[Senate Hearing 117-792]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-792

                  STATE OF TELEHEALTH: REMOVING BARRIERS 
                 TO ACCESS AND IMPROVING PATIENT OUTCOMES
=======================================================================

                                HEARING

                               BEFORE THE
                               
                 SUBCOMMITTEE ON COMMUNICATIONS, MEDIA,
                             AND BROADBAND

                                 OF THE

                         COMMITTEE ON COMMERCE,
                      SCIENCE, AND TRANSPORTATION
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 7, 2021

                               __________

    Printed for the use of the Committee on Commerce, Science, and 
                             Transportation
                             
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                             


                Available online: http://www.govinfo.gov
                
                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
54-261 PDF                 WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------     
               
       SENATE COMMITTEE ON COMMERCE, SCIENCE, AND TRANSPORTATION

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                   MARIA CANTWELL, Washington, Chair
AMY KLOBUCHAR, Minnesota             ROGER WICKER, Mississippi, Ranking
RICHARD BLUMENTHAL, Connecticut      JOHN THUNE, South Dakota
BRIAN SCHATZ, Hawaii                 ROY BLUNT, Missouri
EDWARD MARKEY, Massachusetts         TED CRUZ, Texas
GARY PETERS, Michigan                DEB FISCHER, Nebraska
TAMMY BALDWIN, Wisconsin             JERRY MORAN, Kansas
TAMMY DUCKWORTH, Illinois            DAN SULLIVAN, Alaska
JON TESTER, Montana                  MARSHA BLACKBURN, Tennessee
KYRSTEN SINEMA, Arizona              TODD YOUNG, Indiana
JACKY ROSEN, Nevada                  MIKE LEE, Utah
BEN RAY LUJAN, New Mexico            RON JOHNSON, Wisconsin
JOHN HICKENLOOPER, Colorado          SHELLEY MOORE CAPITO, West 
RAPHAEL WARNOCK, Georgia                 Virginia
                                     RICK SCOTT, Florida
                                     CYNTHIA LUMMIS, Wyoming
                 Melissa Porter, Deputy Staff Director
       George Greenwell, Policy Coordinator and Security Manager
                 John Keast, Republican Staff Director
            Crystal Tully, Republican Deputy Staff Director
                      Steven Wall, General Counsel
                                 ------                                

          SUBCOMMITTEE ON COMMUNICATIONS, MEDIA, AND BROADBAND

BEN RAY LUJAN, New Mexico, Chair     JOHN THUNE, South Dakota, Ranking
AMY KLOBUCHAR, Minnesota             ROY BLUNT, Missouri
RICHARD BLUMENTHAL, Connecticut      TED CRUZ, Texas
BRIAN SCHATZ, Hawaii                 DEB FISCHER, Nebraska
EDWARD MARKEY, Massachusetts         JERRY MORAN, Kansas
GARY PETERS, Michigan                DAN SULLIVAN, Alaska
TAMMY BALDWIN, Wisconsin             MARSHA BLACKBURN, Tennessee
TAMMY DUCKWORTH, Illinois            TODD YOUNG, Indiana
JON TESTER, Montana                  MIKE LEE, Utah
KYRSTEN SINEMA, Arizona              RON JOHNSON, Wisconsin
JACKY ROSEN, Nevada                  SHELLEY MOORE CAPITO, West 
JOHN HICKENLOOPER, Colorado              Virginia
RAPHAEL WARNOCK, Georgia             RICK SCOTT, Florida
                                     CYNTHIA LUMMIS, Wyoming
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on October 7, 2021..................................     1
Statement of Senator Lujan.......................................     1
Statement of Senator Thune.......................................     3
Statement of Senator Wicker......................................     4
Statement of Senator Schatz......................................    29
Statement of Senator Cantwell....................................    33
Statement of Senator Moran.......................................    35
Statement of Senator Blumenthal..................................    39
Statement of Senator Blunt.......................................    41
Statement of Senator Tester......................................    42
Statement of Senator Cruz........................................    44
Statement of Senator Peters......................................    46
Statement of Senator Blackburn...................................    47
Statement of Senator Warnock.....................................    49
Statement of Senator Rosen.......................................    51
Statement of Senator Klobuchar...................................    53
Statement of Senator Young.......................................    56

                               Witnesses

Sterling N. Ransone, Jr., MD, FAAFP, President, American Academy 
  of Family Physicians...........................................     5
    Prepared statement...........................................     7
Hon. Brendan Carr, Commissioner, Federal Communications 
  Commission.....................................................    12
    Prepared statement...........................................    13
Deanna Larson, President, Avel eCare; Founder, American Board of 
  Telehealth; Executive Secretary, American Telemedicine 
  Association....................................................    16
    Prepared statement...........................................    18
Dr. Sanjeev Arora, President and Founder, Project ECHO/ECHO 
  Institute; Distinguished and Regents' Professor of Medicine, 
  University of New Mexico Health Sciences Center (UNMHSC).......    21
    Prepared statement...........................................    22

                                Appendix

Alliance for Connected Care, prepared statement..................    61
Response to written questions submitted to Dr. Sterling Ransone 
  by:
    Hon. Ben Ray Lujan...........................................    64
    Hon. Amy Klobuchar...........................................    65
    Hon. Kyrsten Sinema..........................................    66
    Minority Committee Members...................................    68
Response to written questions submitted to Hon. Brendan Carr by:
    Hon. Ben Ray Lujan...........................................    69
    Hon. Kyrsten Sinema..........................................    69
    Hon. Ron Johnson.............................................    71
    Hon. Roger Wicker............................................    74
    Hon. Shelley Moore Capito....................................    74
    Hon. Mike Lee................................................    75
    Hon. Dan Sullivan............................................    76
Response to written questions submitted to Deanna Larson by:
    Hon. Maria Cantwell..........................................    78
    Hon. Kyrsten Sinema..........................................    79
Response to written question submitted to Dr. Sanjeev Arora by:
    Hon. Ben Ray Lujan...........................................    80
    Hon. Kyrsten Sinema..........................................    81
    Hon. Dan Sullivan............................................    82

