Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic

Abstract Background During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. Objective To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. Design Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015–February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020–December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran’s residential address. Participants All veterans receiving VHA MH services during study period. Main Measures MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. Key Results Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients’ quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45–1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90–0.94; P < 0.001). Conclusions This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.