Why audio-only telehealth is a lifeline to health care

Most of us depend on broadband internet service throughout the course of our day — for work, school, our social lives and maintaining our health. It’s become a staple in most American households; however, we often take this essential service for granted, failing to realize that not everyone has the same access. 

In fact, racial minorities and those with lower levels of education and income are less likely to have broadband service at home. This disparity has real consequences — perhaps most significantly when it comes to the delivery of invaluable telehealth services during the COVID-19 pandemic. 

An important issue being debated in Congress right now is whether to allow people to continue to receive health care services over the telephone (only) at the conclusion of the current public health emergency. As the pandemic picked up speed, the CARES Act allowed the Health and Human Services secretary to waive certain telehealth requirements, hence the origination of audio-only telehealth. The Centers for Medicare & Medicaid Services has now proposed making audio-only telehealth permanent for mental health and addiction treatment beginning in 2022. 

For those without broadband access, video equipment — or even for those who don’t have much experience using computers — the ongoing availability of audio-only telehealth visits is critical. The service has been used extensively during the pandemic. According to CMS, the majority of telephone visits were for mental health. For those without video access, who might otherwise not receive care, discontinuing telephone services could have dire consequences. 

As former members of Congress and co-chairs of the Bipartisan Policy Center’s Behavioral Health Integration Task Force, we encourage lawmakers to extend audio-only telehealth beyond the public health emergency. 

Consider that more than half of adults with mental illness received no treatment in 2019. That number is even higher among Black and Latino communities. Telehealth expands the provider pool, reduces cultural and language barriers and helps eliminate stigma. However, people of color, the elderly, low-income individuals and people living in rural areas are the least likely to have the technology and digital literacy required for traditional, video-based services. Audio-only telehealth ensures access to care for those disadvantaged by the digital divide. 

We believe ensuring the availability of these services is necessary for three reasons. 

First, telehealth using video requires broadband and a high-speed internet connection. A quarter of the rural population does not have broadband access. The same is true for one-third of Indigenous people living on Tribal lands, where there are higher rates of suicide and inadequate access to substance use disorder treatment. Audio-only ensures access in the absence of high-speed connectivity.

Second, many are unable to afford the equipment and internet plan required to support a live, video interaction. According to a 2019 Pew Research Center survey, Black and Hispanic households are less likely to have a computer in their home than their white counterparts. One quarter are fully reliant on smartphones for internet access; one-third cite cost as a barrier. Mobile data plans are also costly, particularly for monthly limits sufficient to support extended video streaming. A one-hour, high definition, encrypted video call uses nearly 2GB of data. To put this in context, the federal Lifeline program, which provides phones to low-income individuals, requires carriers include 4.5GB of monthly data in their plans. Yet, a single telehealth visit could consume half of that monthly data budget. Audio-only visits ensure access to care for those who cannot afford the necessities to access video telehealth services. 

Third, taking advantage of video telehealth services requires digital literacy. The Bipartisan Policy Center recently partnered with Social Sciences Research Solutions on a consumer survey that shows older Americans were more likely to use audio-only health services than video visits over the past year. Overall, 45 percent of adults experience some type of technology or access barrier to participate in telehealth services. These barriers are much more pronounced for the elderly and those living in rural areas.  

The virtual care flexibilities are expected to continue through the end of the public health emergency, the timing of which is still being debated. Regardless, this will provide time to study and collect data so that effective guardrails that focus on patients’ needs and evolving clinical practices can be implemented. Although some lawmakers are concerned about the potential for fraud and abuse with the adoption of audio-only services, there is no evidence of increased risk in comparison to other Medicare Part B services. The Office of the Inspector General for the Department of Health and Human Services must continue to monitor utilization patterns and enforce guardrails, as it currently does for other outpatient services. 

Audio-only health care visits are not a panacea, but for some communities, video services are simply not an option. If the alternative is no care at all, access to providers via the telephone will help mitigate disparities, especially for mental health and addiction care. If significant barriers to telehealth exist, as they do today, Congress should allow audio-only telehealth services to remain available.

John E. Sununu is the former U.S. senator from New Hampshire. Patrick J. Kennedy is the former U.S. representative from Rhode Island and founder of The Kennedy Forum. They co-chair the Bipartisan Policy Center’s Behavioral Health Integration Task Force.