 
                     STATE OF TELEHEALTH: REMOVING
                         BARRIERS TO ACCESS AND
                       IMPROVING PATIENT OUTCOMES

                              ----------                              


                       THURSDAY, OCTOBER 7, 2021

                               U.S. Senate,
             Subcommittee on Communications, Media, and Broadband, 
        Committee on Commerce, Science, and Transportation,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:01 a.m., in 
room SR-253, Russell Senate Office Building, Hon. Ben Ray 
Lujan, Chairman of the Subcommittee, presiding.
    Present: Senators Lujan [presiding], Cantwell, Klobuchar, 
Blumenthal, Schatz, Peters, Tester, Rosen, Hickenlooper, Thune, 
Wicker, Blunt, Cruz, Moran, Blackburn, Young, and Johnson.

           OPENING STATEMENT OF HON. BEN RAY LUJAN, 
                  U.S. SENATOR FROM NEW MEXICO

    Senator Lujan. Well--and we very much appreciate all of our 
panelists who are here today. Over the past year and a half, 
the COVID-19 pandemic has changed so much about how we live our 
lives. To stay safe, we changed how we worked, how we see 
friends, and how we connect with family. But nothing changed so 
fundamentally as our relationship with health care.
    Staying safe became a daily question. At times, hospitals 
and emergency rooms were full, leaving patients with nowhere to 
go. Doctors needed new ways to care for their patients that 
wouldn't further expose them to a virus that could threaten 
their health and well-being. To solve this problem, many 
doctors and patients turned to telehealth at the start of the 
pandemic.
    From February to May 2020, the U.S. Department of Veterans 
Affairs reported weekly appointments on their telehealth 
applications surged from 10,000 to 120,000 a week. Nationwide, 
weekly telemedicine visits increased over 2,300 percent. The 
number of telemedicine appointments are now 23 times higher 
than they were before the pandemic. Nearly one in three health 
care visits now use telehealth services. Not only did usage go 
up, the landscape of American health care changed.
    According to data by the Department of Health and Human 
Services, before the pandemic, over half of all community 
health centers were not equipped to provide telemedicine 
services. Today, that number is under 5 percent. Physicians 
have found ways to incorporate telehealth, including audio only 
options into their practice, and patients have seen benefits 
from the convenience and accessibility that these services have 
offered. These services kept Americans safe when ICU beds ran 
low in Dona Ana County in New Mexico.
    Local, public, and private partners rapidly assembled a 
remote telehealth monitoring program. This allowed many 
patients to recover in their own homes while still under the 
supervision of trained medical staff. The program freed up beds 
and saved lives. I want to thank Ranking Member Thune for his 
partnership and willingness to engage in this discussion, and 
also to Chair Cantwell and Ranking Member Wicker for their 
leadership in making historic investments in telehealth over 
the last few years.
    We all see the urgency here. Congress appropriated $450 
million to the COVID-19 telehealth program in the CARES Act and 
the Consolidated Appropriations Act to increase telehealth 
services. Thanks to Acting Chair Rosenworcel's leadership, the 
Federal Communications Commission continues to support 
essential connections for telehealth. The Commission helps 
fund, secure confidential remote medical consultations, 
especially for those living in rural areas. That is why we are 
here today.
    Over the past year, New Mexico received over $1 million to 
help connect patients. This funding will help improve health 
care in the Presbyterian Medical Services in Santa Fe and 
Albuquerque, and First Choice Community Health Care South 
Valley Family Health Commons. These programs are essential, but 
our work is just beginning. Digital divide is standing in our 
way of connecting all Americans to this vital service. 
According to the FCC, 14.5 million Americans lack even a low 
speed broadband connection. These communities are effectively 
cutoff from many of the benefits of telehealth.
    Native American and Hispanic communities are less likely to 
have access to high speed broadband and are less likely to take 
advantage of telehealth services. Rural areas continue to face 
higher costs for broadband infrastructure. We must connect 
every American to high quality, affordable, resilient 
broadband. Without it, the current patterns of inequality will 
continue to grow. The bipartisan Infrastructure Investment and 
Jobs Act includes $65 billion to increase broadband access and 
adoption.
    We urgently need to deliver this relief to communities 
across the country. Families must be able to talk to their 
doctor without worrying about hitting a data cap. Critical 
remote monitoring systems must remain online during network 
outages, bad weather, and natural disasters. These are 
priorities that I have long advocated for, and I will continue 
to lead the fight in many of these areas and work with my 
colleagues to solve these challenges.
    Finally, to ensure every American has access to telehealth, 
we must focus on solutions that work for underserved and 
unserved communities, underserved by broadband, underserved 
without access to critical health care. The solution must 
include access to affordable broadband Internet service, 
support for connected devices, and access to digital literacy 
programs.
    We have a distinguished panel of experts today to discuss 
the state of telehealth in the country, consider existing 
barriers, and explore solutions. I want to introduce them 
before I turn this over to our Ranking Member as well.
    Dr. Arora, he saw a critical gap in specialized care in New 
Mexico almost 20 years ago. Since then, Project Echo has 
reached over 1 million participants. Commissioner Carr has 
traveled across the Nation gathering stories and evidence of 
the need for rural health--rural telehealth access and turn 
that into policy initiatives. Ms. Larson has made a career of 
her passion to provide better access to quality health care and 
specialty services for residents of rural communities.
    And Dr. Ransone has seen firsthand how telehealth can 
enhance the patient-physician relationship, taking up that 
charge as President of the American Academy of Family 
Physicians.
    And I look forward to their discussion today. And I want to 
recognize Ranking Member Thune for opening remarks.

