A recent federal government funding bill failed to provide additional funding for the Affordable Connectivity Program, a federal broadband subsidy for low-income households that was enacted in December 2021. Now the program is set to run out in May 2024. Ryan Bosch, M.D., president and co-founder of social risk analytics company Socially Determined, recently spoke with Healthcare Innovation about Internet access as a social determinant of health and the impact of this bill.
Healthcare Innovation: When we interview people about working on social determinants, they’ll talk about housing, transportation and food. We don't hear them talking about broadband as much.
Bosch: I think it's natural for the social determinants of health as defined to lead with the more traditional food, housing, transportation, and access to income. The more subtle social risks occur from lack of information access that we call the digital divide, as well as lack of social connectedness, and those two are very related, not just as we age, but at different times during our life. When we are not in the workforce, then we are socially isolated. And that changes our ability to understand what we might have access to. So I think social connectedness and digital access deserve a little more attention.
HCI: A recent funding bill signed by into law by President Biden could lead to some low-income people losing Internet access. Could you talk about what that could mean?
Bosch: The concern about the funding cut is that the individual access to information in the information economy is so important to health literacy and healthcare navigation. Quite often, it's not a single risk factor. It's the impact that digital access has on the entire health of the individual or the family.
We often cite the substitution rule. If I don't have the resources to pay for internet or pay for my cell phone, then I'm going to prioritize other resources, whether that's childcare, purchasing my prescription, or paying my rent that month. These are decisions that are going to come up. Each one of those areas by substitution is another social determinant, whether that's housing, whether that's transportation, whether that's food. We find in our analytics business that it's never a single risk factor. The risk factors are very co-linear. So to be very specific, this concerns me because populations have become accustomed to information, and using information helps them navigate their obstacles like getting a ride to the clinic, getting their prescription, getting their monthly paycheck. Many things come through that access. So the plurality of risk here is what concerns me most.
HCI: This Affordable Connectivity Program was created just within the past few years to expand broadband access. What's the counter-argument somebody would make who fought to cut this out of the budget in Congress?
Bosch: You know, it's hard to speculate exactly what the argument would be. I could speculate that there's increased access at public locations and places of work in certain areas. But that argument is moving money from one pool to pay for it in another pool.
I think the background to any social clinical intervention, quite frankly, is can it provide lift to the population that it serves? I think we as an industry have a charge to be better evidenced and better analytically at defending our interventions. If there's a broadband stipend for a state, it shouldn't be delivered to the northeast corner of the state because that's where the state is more impoverished. We have more responsibility to be very discerning. There is definitely a digital divide. And I think rather than an argument for or against, I would like the argument to be about more discernment. What population needs it and where?
HCI: Are there innovative steps that either health systems or payers can do on a regional or local level to help?
Bosch: I think the most innovative step to prepare for this benefit to run out is to add precision to everything that they're doing. This goes to Medicare Advantage, this goes to managed Medicaid. Value-based care as a program requires knowledge upstream of projected costs to manage the per member per month capitated payment. That same discernment and precision is the answer. And to understand where and how a benefit could be lifted up, not just broadband, but medical assistance, transportation, food as medicine. They have a very precise population of vulnerable individuals that they're seeking to lift up.
HCI: Two years ago I interviewed your colleague Dr. Trenor Williams and an executive from insurer CareFirst BlueCross BlueShield about the way CareFirst was deploying your company’s social risk analytics platform that characterizes and quantifies social risks at a social domain level — around food, housing, financial strain, etc. Since then, have you increased the number and type of organizations you work with?
Bosch: We have indeed expanded our footprint. Our portfolio of customer segments includes payers, providers and life science companies, as well as government. Our focus has been with large payer plans such as CareFirst and others. We have also moved into the life science space. There's an incredible need for increased diversification for clinical trials information, and also for more heterogeneity around research and compliance in the life science world.
Companies that have new medications and new methods of caring for patients through therapeutics are very interested in both the patient side and the prescribing and the provider side, because in both of those areas, social clinical obstacles get in the way.
HCI: Are you also working with more Medicaid managed care organizations?
Bosch: Yes. Many states are starting to require managed care plans to screen members for social determinants, but it ends there. There's not any more teeth really in their Medicaid management. We're working with states to help them drive their managed care organizations to be more accountable to social risk.
