Irv Lichtenwald

Make Broadband the First Salvo in a Rural Renaissance

November 11, 2021

Healthcare IT, Rural Healthcare 7 Minute Read

Yes, South Korea is a small country with much higher population density than the United States—an average of 1,200 people per square mile versus 88 in America—but population density alone can’t explain some dramatic disparities. South Korea has rural and recreation areas, after all.

Since 2017, for example, this east Asian nation has been the world wireless broadband leader in every category: speed, quality, adoption, price, and literacy. The average internet speed in South Korea is four times the global average, and the government is rapidly making available 1 Gbit/s speeds, 142 times the global average, at a cost of $20 a month.

Compare these numbers with those of the United States. In the U.S., nearly 95 percent of the population say they use the internet regularly, but only 79 percent of suburbanites have home access to broadband service. Those in urban areas access broadband at a 77 percent clip, with rural dwellers at 72 percent.

The similarity of those numbers, however, masks a significant gap. Broadband is common in urban and suburban areas, and practically zero percent of these populations are denied access if they want it and can afford it. If people don’t have broadband at home, they almost certainly do at work or in the coffee shop down the street. Contrast that with rural areas, where 35 percent of geographic areas still have no access to broadband service.

The impact of this reality on rural communities extends well beyond a lack of cute cat videos.

“How do you get young people to want to move back into these rural areas when they feel like they’re moving back into a time frame of 20 years ago?” asked Patrick Weiler, the founder and CEO of a company that manufactures asphalt paving equipment in rural Iowa.

As so much of modern life has evolved to include an online component, the internet has steadily grown into an essential utility nearly on par with electricity and water. Weiler’s primary challenge is recruiting, but it’s far from the only obstacle created by unreliable internet service. Indeed, when so many started working from home at the beginning of the pandemic, the necessity of reliable, fast internet became painfully obvious.

“I was shocked to know how many of our employees could not work from home because they did not have reliable internet access,” said Megan Green, a Weiler employee and the founder’s daughter. “We’re talking ‘seven minutes to download an email’ type internet access.”

Of course, as the industry has rapidly digitized overall in recent years, healthcare’s rural representatives have fallen behind their urban cousins in yet another measure of modernized care. In healthcare, however, the urge to engage in false dichotomy obscures the truth. The separation is not an easy distinction between urban/suburban and rural. Rather, it could be said that the real divide is drawn along the familiar lines of financial resources, racial and ethnic identity, and age.

“Consider telehealth, an essential lifeline post-pandemic — particularly with a surge in mental health consultations,” says an analysis in Harvard Business Review (HBR). “Even as many states expanded telehealth policies to accommodate this surge, our research shows that the digital divide hampered access in New Mexico, Montana, Vermont, and Iowa. Other states, including West Virginia, Alabama, Oklahoma, Indiana, Missouri, Tennessee, and South Carolina, were slow in expanding their policies and are poor in terms of digital access as well.”

With telehealth now a healthcare fixture, these states, most of which have extensive rural areas, are hampered in the care they provide by the high-speed network access they do not. Compare this with the situation in the fifth and sixth ranked states per the HBR analysis. Chicago may come first to mind when one mentions Illinois, and certainly LA, SF, and SD epitomize the California lifestyle, but both states have huge swaths of rural land. Utah, ranked number 7, is basically one urban/suburban area embedded in a vast sea of mountains and red rock canyons.

The amount of rural real estate may be much less of a problem than a lack of finances, poor coordination, and a dearth of political will.

A corollary challenge for rural healthcare is that local populations tend to be older and generally less educated than those nearer cities. While most Americans now own smartphones, what they can do with those devices varies far and wide, and healthcare IT is arguably not making a concerted effort to meet many patients where they are.

“Instead of sending patients home with a mountain of paper, follow-up information can be transformed from PDFs to JPG images that fit on a phone for bite-sized, actionable health education,” suggests a HIMSS digital health resource. “Instead of communicating about health plan benefits in English to non-English speaking patients, or providers incurring costs for professional translation of a consent form, technology can provide a seamless native-language experience. We can even adapt to low literacy contexts with images, emojis, and symbols that help communicate the message.”

In other words, the technology can fill in the access gaps if made available and put to full use.

Still, while lack of broadband in rural areas may not tell the entire story of the digital divide, it is a significant component of the overall challenge.

Which is why the Biden administration originally proposed $100 billion for broadband in draft infrastructure legislation. Republicans have countered with $65 billion, but perhaps the real point should be that both parties support the idea of expanding broadband access and are willing to throw federal dollars at it.

The painful truth to diehard capitalists is that without federal involvement, rural broadband access probably won’t get done. The cost of laying fiber optic cable simply exceeds the value companies can expect in return.

But the path forward, even when it appears that this is an opportunity for an easy political win that actually benefits citizens, is still fraught. As is often the case, state laws, which restrict cooperative or municipal broadband arrangements in 18 of the 50, limit available options. This is most unfortunate, as a variety of service options is probably the best approach to blanketing the country with high-speed internet.

But enough about the complexities of federalism. The reality is that corporations and private capital cannot provide broadband everywhere and make money in the process. The same was true of telephone and electrical service in the early 20th century, which required the intervention of the federal government. Congress agrees on the need for a program. Now they need to figure out how to actually make the program work.

Ultimately, it might benefit the states to figure out how broadband fits into a comprehensive program to lift up all areas of rural life: healthcare, transportation, housing, education, employment, retirement. The truth is that America’s rural areas are struggling in most if not all of these segments of society, and most states don’t have the money to address these deeply rooted inequities.

One idea is to use broadband as a case study in developing an effective model for federal, state, and local collaboration to enhance the fortunes of rural Americans. Sure, there are plenty of programs in place now intended to do exactly this, but if they were working as designed, we’d have broadband service like South Korea.

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