                 STATEMENT OF HON. JOHN THUNE, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Thune. Good morning, and thank you, Chairman Lujan, 
for holding this hearing. As a resident of a rural state, I 
have long been a proponent of telehealth for the access it 
gives to rural communities. If you live in a major city, you 
usually don't have to think too much about where you will find 
a doctor if you need one. But that is not always the case for 
Americans in rural areas.
    In the smallest towns in America, access to specialty care 
can be a challenge. The only providers may be primary care 
providers, nurses, pharmacists. These providers are essential 
to rural families, and there are times when specialty care is 
needed. And when there isn't a specialist close by, telehealth 
can help get patients to the medical care they need from a 
remote location through the use of technology. Telehealth 
services are also critical in nursing home facilities.
    In my state, we have strong programs designed to bring on 
demand support into facilities to help avoid unnecessary 
emergency department transfers. By reducing unnecessary senior 
hospitalizations--I should say, my Reducing Unnecessary Senior 
Hospitalizations Act, or the RUSH Act, would help facilitate 
more arrangements like we have in South Dakota, allowing 
medical groups to collaborate with nursing homes, provide 
telehealth services through a Medicare alternative payment 
model.
    I am also pleased to support the bipartisan Connect for 
Health Act, which aims to expand telehealth services through 
Medicare and is supported by more than half of the U.S. Senate. 
The bipartisan CARES Act played an important role in further 
expanding access to telehealth throughout the COVID-19 
pandemic, and I look forward to continuing the conversation 
with my colleagues at the Senate Finance Committee on the path 
forward for Medicare reimbursement post-pandemic.
    In my role on this committee, I will continue to advocate 
for the expansion of broadband services, which has allowed more 
patients in rural areas to take advantage of telehealth 
services. It is critical that any additional broadband funding 
goes to truly underserved areas so we can expand the reach of 
next generation services like telehealth. The Federal 
Communications Commission plays an important role to help 
expand telehealth services through a number of programs.
    Congress, acting in a bipartisan manner, provided a 
significant amount of funding for the FCC's COVID-19 telehealth 
program through the CARES Act and the year-end coronavirus 
relief package. Several health care providers in all 50 states 
have been able to participate in this important program. In my 
home state, there are a number of excellent health care 
providers expanding access to telehealth services by 
participating in this program. The Community Health Care 
Association of the Dakotas received funding for equipment 
necessary to expand remote patient monitoring and other 
telehealth services in community health centers.
    Sanford Health was able to utilize funding to secure 
wireless access points, which is necessary to conduct 
confidential telehealth appointments. And Avera Health and its 
affiliated Avel eCare represented on this panel today to 
receive funding for a number of services, including remote 
monitoring equipment and software to provide care for 
chronically ill patients in their homes. In addition to the 
FCC's COVID-19 telehealth program, the FCC's Universal Service 
Fund provides support for the Rural Health Care Program and for 
the Connected Care Pilot Program, which was spearheaded by 
Commissioner Carr.
    I appreciate Commissioner Carr taking the time to speak 
with us today about these programs. It is my hope that we will 
see you again soon before this committee, as there are many 
other important issues at the FCC of interest to members here.
    And last, I would like to extend my thanks to Ms. Deanna 
Larson, who is President of Avel eCare, for joining us today. 
As President of Avel eCare, Ms. Larson has helped advance 
telehealth services across many areas in the Midwest. Thank you 
to all of the witnesses for being here today, and I look 
forward to hearing from you. Thank you, Mr. Chairman.
    Senator Lujan. Now, recognize Ranking Member Wicker for 
opening remarks.

                STATEMENT OF HON. ROGER WICKER, 
                 U.S. SENATOR FROM MISSISSIPPI

    Senator Wicker. Thank you very much, Chairman Lujan and 
Senator Thune for convening this important hearing on 
telehealth. We have got someone here from South Dakota. We have 
someone here from New Mexico. And us folks in Mississippi kind 
of think that Brendan Carr is an honorary Mississippian. So 
please to see him here. And of course, he is the leading voice 
for telehealth on the FCC. Telehealth is becoming an 
indispensable part of our health care system.
    The COVID-19 pandemic only accelerated the expansion of 
telehealth as more aspects of our lives moved online. Today, 
millions of Americans, particularly in rural and underserved 
communities, rely on telehealth for real time and continuous 
access to medical care. Telehealth is highly cost effective and 
convenient for both doctors and patients. Doctors are able to 
monitor their patients' conditions from afar, collaborate 
quickly with other health care professionals, and provide 
faster diagnosis and treatment.
    Telehealth also helps patients to manage their own health. 
Patients can track their symptoms; send vital information to 
doctors, set up medication reminders, and much more. These 
services are especially helpful to rural Americans, veterans, 
and other underserved populations who routinely face doctor 
shortages and hospital closures. I once supported the expansion 
of telehealth. In 2018, Commissioner Carr and I visited the 
University of Mississippi Medical Center to unveil the FCC's 
new Connected Care Pilot Program. UMMC Center for Telehealth is 
a national leader in telehealth, providing high quality care to 
thousands of Mississippians and Americans across the country.
    The FCC's Connected Care Pilot Program is currently 
studying how investments from the Universal Service Fund can 
support patient and provider use of Connected Care services, 
and how that support can improve health outcomes and reduce 
costs. I am proud to have led efforts to include $450 million 
in the FCC's COVID-19 telehealth program in the CARES Act and 
the Consolidated Appropriations Act.
    These funds help reimburse providers for the connectivity 
and devices they need to keep telehealth available during the 
pandemic. Ultimately, we will not realize the full benefits of 
telehealth without reliable broadband access. Senator Lujan, in 
his statement, correctly said, ``we must conquer the digital 
divide in order to have effective telehealth,'' and he is 
correct there. More than 14 million Americans lack access to a 
broadband connection.
    And a vast majority of those Americans, 11 million, live in 
rural areas. Our Nation's rural communities should have access 
to the range of benefits that come from having a broadband 
connection, including telehealth. The broadband investments we 
are making both at the FCC and through the bipartisan 
infrastructure bill will help achieve that goal.
    Today's hearing is an opportunity to discuss our progress 
in making telehealth more accessible, and I appreciate the 
leadership of the Subcommittee in forwarding this issue. Thank 
you, Mr. Chair.
    Senator Lujan. Thank you, Ranking Member Wicker. And next 
we will recognize our witnesses for their testimony. We are 
first going to hear from Dr. Sterling Ransone, the President of 
the American Academy of Family Physicians and a practicing 
physician coming to us from Deltaville, Virginia. Dr. Ransone.

