Staci Bishop was getting frustrated. A physician assistant at the Southeast Colorado Medical Clinic in Baca County—population: 3,585—she’d scheduled a video call with a patient living roughly 20 miles away. The patient’s weak internet connection, however, was distorting visuals and sound. “We muddled through, but had the situation been more emergent, we could have had a problem,” Bishop says. If the malady had been, say, a cut that needed to be examined for infection, the patient would have been forced to drive to the clinic—potentially exposing herself to a virus that’s killed hundreds of thousands.
When the seriousness of COVID-19 finally dawned on the United States in March, the Centers for Disease Control and Prevention recommended switching many nonemergency visits, such as appointments with mental and behavioral health professionals and follow-ups with patients after hospitalization, to telemedicine appointments. The goal was to limit contact between health care workers and potentially infectious patients while also preserving the already-dwindling stash of personal protective equipment (PPE). Colorado worked quickly to remove barriers to virtual health care: Health First Colorado, the state’s Medicaid program, began reimbursing telephone and live chats on March 20. A few days later, Governor Jared Polis signed an executive order making it easier for private insurers to refund health providers for virtual appointments.
Such changes were a boon for urban medical centers like Denver Health’s clinics; the week of April 6, 75 percent of primary care visits there were occurring virtually, up from exactly zero in 2019. But in some mountain and Eastern Plains towns, where patients—and sometimes clinics—can’t access reliable internet, switching to telehealth has proved difficult. Consequently, as the nation continues to grapple with COVID-19, experts believe Colorado’s rural areas could be at a disadvantage while trying to manage an outbreak.
Expensive infrastructure is partially to blame. Service providers such as CenturyLink rarely install broadband-delivering cables in rural areas because the lines don’t reach enough customers to recoup the investment. Plus, a 2005 state law that seeks to protect private companies from public competition prohibits local governments from building their own internet delivery systems. Communities can vote to opt out of the law (Fort Collins did so in 2015, allowing it to establish Fort Collins Connexion in 2019, one of just a few city-owned fiber networks in the state), but creating public broadband access costs time and money. Such hurdles have resulted in 13 percent of rural households across the state living without broadband access in 2019, according to the Colorado Broadband Office (CBO), which is actually better than the nationwide numbers: 37 percent of rural Americans say they don’t have a broadband internet connection at home, according to a Pew Research Center study conducted this past year.
“Put yourself in the shoes of someone having a crisis right now,” says Jin Tsuchiya, a public policy officer at the Colorado Health Foundation. “Imagine being in Denver, and then imagine being in Lamar.” A Denverite experiencing COVID-19 symptoms could schedule a virtual check-in with a doctor. The patient in Lamar, a rural town in southeast Colorado, is less likely to have adequate bandwidth, forcing an in-person visit. At best, the nurses and doctors who interact with the patient dip into their PPE supply; at worst, the patient has the virus and infects someone else. Then there are the ancillary mental health impacts of the new coronavirus. “Video calls with a social worker or online group therapy would really help in a time like this,” Tsuchiya says, “when we’re being told to not congregate in social settings.”
Poor internet could also limit the ability of health care facilities to respond to outbreaks and other emergencies. Gunnison Valley Health Hospital, for example, lacks the bandwidth to offer telehealth and doesn’t always have a radiologist on-site. During those instances, it sends brain scans from suspected stroke victims and other images to off-site radiologists who partner with the hospital. Trevor Smith, Gunnison Valley Health’s IT director, remembers a time when the hospital’s internet went down. Smith had to beg a rotating radiologist to stay for the weekend; if he had refused, Gunnison Valley Health would have had to send patients in need of scans to a different hospital farther away.
By urging state agencies to create grants to fund internet infrastructure, helping towns apply for that money, and facilitating partnerships, the CBO has done an impressive job closing the broadband gap in the state. Since the office began collecting data in 2015, rural access to broadband has improved from 59 to 87 percent. Meanwhile, Lieutenant Governor Dianne Primavera says her office is leveraging emergency federal aid to bolster telehealth and encouraging stakeholders, such as local governments and hospitals, to apply for FCC telehealth and broadband funding.
But installing cables can take months—even years. Plus, health care professionals such as Michelle Mills, director of the Colorado Rural Health Center, worry pandemic-induced budget shortfalls may stymie expansion plans. (In May, the nonpartisan Legislative Council projected the state would need to cut $3.3 billion from its 2021 budget.) “I think the state is doing the best it can with the funding it has available,” Mills says. Time will tell if its best is good enough.