Telehealth Expansion, Internet Speed, and Primary Care Access Before and During COVID-19
Authors: Tilhou Alyssa Shell , Jain Arjun , DeLeire Thomas 
Published: January 2024

ImportancePrimary care (PC) receipt is associated with better health outcomes. How telehealth expansion and internet speed are associated with PC use is unclear.ObjectiveTo examine the association of telehealth and internet speed with PC use across sociodemographic determinants of health.Design, Setting, and ParticipantsThis cohort study performed difference-in-differences regression of the change in in-person and telehealth PC visits between pre–COVID-19 public health emergency (PHE) (June 1, 2019, to February 29, 2020) and an initial (March 1, 2020, to May 31, 2020) and prolonged (March 1, 2020, to December 31, 2021) PHE period among continuously enrolled nonpregnant, nondisabled Wisconsin Medicaid beneficiaries aged 18 to 64 years. Data were analyzed from March 2022 to March 2023.ExposurePHE-induced telehealth expansion.Main Outcomes and MeasuresChange in PC telehealth (using Current Procedural Terminology codes) visits: (1) count; (2) visit share completed by telehealth; (3) percentage of PHE-induced visit decline offset by telehealth. High-speed internet (HSI) defined as living in a census block group with a median block maximum download speed of 940 megabits per second or greater (June 2020 Federal Communications Commission broadband data); other census block groups classified as low-speed internet (LSI).ResultsIn the total cohort of 172 387 participants, 102 989 (59.7%) were female, 103 848 (60.2%) were non-Hispanic White, 34 258 (19.9%) were non-Hispanic Black, 15 020 (8.7%) were Hispanic, 104 239 (60.5%) were aged 26 to 45 years, and 112 355 (66.0%) lived in urban counties. A total of 142 433 (82.6%) had access to HSI; 72 524 (42.1%) had a chronic condition. There was a mean (SD) of 0.138 (0.261) pre-PHE PC visits per month. In the pre-PHE period, visit rates were significantly higher for female than male participants, non-Hispanic White than non-Hispanic Black individuals, urban than rural residents, those with HSI than LSI, and patients with chronic disease than patients without. In the initial PHE period, female participants had a greater increase in telehealth visits than male participants (43.1%; 95% CI, 37.02%-49.18%; P &amp;lt; .001), share (2.20 percentage point difference [PPD]; 95% CI, 1.06-3.33 PPD; P &amp;lt; .001) and offset (6.81 PPD; 95% CI, 3.74-9.87 PPD; P &amp;lt; .001). Non-Hispanic Black participants had a greater increase in share than non-Hispanic White participants (5.44 PPD; 95% CI, 4.07-6.81 PPD; P &amp;lt; .001) and offset (15.22 PPD; 95% CI, 10.69-19.75 PPD; P &amp;lt; .001). Hispanic participants had a greater increase in telehealth visits than Non-Hispanic White participants (35.60%; 95% CI, 25.55%-45.64%; P &amp;lt; .001), share (8.50 PPD; 95% CI, 6.75-10.26 PPD; P &amp;lt; .001) and offset (12.93 PPD; 95% CI, 6.25-19.60 PPD; P &amp;lt; .001). Urban participants had a greater increase in telehealth visits than rural participants (63.87%; 95% CI, 52.62%-75.11%; P &amp;lt; .001), share (9.13 PPD; 95% CI, 7.84-10.42 PPD; P &amp;lt; .001), and offset (13.31 PPD; 95% CI; 9.62-16.99 PPD; P &amp;lt; .001). Participants with HSI had a greater increase in telehealth visits than those with LSI (55.23%; 95% CI, 42.26%-68.20%; P &amp;lt; .001), share (6.61 PPD; 95% CI, 5.00-8.23 PPD; P &amp;lt; .001), and offset (6.82 PPD; 95% CI, 2.15-11.49 PPD; P = .004). Participants with chronic disease had a greater increase in telehealth visits than those with none (188.07%; 95% CI, 175.27%-200.86%; P &amp;lt; .001), share (4.50 PPD; 95% CI, 3.58-5.42 PPD; P &amp;lt; .001), and offset (9.03 PPD; 95% CI, 6.01-12.04 PPD; P &amp;lt; .001). Prolonged PHE differences were similar. Differences persisted among those with HSI.Conclusions and RelevanceIn this cohort study of Wisconsin Medicaid beneficiaries, greater telehealth uptake occurred in groups with higher pre-PHE utilization, except for high uptake among Hispanic and non-Hispanic Black individuals despite low pre-PHE utilization. HSI did not moderate disparities. These findings suggest telehealth and HSI may boost PC receipt, but will generally not close utilization gaps.