 STATEMENT OF STERLING N. RANSONE, JR., MD, FAAFP, PRESIDENT, 
             AMERICAN ACADEMY OF FAMILY PHYSICIANS

    Dr. Ransone. Thank you. Chairman Lujan, Ranking Member 
Thune, and members of the Committee, I am Dr. Sterling Ransone, 
President of the American Academy of Family Physicians, and I 
am honored to be here today representing the 133,500 physician 
and student members of the AAFP.
    In addition to my leadership role at the AAFP, I am the 
Physician Practice Director at Riverside Fishing Bay family 
practice in Deltaville, Virginia, and Assistant Clinical 
Professor of Family Medicine and Population Health at Virginia 
Commonwealth University. I have practiced in a rural community 
for more than 20 years with my wife, who is a pediatrician, and 
I have seen firsthand how telehealth can be used as a tool to 
enhance the patient-physician relationship, increase access to 
care, improve health outcomes by enabling timely care 
interventions, and decrease costs when utilized as part of a 
patient's medical health.
    Full success of telehealth cannot be achieved without 
significantly improving our Nation's broadband infrastructure. 
The ongoing pandemic has highlighted the importance of 
broadband for access to many primary care services, especially 
in the areas of mental and behavioral health care. Broadband 
access must be recognized as a social determinant of health. 
The COVID-19 pandemic has underscored the strong link between 
digital equity and health equity.
    In order to realize the potential of telehealth and address 
health disparities, Congress must invest in efforts to ensure 
universal access to affordable broadband services for all 
individuals and their health care providers. The AAFP supports 
the FCC's Rural Health Care Program, which has helped many 
rural clinicians obtain high-speed broadband connections. This 
has allowed practices like mine to implement telehealth 
services onsite, which can in turn provide patients access to 
tertiary care by connecting them and me to remote specialists.
    However, to provide virtual primary care to patients at 
home, both the clinician and the patient need access to 
broadband. Many of my patients, particularly those enrolled in 
Medicaid, are unable to afford high-speed Internet at home, 
which affects their ability to use telehealth services and 
limits my engagement with them outside the office. Beyond 
virtual visits, the lack of broadband access is also limiting 
the potential of other digital health tools, such as patient 
portals and remote patient monitoring. It is not enough simply 
to expand access to broadband.
    Congress must ensure that patients in need of access, end-
user devices such as tablets or computers, we need them to 
connect to digital health tools, and we should invest in 
training and assistance so patients can confidently use those 
tools to ensure that they are not further marginalized. For 
many small physician practices, the cost of telehealth 
technology can be prohibitive. In addition to hardware costs, 
many telemedicine vendors charge setup fees up to $3,000 and 
recurring subscription and transaction fees.
    Congress should ensure that small practices are adequately 
supported, either by making them eligible for funding through 
existing FCC telehealth programs or by creating a new program. 
Supporting telehealth adoption within these offices will 
improve equitable and timely access to health care and promote 
competition by enabling smaller practices to remain 
independent.
    As this committee is acutely aware, our Nation has a long 
way to go before all Americans have high-speed broadband and 
the tools and knowledge to leverage it for virtual video health 
care visits. Further, there may be times that an old fashioned 
phone call is the best way for a clinician to access and treat 
a patient. Therefore, it is critical to preserve access to 
audio only telehealth services provided by a patient's usual 
source of care. Coverage and payment policy should support 
patients and clinicians' ability to choose the most appropriate 
modality of care.
    As a family physician, I am a highly trained professional 
and I adhere to the standards of care. I also truly know my 
patients have formed--truly know my patients and have formed 
trusted relationships with them over the years. No two patients 
or cases are alike, and I should be able to choose how to best 
care for them based on my clinical judgment, not based on 
arbitrary insurance rules. Telehealth benefit expansions must 
increase access to one's own physician and promote high 
quality, comprehensive continuous care.
    Expanding telehealth services in isolation without regard 
for previously existing patient-physician relationships, 
knowledge of medical history, or the eventual need for a 
follow-up, hands-on physical exam can undermine the basic 
principles of the medical home, increase fragmentation of care, 
and lead to the patient receiving suboptimal treatment.
    Telehealth can't fully replace in-person care. Federal 
policy should support physician practices like mine in adopting 
and sustaining telehealth availability so that we can serve our 
patients both virtually and in the pandemic. The COVID-19 
pandemic has illustrated that telehealth can be an essential 
part of health care, but more needs to be done to ensure that 
every person in every community of our country has access to 
high quality virtual care as part of their medical home.
    I appreciate the opportunity to discuss our recommendations 
with the Committee. Thank you.
    [The prepared statement of Dr. Ransone follows:]

