How Digital Health Promotes Health Equity in California: Opportunities & Hurdles

While California is a national and global health care innovation and technology pacesetter, the question of equitable access to health care remains a key challenge. With sprawling urban centers and vast rural areas, California presents a unique challenge: ensuring that every resident, regardless of where they live, who they are, or their socioeconomic status, has the same access to quality health care. California is among only a few states in the nation where no single racial or ethnic group forms a majority. Instead, California is a minority-majority state, yet equitable access to care remains elusive.  

Due to the COVID-19 pandemic and subsequent digital health flexibilities rapidly adopted at the federal and state levels, evidence continues to mount that digital health modalities can be game-changing solutions to bridge gaps, reduce disparities, and foster health equity across California. These modalities are more than just digital tools – they are potential equalizers in the realm of health care, ensuring that a patient in Los Angeles, Sacramento, or San Francisco has the same care opportunities as someone in the Central Valley, the Inland Empire, or along the coast in Northern California. However, as with any innovation that “disrupts” established care delivery, virtual health care services are not devoid of structural bias. As we delve deeper into its impact, we will explore digital health implementation in California, discuss the critical importance of health equity, and identify barriers we will partner to navigate.  

Join us as we navigate this crucial intersection of technology and well-being, highlighting both the successes and the pathways yet to be explored in the mission of equitable health care for all Californians.  

The Importance of Health Equity 

Health equity, as articulated by the Centers for Disease Control and Prevention (CDC), would ensure that everyone has a fair and just opportunity to attain their highest level of health. Historical and contemporary injustices have given rise to persistent health disparities – preventable differences in health outcomes that underserved communities face, due to discriminatory practices, social or economic inequality, rurality, and a broad range of social drivers of health. Due to this structural inequality, for example, residents of rural communities, as well as racial and ethnic minority groups in the United States, often grapple with higher rates of diseases, such as diabetes, hypertension, and heart disease. These disparities remain evident even when adjusted for factors like age or income, indicating deep-rooted systemic structural inequality.  

In California, certain racial and ethnic communities face stark differences in life expectancy, quality of health care, and access to essential medical services. This extends to other underserved groups, including the LGBTQIA+ community, women, individuals with disabilities, and those who prefer a language other than English. Their journey through the health care system is riddled with barriers, from structural impediments and distrust stemming from current and historical practices.  

Digital modalities (from telehealth, remote patient monitoring, eConsults, and more) are potent solutions to bridge many of these barriers as long as it is designed, developed, tested, deployed, and evaluated to advance equitable access.

Advancing Health Equity in California via Digital Health  

Given California’s topography and demographics, solutions must be tailored to meet the unique needs of each community. Historically, regions with either dense urban populations or remote rural expanses presented hurdles in the equitable distribution of health care services. Transportation limitations, financial constraints, language barriers, and the scarcity of specialized health care providers often compounded these challenges. Digital health modalities like telehealth have begun to dismantle some of these barriers by bringing health care to where patients are located. 

For instance, a patient in a frontier community of California can now engage with a specialist located in a metropolitan hub without the cost and time of traveling for care. Moreover, virtual platforms have opened doors for individuals who prefer a language other than English to obtain real-time translation services or receive care from bilingual health care providers, fostering clarity in communication. There are a broad range of options to expand access utilizing digital health, including specialized services, mental health support, continuous monitoring for chronic ailments, and tailored health education, ensuring a comprehensive healthcare approach for every individual. 

The Transformative Potential of Telehealth 

In light of the exhaustive insights from the California Health Care Foundation, there is a resounding echo of telehealth’s transformative potential. The COVID-19 pandemic acted as a catalyst, rapidly ushering in a digital revolution in health care across California. As in-person visits plummeted during the pandemic’s peak, virtual care services surged to unprecedented heights, particularly for primary and behavioral health care.  

The hybrid model of care – combining in-person, video, and audio visits – emerges as a front-runner, ensuring that individual patient needs are met while maintaining care quality. As articulated by Lori Uscher-Pines from the RAND Corporation, the flexibility of the hybrid model allows patients to access the kind of care that resonates best with their preferences and circumstances.  

