Introduction

Unequal access to high-quality healthcare remains one of the most urgent health concerns within the United States1 and throughout the world2. Inequities in access to healthcare worsen health and contribute to over $300 billion in excess healthcare spending in the U.S3. Given the health and economic impacts of inequitable access to healthcare, identifying solutions for addressing these inequities is critical. One proposed solution for improving the unequal distribution of healthcare resources is expansion of telemedicine4,5, defined by the World Health Organization as “the delivery of healthcare services over distance”6. While there are disparities in patient use of telemedicine7, the overall potential of telemedicine is substantial; telemedicine enables patients in resource-poor settings across the world to receive care from clinicians in resource-rich settings thousands of miles away8. A prime example of the benefits of telemedicine is demonstrated in cardiovascular care9. In Liu et al.’s recent study “Improving access to cardiovascular care for 1.4 billion people in China using telehealth,” patients used telemedicine to consult providers outside of their province about their cardiovascular concerns, with patients in poorer areas contacting physicians in regions where China’s top hospitals are located10. These findings validate the utility of telemedicine for expanding cardiovascular care within developing countries, while drawing attention to limitations of telemedicine’s effects on health equity within the U.S.

Expanding cardiovascular care through telemedicine

Liu et al.10 analyzed telehealth data in China from 2016 to 2020, investigating trends in hospital usage, patient usage, and diagnoses on mobile applications that allowed patients to connect with remote healthcare providers and schedule online or in-person appointments. In 2016 and 2020, cardiovascular concerns, including coronary heart disease, hypertension, and arrhythmia, were the top diagnoses documented by providers on the telehealth application with the widest reach in China. Additionally, in 2020, more than 94.6% of telehealth apps included in the study allowed patients to choose the physician they wished to see. Patients demonstrated geographical preferences; although less developed regions experienced the greatest growth in hospital availability of telehealth, patients from these areas of China contacted physicians in more developed areas, including Beijing, Shanghai, and Guangdong, where 51 of the top 100 hospitals are located11. While telemedicine does require patients to have access to internet or cellular data and a computer or other smart device, even areas of low GDP in China demonstrate widespread internet and cellphone usage12,13. Therefore, despite equity concerns about patient access to telemedicine, Liu et al. argue that telemedicine may be used to expand healthcare access in China and other countries with low GDP.

What are the implications of these findings within the U.S.?

Inequities in the distribution of healthcare resources similarly exist within the U.S14. While 20% of the U.S. population lives in rural America, only 10% of physicians practice in these rural areas15. These disparities become even more striking when considering rural residents’ access to medical specialists: patients in rural counties must drive an average of 87 miles to their nearest cardiologist16, and, in 2019, deaths due to heart disease were 21% greater in rural areas than in urban areas17. Such disparities have evoked suggestions18 to employ telemedicine programs similar to that studied by Liu et al. to expand cardiovascular care access within the U.S. However, unlike in China and other developing countries, where there may be less stringent regulations on telehealth10,19,20, medical licensure laws pose a major obstacle to telemedicine in the U.S. These licensure laws restrict physicians to practice medicine only within their home licensure state. Practically, this means patients may be required to drive hundreds of miles for a virtual appointment with a physician simply to abide by these regulations21. While physicians in the U.S. can apply to obtain licensure in an additional state22, as of 2018, only 15% of physicians were licensed in two states and only 7% in three or more states23. Variations in credentialing, continuing education requirements, and the time-intensive application process are all reported limitations to obtaining interstate licensure24. Licensure laws are rooted in the 10th Amendment of the Constitution, which effectively gives states oversight of medical operations within their boundaries25. The constitutional basis for these licensure laws explains why modifying these regulations is a formidable challenge. Still, considering the geographic inequities in healthcare across the U.S., working within these regulations to streamline physician licensure across states may be helpful to expand the reach of telemedicine26.

Considering health equity in rural America

Liu et al.’s findings support the role of telemedicine in expanding cardiovascular care in China, while drawing attention to the licensure requirements that prevent similar country-wide implementations of telemedicine within the U.S. Increasing physician licensure across states may extend access to virtual care for medically underserved areas of the U.S., and policy initiatives to expand interstate physician licensure agreements should thus be considered. At the same time, additional barriers limit the health equity impacts telemedicine can achieve. For instance, disparities in internet access persist, with 17% of individuals in the rural U.S. lacking broadband internet access as of 201927. Telemedicine further fails to address root causes of geographic health inequities, including lower participation in health insurance28, lower patient volumes that increase the cost of care29, and higher rates of poverty in rural/remote areas30, factors that not only impact patients’ access to virtual care but also hinder in-person healthcare delivery in rural areas29.

Even in the era of telemedicine, high-quality in-person care remains necessary for many conditions, including heart attacks and strokes. Addressing systemic barriers to on-site rural healthcare thus remains critical. While telemedicine may offer one solution for reducing inequities in healthcare across rural and urban areas, this technology must be considered alongside the many changes necessary to advance health equity and strengthen in-person care in rural America. Achieving equitable care may therefore require revisiting restrictive licensure laws to capitalize on expanded telemedicine access and actively strengthening rural healthcare systems so that individuals across the country can access high-quality, in-person care.