  Prepared Statement Sterling N. Ransone, Jr., MD, FAAFP, President, 
                 American Academy of Family Physicians
    Chairman Lujan, Ranking Member Thune and members of the Committee: 
I am Dr. Sterling Ransone, president of the American Academy of Family 
Physicians (AAFP), and I am honored to be here today representing the 
133,500 physician and student members of the AAFP.
    In addition to my leadership role at the AAFP, I am the physician 
practice director at Riverside Fishing Bay Family Practice in 
Deltaville, Va., and an assistant clinical professor of family medicine 
and population health at Virginia Commonwealth University.
    Having practiced in a rural community for more than 20 years with 
my wife, who is a pediatrician, I have seen firsthand how telehealth 
can enhance the patient-physician relationship; increase access to 
care; improve health outcomes by enabling timely care interventions; 
and decrease costs when utilized as a component of, and coordinated 
with, continuous care. Telehealth services during the pandemic have 
allowed patients and families to maintain access to their usual source 
of primary care, ensuring care continuity.
    Full success of telehealth cannot be achieved without significantly 
improving our Nation's broadband infrastructure. The ongoing pandemic 
has highlighted the utility and importance of broadband for access to 
primary care, mental and behavioral health care, education, remote 
work, applications for support programs, and public health information.
    Without broadband, many rural, tribal, and urban areas lack 
critical resources, and physicians face greater difficulty serving 
these communities. Recent research found that lack of access to high-
speed Internet was a primary barrier to equitable telehealth access for 
patients in rural areas, and stories from family physicians confirm 
that too many people have been left out as telehealth has grown during 
the COVID-19 pandemic.\1\ We must make sure that, moving forward, we 
have policies and programs in place that enable equitable telehealth 
access and utilization.
---------------------------------------------------------------------------
    \1\ Kelly A Hirko, Jean M Kerver, Sabrina Ford, Chelsea Szafranski, 
John Beckett, Chris Kitchen, Andrea L Wendling, Telehealth in response 
to the COVID-19 pandemic: Implications for rural health disparities, 
Journal of the American Medical Informatics Association, Volume 27, 
Issue 11, November 2020, Pages 1816-1818, https://doi.org/10.1093/
jamia/ocaa156
---------------------------------------------------------------------------
    As Congress considers investments in our Nation's broadband 
infrastructure and policies to expand telehealth access beyond the 
public health emergency, the AAFP offers the following recommendations.

   Invest in efforts to ensure universal access to affordable 
        broadband services for individuals and health care providers.

   Invest in programs that provide end-user devices and digital 
        literacy training and assistance to patients in need.

   Expand and target Federal telehealth programs to support 
        small physician practices.

   Preserve access to audio-only telehealth.

   Adopt coverage and payment policies that support physicians' 
        and clinicians' ability to choose the most appropriate modality 
        of care.

   Adopt telehealth policies that enhance the physician-patient 
        relationship rather than disrupt it, and also incentivize 
        coordinated, continuous care provided by the medical home.

   Monitor the impact of telehealth and broadband on health 
        care access and equity by ensuring that data collection and 
        evaluation include race, ethnicity, gender, language, and other 
        key factors.

