealth use remains notably higher than pre-2020 levels.

Access to quality, prevention-based healthcare is a cornerstone of public health. Barriers to healthcare, including transportation and proximity to medical facilities, leave up to 20% of adults from receiving necessary healthcare. Increasing access to a variety of care delivery mechanisms, including telehealth, can help alleviate this issue. This is particularly important for people who live in rural areas, who tend to experience higher rates of disease and disability while facing limited access to healthcare providers and transportation than their urban counterparts.

Despite the potential for telehealth to bridge the gap for rural populations, telehealth services are used in higher rates in urban areas. In part, this is due to barriers to access, which include more limited access to smartphones and broadband internet in rural areas. In 2021, 72% of adults in rural areas had access to high-speed broadband internet compared to 79% and 77% of suburban and urban households, respectively. While the Coronavirus Aid, Relief, and Economic Security Act established a payment rule to allow rural health centers to provide telehealth services, it limits reimbursement for this service to one billable code for all potential telehealth services.

The federal government has certainly taken notice of the popularity and promise of expanding telehealth.

The Biden Administration is prioritizing telehealth in the Department of Health and Human Services FY25 budget request, which includes $38 million for HRSA and funding for the National Cancer Institute Telehealth Research Centers of Excellence, legislative proposals for permanent expansion of telehealth and other remote care services within CMS private insurance, and banning facility fees to ensure telehealth users do not overpay for their care. Congress, too, is paying close attention to telehealth’s benefits. Since 2020, Congress has passed several extensions to ensure Medicare beneficiaries retain telehealth benefits through the end of 2024. Efforts on Capitol Hill are ongoing, and include:

  • Congressman Mike Thompson established the bipartisan Congressional Telehealth Caucus in 2017, which advocates for expanding the use of telemedicine.
  • Congressman David Schweikert introduced the Preserving Telehealth, Hospital, and Ambulance Access Act (H.R.8261), which would extend the Medicare telehealth waiver until 2026. It was advanced by the House Committee on Ways and Means by a 41-0 vote.
  • In April, the House Energy & Commerce Subcommittee on Health held a hearing titled, “Legislative Proposals to Support Patient Access to Telehealth Services”. Member comments on telehealth legislation focused on the promise of telehealth for improving access and equity, arguments for expanding telehealth flexibilities for all types of health care, and advocacy for the Affordability Connectivity Program to ensure Americans have broadband access. Concerns included ensuring telehealth does not completely replace in-person visits and, in a bipartisan manner, worries about fraud and abuse. Telehealth bills in this markup include:
    • The Telehealth Enhancement for Mental Health Act of 2024 (H.R.7858): This legislation would update the Medicare reimbursement Subcommittee process by creating a new modifier or code specifically for telehealth-delivered mental health services. It was advanced by the House Energy & Commerce on Health by a 22-0 vote.
    • The Telehealth Modernization Act of 2024 (H.R.7623): This legislation would permanently extend telehealth flexibilities for Medicare beneficiaries and would include federally qualified health centers and rural health clinics. An amended version, which would extend this flexibility for two years, rather than permanently, was advanced by the House Energy & Commerce Subcommittee on Health by a 21-0 vote.
  • Senate Committee on Finance Hearing on Rural Health Care: This hearing examined the challenges faced by rural healthcare systems, including workforce retention challenges, closing facilities, and patients finding in-network providers. Among solutions posed, telehealth was supported by legislators and witnesses alike.
  • House Farm Bill Draft: A discussion draft of the Farm, Food, and National Security Act of 2024 released last month included a provision that would set aside funding each year for “development needs,” including telehealth.

While telehealth is a widely popular and bipartisan issue, lawmakers are working to determine the best path forward for this method of healthcare delivery. In addition to determining how extensions may drive service use and cost, lawmakers and regulators must also consider privacy challenges and service quality concerns. While important, these concerns are likely outweighed by the benefits of telehealth. ASTHO supports policies that increase access to care, especially those that bridge the gap for underserved and rural communities. Advancements that allow for maximum use of telehealth and broaden the delivery system are effective in improving access to health services and thereby improving health and well-being.