Link Health, a Boston-based program that utilizes a three-pillar, community-based strategy, increased access to the Internet in marginalized communities by leveraging the Affordable Connectivity Program.
Authors: Nicholos P. Joseph, MD, MPP https://orcid.org/0000-0001-9365-879X, Ahmad M. Hider, MPhil https://orcid.org/0000-0001-8897-8932, Dominick Contreras, AB, David E. Velasquez, MBA, MPP https://orcid.org/0000-0002-1516-4572, and Alister Martin, MD, MPPAuthor Info & Affiliations
Regulatory changes to the landscape of medicine in the United States, such as changes in privacy and licensure as a result of the Covid-19 pandemic, have expedited the transition to telemedicine in health care. With the rise of telehealth as an essential health service, connectivity to the Internet has become increasingly important, but many disadvantaged communities remain without consistent access. A recently passed federal benefit, known as the Affordable Connectivity Program (ACP), aims to remedy this issue by providing access to wireless Internet for low-income households. To date, however, the ACP’s benefits remain significantly underutilized by individuals and families eligible for the program. Link Health is a grassroots initiative designed to increase uptake of the ACP by establishing on-site, health center–based Internet clinics in historically underserved communities throughout the Greater Boston, Massachusetts area. By working with local community health centers and community-based organizations, Link Health functions as the intermediary between lower-income populations who qualify for the ACP and Internet service providers by raising awareness of the ACP and assisting individuals through the eligibility and sign-up process. In this article, the authors detail the strategies employed to maximize uptake of the ACP in low-income communities. These efforts can be deployed in vulnerable communities around the United States to increase access to necessary care and continue to close the digital divide.
- Increasing uptake of the ACP in vulnerable communities is possible by establishing on-site, health center–based Internet clinics in neighborhoods with high proportions of lower-income patients.
- Cultivating close partnerships with community-based organizations and health care sites is critical to effectively reach the populations of interest.
- Effective outreach and enrollment in target communities is possible by utilizing a get-out-the-vote framework and grassroots organizing strategy.
In November 2021, the passage of the Infrastructure Investment and Jobs Act provided $14 billion in funding to provide subsidies on access to the Internet for eligible households through an initiative now known as the Affordable Connectivity Program (ACP). Through the ACP, individual households that qualify are provided (1) a monthly $30 subsidy (increased to $75 for households on tribal lands) to help pay for Internet plans offered by Internet service providers (ISPs), and (2) a $100 subsidy for the purchase of a tablet or laptop. Anyone utilizing a government assistance program (SNAP [Supplemental Nutrition Assistance Program], WIC [Special Supplemental Nutrition Program for Women, Infants and Children], Medicaid [MassHealth in Massachusetts], etc.) or who is below 200% of the federal poverty limit is eligible for the ACP.1 Households are thus able to save much-needed funds and can more easily access health care that they might otherwise struggle to obtain given the high cost of Internet services. The ACP is set to expire once its funds are fully utilized — and experts say that this will occur sometime around mid-2024.2
Regulatory waivers instituted at the beginning of the Covid-19 pandemic allowed for the rapid expansion of telehealth as a primary health service for patients.3 But while an increased demand for telehealth services has indeed occurred across the nation, the digital divide has continued to expand, leaving many vulnerable patients without access to the Internet to receive their necessary care.4–6 Patients who qualify for the ACP are also those who disproportionately suffer from multiple chronic health conditions, making their access to telehealth services essential to help reduce this inequity.7 Link Health strived to help mitigate this disparity in access to wireless Internet. Below, we detail our approach to reach these eligible populations to help increase uptake of the ACP.
Uptake of the ACP’s benefits has varied across the United States. While some cities and counties have experienced an increase in the uptake of the program, many others have not.8 The Federal Communications Commission (FCC) revealed that only 16 million households have signed up for this program since its inception in November 2021, even though 48.6 million households are eligible.9 This lag in uptake appears to be amplified in places with a higher concentration of lower-income individuals. Recent estimates have shown that 15% to 24% of Americans lack any sort of Internet broadband connection.10 The challenge of providing low-income residents with affordable Internet access was clear.
While an increased demand for telehealth services has indeed occurred across the nation, the digital divide has continued to expand, leaving many vulnerable patients without access to the Internet to receive their necessary care.
Link Health’s objective is to increase access to and enrollment in the ACP among eligible populations to allow them to access the Internet more readily by reducing its cost. Increased accessibility to Internet services allows for individuals to receive the care they need when they otherwise may not be able to do so. Leveraging a get-out-the-vote framework, Link Health executed on this objective by focusing on three fundamental pillars of outreach — active, passive, and digital — and simultaneously establishing on-site, health center–based ACP sign-up events.
ASSEMBLING A TEAM
Our initiative began with the assembly of a team of diverse stakeholders and leaders. Our pilot program conducted its work across Greater Boston in partnership with Massachusetts General Hospital, East Boston Neighborhood Health Center, Dimock Health Center, and South End Community Health Center. These community-based organizations, in close collaboration with former electoral campaign staff, were critical in identifying our initial core team of Link Health staff members. These staff members were largely recruited from the communities we aim to serve.