    Broadband access must be recognized as a social determinant of 
health. The COVID-19 pandemic has underscored the strong link between 
digital equity and health equity. Having access to broadband, 
especially in times of pandemic and disaster, is vital for connecting 
people to the most basic necessities, such as health care, education, 
and employment. It is estimated that 42 million Americans don't have 
the ability to purchase broadband Internet service.\2\ And rural 
Americans are 10 times more likely to lack broadband access than their 
urban counterparts.\3\ Additionally, rural areas tend to rely on older 
broadband technologies such as DSL, satellite internet, or cellular-
based fixed wireless access. These broadband technologies are useful 
for limited web-browsing, but typically are not reliable enough to 
support telehealth services. In order to realize the potential of 
telehealth and address health disparities, Congress must invest in 
efforts to ensure universal access to affordable broadband services for 
individuals and health care providers.
---------------------------------------------------------------------------
    \2\ Busby, J., Tanberk, J., & Cooper, T. (2021, August 29). 
BroadbandNow estimates availability for all 50 states; confirms that 
more than 42 million Americans do not have access to Broadband. 
BroadbandNow Research. Retrieved October 2, 2021, from https://
broadbandnow.com/research/fcc-broadband-overreporting-by-state.
    \3\ Congressional Research Service. (2019, March 22). Broadband 
loan and grant programs in the USDA's rural utilities service. 
Retrieved October 2, 2021, from https://sgp.fas.org/crs/misc/
RL33816.pdf.
---------------------------------------------------------------------------
    The AAFP supports the Federal Communications Commission's (FCC) 
Rural Health Care (RHC) Program, which has helped bridge the digital 
divide for many rural health care providers by allowing them to obtain 
high-speed broadband connections similar to their urban and suburban 
counterparts. These broadband connections have allowed rural practices 
like mine to implement telehealth services on-site, which can provide 
patients with timely access to comprehensive care by connecting them 
and me to remote specialists. However, to provide virtual care to 
patients at home, both the clinician and the patient need access to 
broadband.
    Lack of broadband Internet is associated with fewer telehealth 
visits, and rural and low-income urban populations are less likely to 
have broadband internet.\4\,\5\ Affordability remains one of 
main barriers to broadband adoption. The lack of reliable and 
affordable Internet access is especially severe in rural communities, 
where only two out of every three people say they have broadband 
access.\6\ I have seen many of my patients, particularly those enrolled 
in Medicaid, who are unable to afford high-speed Internet at home, 
which affects their ability to use telehealth services and limits my 
engagement with them outside the office.
---------------------------------------------------------------------------
    \4\ Wilcock, A. D., Rose, S., Busch, A. B., Huskamp, H. A., Uscher-
Pines, L., Landon, B., & Mehrotra, A. (2019, July 29). Association 
Between Broadband Internet Availability and Telemedicine Use. JAMA 
Intern Med, 179(11), 1580-1582. https://jamanetwork.com/journals/
jamainternalmedicine/article-abstract/2739054
    \5\ Velasquez, D. & Mehrotra, A. (2020, May 8). Ensuring The Growth 
Of Telehealth During COVID-19 Does Not Exacerbate Disparities In Care. 
Health Affairs Blog. https://www.health
affairs.org/do/10.1377/hblog20200505.591306/full/
    \6\ Vogels, E. (2021, September 10). Some digital divides persist 
between rural, urban and Suburban America. Pew Research Center. 
Retrieved October 2, 2021, from https://www.pewre
search.org/fact-tank/2021/08/19/some-digital-divides-persist-between-
rural-urban-and-suburban-america/.
---------------------------------------------------------------------------
    The FCC's Lifeline Program has been critical in helping low-income 
Americans access broadband; however, it is used almost exclusively for 
mobile, rather than in-home, broadband services. Mobile services have 
significant value, but broadband at home creates additional public 
benefits--including the ability to connect with your physician via 
telehealth. Additionally, mobile or wireless broadband connections may 
not have sufficient bandwidth depending on the telehealth platform. We 
urge Congress to expand and reform the Lifeline Program so it can also 
provide broadband access in homes and in turn expand access to 
telehealth.
    Beyond virtual visits, the lack of broadband access is limiting the 
potential of other digital health tools, such as patient portals and 
remote patient monitoring. Patients who cannot access the online 
patient portal cannot view their own or a family member's health data, 
message securely with their physician, schedule appointments online, or 
request prescription refills online. Remote monitoring devices can feed 
real-time patient data, such as vitals, to clinicians and allow them to 
adjust medications and treatment regimens as needed without bringing 
the patient back into the office; however, these devices work only with 
a strong, reliable Internet connection. I have a patient with 
congestive heart issues who drives more than an hour each way to see me 
and who would benefit tremendously from this technology, but we can't 
use it because of poor bandwidth.
    A 2020 report found that access to broadband for Black and Hispanic 
Americans is an estimated 10 years behind that of white Americans.\7\ 
As stated in our joint principles for telehealth policy in partnership 
with the American Academy of Pediatrics and the American Colleges of 
Physicians, equitable access to broadband is critical to reducing 
health disparities and addressing many social determinants of health, 
including education and employment.
---------------------------------------------------------------------------
    \7\ Walia, A. (2020, September 3). America's Racial Gap & Big 
Tech's closing window. Deutsche Bank Research. Retrieved October 2, 
2021, from https://www.dbresearch.com/PROD/RPS_EN-
PROD/America%27s_Racial_Gap_%26_Big_Tech%27s_Closing_Window/
RPS_EN_DOC_VIEW
.calias?rwnode=PROD0000000000464258&ProdCollection=PROD0000000000511664.

