Focus on Broadband and Chronic Disease

Chronic diseases such as diabetes, heart disease, cancer, and obesity are the leading cause of illness, disability, and death in America . They are also key factors impacting the United States’ annual health care costs, estimated at $4.5 trillion .

The Key Role of Broadband Connectivity

Telehealth and other broadband-enabled solutions and technologies can play an important role in chronic disease prevention and management, leading to improved patient outcomes, access to care, and cost savings.  Previous Connect2Health Task Force research has shown that counties with higher levels of broadband connectivity—i.e., access and, more significantly, adoption and use—had lower diabetes prevalence, suggesting that there is a relationship between broadband connectivity and chronic disease.  In fact, meta-analyses have shown that telehealth and other digital health innovations are effective for continuous management of numerous chronic disease conditions.  For example:

• Remote patient monitoring has helped improve average blood sugar (glucose) levels, reducing hospitalizations, and reducing instances of diabetic ketoacidosis. Relatedly, remote blood pressure monitoring can also help improve health outcomes and save money.
• Patients can utilize connected blood pressure cuffs and implantable devices that instantaneously transmit results to their medical provider.  This real-time relay of information, along with emerging machine learning and artificial intelligence to track trends and changes in patient metrics, can help doctors and patients quickly and more accurately adjust medication therapy, such as by changing the prescription drug or dosage, leading to more effective management of blood pressure.
• The internet has also become a primary resource for health-related information, and the Internet facilitates ongoing communication outside clinic visits essential for chronic disease management.
• The Community Preventive Services Task Force, an independent panel established by the U.S. Department of Health and Human Services, recommends internet-based interventions to quit tobacco, and electronic screening and brief intervention (e-SBI) to reduce heavy drinking and alcohol-related problems.
• Telehealth interventions can improve dietary outcomes (including children’s nutrition), such as eating more fruits and vegetables and reducing sodium intake and promote weight loss.

While these connected health interventions have significant potential, lack of broadband connectivity can inhibit patients’ use of remote monitoring services. For example, according to recent data, 28% of people living in rural areas and 23% of people living on tribal lands do not have access to adequate broadband.  In addition, Internet access gaps can affect the use of connected health in rural and other vulnerable populations.

Background on Chronic Disease in the U.S.

Chronic diseases are defined broadly as health conditions that last one year or more, require ongoing medical attention, and limit activities of daily living. For example:

• About 10% of Americans have diabetes, and more children and young adults are developing diabetes than in the past.
• The diabetes rate is expected to rise to 26.8% of the population by 2050, and the population-level health care cost attributable to diabetes is projected to increase from $186 billion in 2020 to $765 billion in 2050.
• Cardiovascular disease is the leading cause of mortality in the United States, and trends are increasing. Heart disease and stroke could affect 60% of U.S. adults by 2050, with annual health care costs projected to almost quadruple, from $393 billion currently to $1490 billion by 2050.
• In 2021, 1,777,566 new cancer cases were reported; and in 2022, over 600,000 people died of cancer in the United States. By 2040, new cancer cases are expected to increase to 29.9 million per year, and the number of cancer-related deaths is expected to increase to 15.3 million per year.
• Obesity rates are expected to climb from 43.1% to 60.6% of the population by 2050, and obesity is expected to affect the health condition of a third of all children by 2050, up from 20% in 2020.

Smoking, poor nutrition, physical inactivity, and excessive alcohol use causes most chronic diseases. Cigarette smoking causes cancer, heart disease, stroke, lung diseases, and diabetes and leads to more than 480,000 deaths each year in the United States. Poor nutrition and physical inactivity are significant risk factors for obesity, type 2 diabetes, heart disease, stroke, some types of cancer, and depression. Meanwhile, excessive alcohol use is associated with high blood pressure, heart disease, stroke, liver disease, and some types of cancer.

Some groups are impacted more strongly by chronic disease than others because of the conditions in which they are born, grow, work, and live that limit their ability to make healthy choices. These Social Determinants of Health include factors such as poverty, unsafe or unhealthy environments, unsafe or unaffordable housing, food insecurity, and lack of access to quality education and jobs. The FCC’s Connect2Health^FCC Task Force’s (Task Force) Chronic Disease Conceptual Framework provided below summarizes these conditions in Demographic Factors, Community & Geographic Factors, Risk Factors, Access to Care, and Quality of Care. For instance:

• The location and quality of food retail options as well as the cost of healthy foods impact dietary patterns, an important risk factor for chronic disease.
• Access to primary care physicians offers early chronic disease detection, treatment, management, as well as preventive care.
• Uninsured adults are less likely to receive preventive services for chronic conditions such as diabetes, cancer, and cardiovascular disease.
• Veterans have higher rates of chronic disease than the general population.
• Generally, people experiencing poverty are at higher risk for chronic disease.