Roles were clearly defined as our efforts began. Our field director oversees the planning and execution of Link Health events. Our data manager oversees data uptake and integration across our three-pillar approach. Our volunteer coordinator uses outbound email to recruit members from neighboring health care facilities and medical schools to serve as on-site ACP sign-up volunteers.
Primarily, we actively signed up patients through our twice-weekly clinics at community health centers within Boston neighborhoods with historically higher proportions of disadvantaged individuals. During these clinics, our team walked patients through the ACP sign-up process with use of an on-site computer. Additionally, we promoted ACP enrollment by including sign-up codes in a variety of patient-facing materials (e.g., discharge paperwork, posters, and handouts). In contrast to our in-person clinics, during which our team actively facilitated sign-ups, these code-based sign-ups were designed to be completed with use of the patient’s own phone.
To meet communities where they are, Link Health employs a three-pillar engagement strategy using active, passive, and digital methods.
- Active: We leverage our partnerships with hospitals and clinics to allow us to facilitate ACP sign-ups through in-person events.
- Passive: We create and disseminate posters and handouts, and leverage discharge paperwork in participating health centers, to encourage ACP sign-ups.
- Digital: We deploy text messages, sent to patients from participating community health centers, to encourage ACP sign-ups.
Link Health employs a political campaign model with a small team of predominantly Black and Brown community organizers from the target communities. We also utilize health care worker volunteers to conduct place-based, in-person sign-ups for the ACP. The community organizers have knowledge of the communities and skills to effectively reach difficult-to-reach populations using get-out-the-vote (GOTV) tactics. We leverage health care worker volunteers to address initial reluctance about the ACP in communities of color, where there may be mistrust in the government or other reasons for hesitation. The health care worker volunteers facilitate a “warm handoff” to our staff, who are trained to complete ACP sign-ups. We hold in-person sign-up events at community health centers and train our volunteers to help patients complete the ACP sign-up process during downtime in the waiting room. Our health center and hospital partners have a stake in the ACP program because it allows them to provide telehealth services to their patients.
Our passive enrollment approach utilizes materials such as posters, handouts, and discharge paperwork to allow patients to sign up for the ACP on their own devices. Given the high demand and limited capacity that we see for active enrollment in our clinics, these materials are used by community partners and hospitals to invite patients to enroll. This approach has been successful in increasing enrollment, particularly in high-demand areas such as the Massachusetts General Hospital emergency room.
To meet communities where they are, Link Health employs a three-pillar engagement strategy using active, passive, and digital methods.
As part of our multipronged ACP sign-up approach, Link Health leverages a text message–based approach for ACP sign-ups. The mechanism works through a warm handoff system using multilingual digital navigators to assist with ACP enrollment via text messaging services. After receiving their personalized text message, patients are then connected to one of our digital navigators, who walks them through the ACP sign-up process.
ACTIVE APPROACH OUTREACH SEQUENCE
Our active approach utilizes a three-step sequence that includes pre-clinic, clinic, and post-clinic steps (Figure 1). This design was proposed to maximize engagement with community members. Link Health utilizes 3 to 10 volunteers per clinic, depending on foot traffic and the physical size of each clinic.
Pre-clinic operations begin approximately 5 days prior to the in-person clinic. The goals of this step of the process are (1) to ensure that Link Health has the necessary resources and processes in place to execute the upcoming clinic event, and (2) to ensure that the community is aware of the event. In particular, volunteers are recruited to ensure that the clinics are fully staffed and the community is notified of the upcoming clinic through text banking, phone banking, and/or canvassing. Other details regarding clinic space and specific patient outreach are coordinated with the selected health center.
On the day of the in-person clinic, volunteers are assigned one of the following roles: Street Outreach, Screener, Filer, or Closer. Link Health welcomes health professional volunteers (e.g., physicians, medical students, physician assistants), who help to communicate the importance of Internet accessibility to individual health through one-on-one conversations with eligible members of the community.
The general process of a Link Health clinic begins with street outreach. The volunteers assigned to this role canvas the area surrounding the clinic to introduce community members to the ACP and direct them to the clinic if they are interested in enrolling. Interested community members will then meet with a Screener, who is paired with a health professional. This pair of volunteers answer any initial questions about the program and use online screening metrics to determine ACP eligibility.11 If the individual is deemed eligible, they move on to the Filer. This volunteer oversees the creation of an FCC account for the individual and assists them in applying for the ACP. Those who do not have time to stop and sign up are provided with printouts of Link Health resources, such as fictitious $30 dollar handouts (Figure 2) that function as behavioral nudges to create engagement and interest in the ACP. Handouts are also meant to be shared with other community members who may be eligible for the ACP. If the patient’s application is accepted, they move on to the final step, during which the Closer provides the individual with their FCC log-in information and guidance on how to contact their ISP to apply their benefit to their Internet account.