---------------------------------------------------------------------------
    The COVID-19 pandemic has reinforced how lack of access to 
broadband and end-user devices perpetuates digital health inequity, and 
limited access to virtual health information worsens the digital 
divide.\8\,\9\ It is not enough to simply expand access to 
broadband. Congress must ensure that patients in need can access end-
user devices, such as tablets, to connect to digital health tools and 
invest in training and assistance so patients can confidently use those 
tools to ensure we don't further marginalize and disenfranchise them.
---------------------------------------------------------------------------
    \8\ Rowlands, G. (n.d.). Digital Health Literacy. World Health 
Organization. Retrieved October 2, 2021, from https://www.who.int/
global-coordination-mechanism/activities/working-groups/17-s5-
rowlands.pdf.
    \9\ Nelson, H. (2021, February 4). Lack of access to health 
information threatens digital divide. Patient Engagement HIT. Retrieved 
October 2, 2021, from https://patientengagementhit.com/news/lack-of-
access-to-health-information-threatens-digital-divide.
---------------------------------------------------------------------------
    One out of three households headed by someone over the age of 65 
does not have a computer, and more than half of people over the age of 
65 do not have a smartphone.\10\ Children in low-income households are 
less likely to have access to a computer, and 30 percent of Black or 
Hispanic children do not have a computer, compared with 14 percent of 
whites.\11\ Digital literacy also varies with age, income, and 
ethnicity. Many of our members have shared the challenges their 
patients have faced during the COVID-19 pandemic in accessing 
telehealth services and their patient portal. In my practice, I have 
seen that seniors have a significant learning curve when accessing 
these tools unless they have a younger family member to help them log 
on or troubleshoot technology issues.
---------------------------------------------------------------------------
    \10\ Ryan, C. & Lewis, J. M. (2017, September). Computer and 
Internet Use in the United States: American Community Survey Reports. 
United States Census Bureau. https://www.census.gov/content/dam/ 
Census/library/publications/2017/acs/acs-37.pdf
    \11\ Child Trends. (2018, December 13). Home Computer Access and 
Internet Use. https://www.childtrends.org/ indicators/home-computer-
access
---------------------------------------------------------------------------
    To achieve the full promise of telehealth, Congress must act to 
address these structural barriers to virtual care. The AAFP has called 
for the creation of a pilot program to fund digital health navigators; 
development of digital health literacy programs; and deployment of 
digital health tools that provide interpretive services at the point of 
care, are available in non-English languages, easily and securely 
integrate with third-party applications, and include assistive 
technology. Such a pilot should include robust evaluation to 
demonstrate how the interventions have addressed gaps in care or 
increased access for underserved populations.
    I applaud Congress' and the FCC's efforts and recognition that 
closing the digital divide, especially during a pandemic, is critical 
to ensuring that Americans continue to have access to care via 
telehealth. Programs such as the COVID-19 Telehealth Program and 
Connected Care Pilot Program have increased telehealth adoption among 
community health centers and hospitals serving communities most in 
need. The COVID-19 Telehealth Program has also helped ensure patients 
have the connected devices they need to benefit from comprehensive 
telehealth and remote monitoring services. Unfortunately, these have 
largely excluded primary care practices, for which the startup and 
ongoing costs of telehealth impede adoption.
    For many small physician practices, especially those that serve a 
disproportionate number of Medicaid and uninsured patients, the costs 
of telehealth technology can be prohibitive. Many telemedicine vendor 
solutions charge setup fees ranging from $400 to $3,000 dollars, in 
addition to recurring subscription or transaction fees. Congress should 
ensure that small practices are adequately supported, either by making 
them eligible for funding through existing telehealth programs or by 
creating a new program. Supporting telehealth adoption within these 
practices will improve equitable and timely access health care and 
promote health care competition by enabling smaller practices to remain 
independent.
    The AAFP supports the Connected Care Pilot Program's focus on 
improving equitable access to quality telehealth services for low-
income patients by addressing the high cost of broadband connectivity, 
including equipment and information services, and urges the FCC to 
extend and expand this program.
    As this Committee is acutely aware, our Nation has a long way to go 
before all Americans have high-speed broadband and the tools and 
knowledge to leverage it for virtual video health care visits. Further, 
there may be times that an old-fashioned phone call is the best way for 
a clinician to treat a patient. Therefore, it is critical to preserve 
access to audio-only telehealth services provided by a patient's usual 
source of care.
    A survey of AAFP members conducted in May 2020 found that audio-
only telephone was the most commonly used tool for conducting virtual 
visits, and a follow-up survey in September 2020 found that 80 percent 
of respondents were still using telephone visits.\12\ From my own 
experience, and talking with other family physicians, I can tell you 
that the reasons for this are lack of reliable, high-speed Internet 
connection; patients' inability to navigate complex technology required 
for video visits; and the challenge for physicians of adopting or 
perfecting a video-visit platform.
---------------------------------------------------------------------------
    \12\ AAFP Virtual Care Survey, May 2020
---------------------------------------------------------------------------
    A comprehensive review of literature comparing the effectiveness of 
video conference versus telephone in the delivery of health care found 
that patient outcomes were generally comparable between video 
conference and phone, with no consistent differences in patient 
mortality or satisfaction.\13\ These findings underscore that telephone 
can be an effective and appropriate means of providing telehealth care.
---------------------------------------------------------------------------
    \13\ Rush, K. L., Howlett, L., Munro, A., & Burton, L. (2018, 
October). Videoconference Compared to Telephone in Healthcare Delivery: 
A Systematic Review. Int J Med Inform, 118, 44-53. https://
pubmed.ncbi.nlm.nih.gov/30153920/
---------------------------------------------------------------------------
    However, face-to-face interactions between a physician and a 
patient are important components of a patient's care that allow a 
physician to gather a comprehensive understanding of the patient and 
their needs and build trust and communication. Unlike video visits, 
telephone visits do not allow physicians the benefit of being able to 
visually examine a patient or read body language and facial 
expressions. AAFP members sharing their experiences with telehealth 
said they feel much more comfortable evaluating patients they know over 
the phone. To protect patient safety and reduce potential for fraud, it 
may be prudent to limit coverage of telephone visits to established 
patients.
    Recent studies of telehealth utilization by patients with limited 
English proficiency show that non-English speakers have used telehealth 
far less than English speakers. Many physicians routinely use telephone 
translation services to provide linguistically appropriate care, and 
these services can be more seamlessly integrated into telephone visits, 
whereas integrating translation services into audio-video platforms can 
be costly and complex. Preserving access to audio-only telehealth 
services is important for ensuring equitable access to care.
    Coverage and payment policies should support patients' and 
clinicians' ability to choose the most appropriate modality of care 
(i.e., audio-video, audio-only or in-person) and ensure appropriate 
payment for care provided. Some patients and some cases are better 
suited to virtual care, and others require in-person care; some issues 
can be effectively treated through a phone call, whereas others require 
a visual examination. As a family physician, I am highly trained and 
adhere to standards of care. I also know my patients and have formed 
trusted relationships with them over years. No two patients or cases 
are alike, and I should be able to choose how to care for them based on 
my clinical judgement, not based on arbitrary insurance rules.
    Telehealth benefit expansions must increase access to care and 
promote high-quality, comprehensive, continuous care. Telehealth, when 
implemented thoughtfully, can improve the quality and comprehensiveness 
of patient care and expand access to care for under-resourced 
communities and vulnerable populations. As outlined in our Joint 
Principles for Telehealth Policy, in partnership with the American 
Academy of Pediatrics and the American College of Physicians, the AAFP 
strongly believes that the permanent expansion of telehealth services 
should be done in a way that advances care continuity and the patient-
physician relationship. Expanding telehealth services in isolation, 
without regard for previous physician-patient relationship, medical 
history, or the eventual need for a follow-up hands-on physical 
examination, can undermine the basic principles of the medical home, 
increase fragmentation of care, and lead to the patient receiving 
suboptimal care. In fact, a recent nationwide survey found that most 
patients prefer to see their usual physician through a telehealth 
visit, feel it is important to have an established relationship with 
the clinician providing telehealth services, and believe it is 
important for the clinician to have access to their full medical 
record.\14\
---------------------------------------------------------------------------
    \14\ Welch, B. M., Harvey, J., O'Connell, N. S., & Mcelligott, J. 
T. (2017). Patient preferences for direct-to-consumer telemedicine 
services: A nationwide survey. BMC Health Services Research, 17(1). 
doi:10.1186/s12913-017-2744 https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC57
04580/
---------------------------------------------------------------------------
    Telehealth cannot fully replace in-person primary care. Researchers 
at the Robert Graham Center recently conducted an analysis of National 
Ambulatory Medical Care Survey (NAMCS) data to estimate what proportion 
of primary care visits can be provided via telehealth.\15\ They found 
that two-thirds of all primary care visits in 2016 required at least 
one in-person service. The study also revealed how crucial primary care 
practices are in providing preventive and chronic care: 95 percent of 
immunizations and annual wellness visits, one-third of pap tests, 70 
percent of foot exams and more than half of neurological and retinal 
exams. Equally important, according to the Graham Center analysis, more 
than 90 percent of all rapid strep tests and throat cultures occurred 
in a primary care office setting, and one in four casts/splints/wraps 
were performed by primary care physicians. While telehealth can expand 
the reach of primary care by making it more convenient and accessible 
to patients in their homes, it is clear that virtual-only providers 
cannot offer fully comprehensive primary care. This underscores the 
importance of Federal policymakers supporting physician practices like 
mine in adopting and sustaining telehealth so that we can offer our 
patients both in-person and virtual care.
---------------------------------------------------------------------------
    \15\ Jabbarpour, Y., et al., Not Telehealth: What Primary Care 
Visits Need In-Person Care?. Journal of American Board of Family 
Medicine. https://www.jabfm.org/sites/default/files/COVID_20-
0247_Man.pdf
---------------------------------------------------------------------------
    While the rapid expansion of telehealth has yielded many benefits 
for patients and clinicians, not everyone has benefited equally. 
Without sufficient investment and thoughtful policies, telehealth could 
actually worsen health disparities. Prior to the COVID-19 pandemic, 
evidence suggested that telehealth uptake was higher among patients 
with higher levels of education and those with access to employer-
sponsored insurance. Another study found that patients with limited 
English proficiency utilized telehealth at one-third the rate of 
proficient English speakers. Anecdotes from family physicians suggest 
that the same trend may hold true for the past year--that those 
benefitting most from telehealth are those who already had better 
access to care. With respect to broadband, more accurate information 
can help Federal agencies direct funds to those households truly in 
need, and in turn will help address the digital divide. As Congress 
seeks additional studies to inform the direction of permanent 
telehealth policies and additional broadband investments, you should 
ensure the collection and reporting of data stratified by race, 
ethnicity, gender, language, and other key factors.
    In closing, the COVID-19 pandemic has illustrated that telehealth 
can and should be an essential part of health care. But more needs to 
be done to ensure that everyone in this country has access to high-
quality virtual care as part of their medical home. Thank you for the 
opportunity to discuss our recommendations with the Committee.