Yet, as we delve deeper into the advantages, it’s essential to address the nuances. While telehealth increases accessibility, especially for communities facing geographic and logistical barriers, concerns around the digital divide cannot be overlooked. Not every individual has the luxury of uninterrupted internet access or the proficiency to navigate digital platforms, underscoring the need to increase access to broadband that is also affordable and supports sufficient speeds, bolster digital literacy efforts, and make virtual platforms more user-friendly.  

Furthermore, the journey to optimal virtual care goes beyond technological access. The health care paradigm, especially in the Californian context, is enriched with a diverse tapestry of cultures and languages. Ensuring that virtual platforms understand and address linguistic needs and cultural competency while catering to specific groups such as the hearing-impaired is critical. This inclusionary approach is pivotal to advancing health equity in the state, ensuring that everyone, regardless of their background or ability, can access quality care.  

The emphasis now is on striking the right balance – a balance that brings together the best of both worlds: the human touch of in-person care and the convenience and reach of virtual care. 

Virtual Care Challenges Facing Californians 

While the rapid increase of digital health modalities as a result of the COVID-19 Public Health Emergency (PHE) has undoubtedly heralded a new era of accessibility and convenience, the sunset of the PHE presents a new array of challenges that must be addressed. Addressing the following barriers is essential to maintaining equitable access to virtual care modalities for all Californians:  

• Digital Divide: At the very foundation of telehealth is access to stable internet connectivity and compatible devices. While urban areas often benefit from robust digital infrastructure, rural regions continue to grapple with limited or inconsistent broadband and satellite services. Furthermore, not every Californian has access to or proficiency with the required technology, placing them at a disadvantage when digitally enabled health care delivery is theoretically the most accessible source of care. And, even where broadband exists, it may not be affordable.  
• Linguistic and Cultural Barriers: Virtual care platforms need to be universally accommodating. While many tools have begun integrating translation services, ensuring that care is truly comprehensive involves understanding and addressing linguistic needs and cultural nuances and beliefs that may influence a patient’s approach to health. For example, in the vast rural regions of California, cultural competency is not just a checklist but a cornerstone of effective care. Rural residents may have distinct perspectives on health, wellness, and medical intervention rooted in traditional beliefs, community experiences, or historical interactions with health care systems. This means that telehealth platforms and providers need to be educated on these unique cultural markers to offer relevant and respectful care. Ignoring these can not only result in ineffective treatment but can further alienate these communities, exacerbating existing disparities. Similarly, the needs of the hearing-impaired community require careful attention. Ensuring that the digital platforms are compatible with assistive technologies, that visual cues are clear and unhindered, and that there’s a system in place for feedback and continual improvement tailored to the unique challenges faced by the community. Thus, the goal should be to shape virtual care platforms that are truly holistic. They should be designed not just with clinical efficiency in mind but with a heart for inclusivity, understanding, and respect for every Californian’s diverse background and needs.  
• Payment Hurdles: Securing payment for digital health services presents a labyrinth of restrictions and onerous requirements. The myriad of coding and coverage policies, along with varied reimbursement amounts that differ among federal programs, Medi-Cal, and commercial health plans, are increasing as compared to the clear and consistent coverage and payment policies authorized during the COVID-19 PHE. The complexity disparately impacts patients, providers, rural, and underserved communities as some of the most complex and restrictive policies apply to federally qualified health centers and rural clinics. 
• Regulatory Complexity: Federal and state regulations are another significant challenge for providers and patients alike. The changes to federal Drug Enforcement Administration (DEA) prescribing regulations and rapidly iterating and evolving privacy and security standards are not necessarily aligned at the federal and state levels.  
• Patient/Provider Relationship: While digital health virtually bridges geographical distances, the absence of physical presence can sometimes attenuate the intimacy and trust inherent in a patient/provider relationship. Adapting to this new model demands a recalibration of communication techniques and “webside” manners.  

Recognizing these challenges is the first step towards innovation and evolution, ensuring that as we stride forward in the digital health revolution, no Californian is left behind. As we look to the future, there’s hope that with collective efforts, these barriers can be dismantled, making way for a truly inclusive and equitable health care paradigm. To learn more about improving access to telehealth for all patients in your care, check out this helpful resource from Telehealth.HHS.gov.