Mapping the Intersection of Broadband and Chronic Disease

Since 2017, the Mapping Broadband Health in America platform has allowed users to view the intersection of broadband connectivity and chronic disease outcomes, access to care indicators, chronic disease risk factors, social and economic factors, and physical environment factors. The 2024 release includes a new conceptual model (shown below) to outline the complex intersection of broadband and chronic disease. Mapping Broadband Health in America platform users can now:

• Ask questions like, what is the status of Internet connectivity in areas where diabetes prevalence, cancer, or poor/fair health are highest?
• Generate actionable insights for policies and programs about how broadband connectivity can be leveraged to improve chronic disease outcomes and identify health disparities.
• Display selected data on broadband connectivity (e.g., fixed and mobile access, Internet adoption, rural access) and chronic disease outcomes with key variables to generate customized maps at the state and county levels.
• View diabetes, cancer, or obesity rates filtered by demographics, social and economic factors, race/ethnicity, physician access, and rurality to visualize patterns, possible disparity issues, and locations where broadband-enabled interventions are most impactful.

KEY:   (Orange represents the most recently-added items from the November 2024 release; blue diagonal lines denote items included in the previous release; and purple vertical lines indicate domains that will be considered in future work.)

The Task Force identified relevant demographic factors that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The DEMOGRAPHIC FACTORS box of the framework includes seven measures:

• Age: Almost a quarter of the U.S. population is expected to be 65 or older by 2060, and aging increases the risk of chronic disease. The majority of the adult population 50 years and older, across all races, will have at least one chronic disease by 2050, with the majority between the ages of 60 to 79 years.
• Gender: Women are more likely than men to have multiple chronic conditions at the same time and more likely to have certain chronic conditions, such as Alzheimer’s disease and depression.
• Median Household Income: Residents of impoverished communities are at increased risk for chronic disease. For example, individuals with lower incomes more likely to experience both cardiovascular disease and adverse psychosocial factors that are risk factors for cardiovascular disease.
• Unemployment: Unemployment is associated with increased risk of developing chronic disease, including stroke, heart attacks, heart disease, and arthritis.
• Education: In the southeastern region of the U.S., areas with low educational attainment have the highest rates of chronic disease.
• Race & Ethnicity: Chronic disease prevalence varies by race. Black, Hispanic, and American Indian or Alaska Native (AIAN) adults are more likely to have diabetes than White adults. AIAN adults are also more likely to have had a heart attack or heart disease than White adults, while rates for Black, Hispanic and Asian adults are lower than White adults. White adults have lower rates of asthma than Black and AIAN adults but higher rates than Hispanic and Asian adults.
• Rurality: Rural residents have higher prevalence of multiple chronic conditions and are more likely than urban residents to die prematurely of heart disease, cancer, chronic lung disease, and stroke.

The Task force identified relevant community factors that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The COMMUNITY FACTORS box of the framework includes two measures:

• Severe Housing: Housing instability is associated with higher prevalence of obesity, hypertension, diabetes, and cardiovascular disease. Homeowners report lower prevalence of multiple chronic conditions, including angina, diabetes, asthma, stroke, and kidney disease.
• Injury Deaths: Falls are a major cause of unintentional injury death, and common chronic conditions such as arthritis, stroke, diabetes, dementia, and poor vision can increase the risk of falling.

The Task Force identified relevant health behaviors and risk factors that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The HEALTH BEHAVIORS & RISK FACTORS box of the framework includes seven measures:

• Excessive Drinking: Excessive drinking is associated with increased prevalence of chronic diseases such as high blood pressure, heart disease, stroke, liver disease, and dementia.
• Smoking: Smoking is the leading preventable cause of death, disability, and disease in the U.S. Smoking causes heart disease, stroke, lung disease, diabetes, and other chronic diseases.
• Physical Inactivity: Physical inactivity is a risk factor for heart disease, diabetes, and obesity. Only 1 in 4 adults and 1 in 6 young people get the recommended amount of physical activity.
• Food Insecurity/nutrition: Food insecurity is associated with multiple chronic health conditions, including diabetes, hypertension, heart disease, chronic kidney disease, and depression. Individuals with chronic diseases are also more likely to lack the transportation and income necessary to obtain healthy food.
• Social Vulnerability: Social Vulnerability is a composite measure based on 16 demographic factors collected in the American Community Survey, including poverty, unemployment, housing cost burden, education, health insurance, age, disability status, single-parent households, English language proficiency, racial and ethnic minority status, housing type and transportation. Some chronic diseases are associated with multiple Social Vulnerability factors. For example, chronic obstructive pulmonary disease (COPD) prevalence at the county level is strongly associated with disability, single-parent households, and socioeconomic factors of Social Vulnerability.
• Veteran Prevalence: Among adults aged 25 and over, the prevalence of multiple chronic conditions is higher among veterans than non-veterans. Obesity, diabetes, heart disease, stroke, chronic obstructive pulmonary disease (COPD), and chronic kidney disease are all more prevalent among veterans.
• Cancer Screening: Cancer screening leads to earlier detection and improved cancer outcomes. The platform now includes the mammography screening prevalence data.