After the in-person clinic, patients who had issues with their ACP application are contacted for follow-up by Link Health Clinic Fellows. Individuals are able to ask any lingering questions and are provided with any necessary support from Link Health. In addition, all patients who sign up for the ACP with Link Health are given a telephone support number, which is managed by Link Health staff. Patients can text or call this number in case of any questions or concerns.
Bridging the digital health divide in poor and underserved communities by providing them with access to the ACP has surfaced several barriers in maximizing our effectiveness.
Across all outreach approaches, Link Health has distributed over $77,000 in yearly payments to low-income patients to pay their Internet bills.
LACK OF AWARENESS
ACP benefits have been available since December 2021. Yet many of the individuals whom we encountered at our clinics were unaware of this program pre-intervention. Building trust within the community was integral to raising awareness and effectively signing up community members for ACP benefits. As our clinics exist within communities with significant proportions of marginalized individuals, the shadow of medical mistrust is always present. Given Link Health’s focus on a more holistic view of health that extends beyond traditional definitions (e.g., the critical need for Internet access to health), community trust was essential to ensure engagement with the ACP. To build this trust, Link Health sought to take intentional steps to create an environment in which trust could be bred. The first was ensuring that informational materials were made available in the community member’s primary language (Spanish, Haitian Creole, etc.). The second was staffing the clinics with individuals of color and those who spoke the local languages of the community, including health care providers who provided free “Internet consultations.” Last, local partnerships with community-based organizations were leveraged to better integrate Link Health into the community. We further addressed this barrier through consistent outreach with documents that were cosponsored by Link Health and our partner neighborhood health centers.
ACP REGISTRATION ELIGIBILITY
Technical issues related to the enrollment process on the ACP government website prevent certain individuals from qualifying for ACP benefits in real time. For example, individuals who qualify for the ACP through SNAP or WIC eligibility must input additional verification documents on the official ACP government website. There is no available way to quantify the number of missed opportunities for those who qualify for the ACP due to WIC and SNAP eligibility. In part, this is because many individuals qualify for the ACP in other ways (e.g., Medicaid). However, there have been cases in which individuals who qualified for WIC and SNAP became frustrated with the prolonged timeline of submitting documentation and then waiting for verification from the ACP. One mitigation strategy that was employed to combat this barrier involved virtually following up with patients at home, where they had more time and greater access to their necessary ACP documentation. In addition, the Screener and Filer took time to better educate people about the documentation needs of the ACP, which helped to prevent logistical barriers in the case of a prolonged application process. In almost all cases, these individuals do not have these files on hand or are unfamiliar with the information being asked of them (e.g., benefit, expiration date) while at the clinic. One exception involved individuals who qualify for the ACP through Medicaid. These individuals do not need to input additional information and are thus able to qualify for the benefit after the Link Health intervention, largely because their names can be directly located in the federal government system.
Due to the complexities of the ACP sign-up process, communicating with individuals in their native language is critical for success. We intentionally recruited multilingual volunteers to interface with non-English-speaking individuals. In addition, through partnership with the We Got Us Project, we managed to translate our materials into six other languages (Haitian Creole, Chinese [Simplified], Tagalog, Somali, Portuguese, and Vietnamese) based on the most common languages spoken in our clinic locations.
After 35 weeks of operation (as of March 30, 2023), we have held 35 clinics, with all being hosted in predominantly Black and Brown neighborhoods in the South End of Boston and East Boston. To date, we have screened >1,500 patients and have successfully enrolled 216 patients for the ACP benefit (Figure 3). Thirty-six of the 216 patients were signed up through our digital approach, while the rest were enrolled for the program through either the active or passive approach. Of note, 81.4% of individuals who enrolled in the ACP through Link Health identified as a racial/ethnic minority, with 63.9% being Hispanic/Latinx and 17.5% being Black/African American (Figure 4). Most individuals who signed up for the ACP qualified through MassHealth (46.9%), followed by SNAP (24.8%). Most enrolled individuals fell between the ages of 37 and 55 years (42.1%) and ≥55 years (35.7%). Across all outreach approaches, Link Health has distributed over $77,000 in yearly payments to low-income patients to pay their Internet bills.
Link Health provides a framework based on a three-pillar approach used in political organizing. So far, we have been able to meet the needs of lower-income individuals who have not yet been able to access the Internet or who have faced significant cost barriers in effectively doing so.12 As health care continues to recognize the benefits of the Internet, and by extension, telemedicine, it is crucial that we ensure that all communities are able to access this service. Through approaches used by Link Health and other organizations working to bridge the digital divide, other entities interested in improving the health and livelihoods of individuals may be able to leverage the ACP to connect patients to one of the most vital services in the 21st century.
Nicholos P. Joseph, Ahmad M. Hider, Dominick Contreras, David E. Velasquez, and Alister Martin have nothing to disclose.
- Federal Communications Commission. Affordable Connectivity Program. March 15, 2023. Accessed April 7, 2023. https://www.fcc.gov/acp.
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