The Task Force identified relevant health outcomes that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The HEALTH OUTCOMES box of the framework includes four measures on the platform:

• Cancer: Cancer variables include breast cancer incidence and breast cancer mortality. Cancer is the second leading cause of death in the United States. The platform will include additional cancer-related data (e.g., colon cancer, lung cancer) in future releases.
• Diabetes: Diabetes shares risk factors with many other chronic diseases and is itself a risk factor for kidney disease, cardiovascular disease, and hypertension.
• Obesity: The prevalence of obesity was over 40% among U.S. adults aged 20 and older between 2017 and 2020 and is increasing. Obesity contributes to multiple chronic diseases and is independently associated with cardiovascular disease and cardiovascular disease mortality.
• Premature Death: Three of the five leading causes of premature death in the U.S. from 2010-2022 were chronic diseases: stroke, chronic lower respiratory disease, and heart disease. Variation in the rate of premature death due to noncommunicable chronic disease at the county level is associated with demographic composition, socioeconomic features, health care environment, and population health status.

The Task Force identified relevant access to care components that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The ACCESS TO CARE box of the framework includes nine measures:

• Access to Care
  • Transportation: Transportation barriers to health care have a disproportionate effect on individuals with chronic diseases, preventing them from attending medical appointments or traveling to pharmacies. Some evidence suggests that providing transportation in combination with other tailored services can improve health outcomes for patients with chronic diseases.
    • Distance to emergency room: Median distance in miles to the nearest emergency department, calculated using population weighted tract centroids in the county.
    • Percent of households with no vehicle: Percent of housing units with no vehicle available.
  • Health Insurance: Health insurance can help individuals with chronic diseases receive diagnosis and treatment. For example, having health insurance is associated with earlier cardiovascular disease detection and reduced risk of major cardiac events.
    • Medicaid insurance: Percentage of population with any Medicaid/means-tested public health insurance coverage.
    • Medicare insurance: Percentage of the population with Medicare health insurance coverage only.
    • Private insurance: Percentage of the population with private health insurance coverage.
    • Health insurance: Percent of persons under 65 with medical insurance.
  • Dental Providers & Physicians: Number of dentists. Untreated periodontitis (gum disease) can make other chronic conditions worse. Evidence suggests that periodontal treatments can improve lung function in patients with chronic obstructive pulmonary disease (COPD), improve severity measures in patients with diabetes, and improve measures of inflammation in patients with cardiovascular disease.
  • Mental Health Providers: Number of mental healthcare providers. In the U.S., 1 in 3 individuals lives in an area with a shortage of mental health providers. Individuals with mental health conditions such as depression are at higher risk for developing certain chronic diseases, including heart disease, diabetes, stroke, and Alzheimer’s disease. Chronic disease can also increase the likelihood of developing mental health conditions; Americans with diabetes are 2-3 times more likely to develop depression.
  • Access to Cancer Care: People living in rural areas tend to have limited access to cancer care. Access to cancer care currently includes number of hospitals with mammography services. Additional variables (e.g., number of hospitals with chemotherapy services) will be added in future releases.

The Task Force identified relevant quality of care components that influence chronic disease outcomes and where broadband-enabled interventions might help bridge the gaps. The QUALITY OF CARE box of the framework includes one measure:

• Preventable Hospitalization: Rate of hospital stays for ambulatory-care sensitive conditions per 100,000 Medicare enrollees (age-adjusted). Women, Black and American Indian/Alaska Native adults, adults ages 65 and older, and adults from lower-incomecommunities are all more likely to experience preventable hospitalization. These populations are also more likely to have chronic diseases such as diabetes, heart disease, and Alzheimer’s disease.

Future Work

The Mapping Broadband Health in America platform is a foundational tool for understanding the intersection of broadband and health, giving policymakers, researchers, advocacy groups, and other interested parties a concrete path to a more connected and healthier future for all Americans.

The next phase of the Mapping Broadband Health in America platform will incorporate additional cancer variables and heart disease data.

The Task Force will continue to refine the conceptual approach going forward and welcomes comments and suggestions from interested parties via e-mail to engageC2H@fcc.gov(opens new browser window with "Mapping" in the subject line).