    Founded in 1947, the AAFP represents 133,500 physicians and medical 
students nationwide. It is the largest medical society devoted solely 
to primary care. Family physicians conduct approximately one in five 
office visits--that's 192 million visits annually, or 48 percent more 
than the next most-visited medical specialty. Today, family physicians 
provide more care for America's underserved and rural populations than 
any other medical specialty. Family medicine's cornerstone is an 
ongoing, personal patient-physician relationship focused on integrated 
care. To learn more about the specialty of family medicine, the AAFP's 
positions on issues and clinical care, and for downloadable multimedia 
highlighting family medicine, visit www.aafp.org/media. For information 
about health care, health conditions, and wellness, please visit the 
AAFP's award-winning consumer website, www.familydoctor.org.

    Senator Lujan. Thank you, Dr. Ransone. Next, we are going 
to hear from Commissioner Brendan Carr of the Federal 
Communications Commission. Commissioner, floor is yours.

     STATEMENT OF HON. BRENDAN CARR, COMMISSIONER, FEDERAL 
                   COMMUNICATIONS COMMISSION

    Mr. Carr. Thank you. Chairman Lujan, Ranking Member Thune, 
Ranking Member Wicker, distinguished members of the Committee, 
thank you for the invitation to testify. I would like to begin 
by commending the Subcommittee for convening this important 
hearing on telehealth, and for the leadership that members here 
have shown in supporting these vital offerings and extending 
Internet connectivity to more Americans.
    Expanding access to telehealth has been a top priority for 
me, and it is one that has long benefited from bipartisan 
support at the agency and here in Congress. In fact, I have had 
the chance to see firsthand the benefits that telehealth brings 
to communities across the country. In New Mexico, on a visit to 
the Mescalero Apache Reservation, I met with the team at the 
Mescalero Indian Hospital. Thanks to a high speed connection, 
community members can now have one-on-one video sessions with 
world class mental and behavioral health specialists located 
all the way back in Albuquerque.
    Without telehealth, this type of care would be out of reach 
for many people in that community. I have seen similar benefits 
in remote parts of South Dakota. In Pine Ridge, I toured a 
smart emergency room that connects hundreds of miles away back 
to Sioux Falls. A team of emergency room specialists there can 
walk the generalists at Pine Ridge through complicated 
emergency procedures in cases where there is no time to 
transfer a patient to a more specialized facility. This 
important form of telehealth, connecting one facility to 
another, is vital.
    With rural hospitals closing, a shortage of specialists, 
and the challenges of traveling long distances for care, we 
must continue to support this mode of telehealth. At the same 
time, there is a complementary trend emerging. Whether you call 
it remote patient monitoring or connected care, patients are no 
longer limited to receiving care in-person at a brick and 
mortar facility.
    I first learned about this new trend on a visit to the 
Mississippi Delta with Senator Wicker a few years back, and 
that is where I heard about an innovative program that sent 
diabetes patients home with a blood glucose monitor and a 
connected tablet. The constant monitoring and feedback improved 
outcomes for those patients, and I thought we should build on 
that model back at the FCC.
    So I worked with my colleagues to create a $100 million 
connected care pilot program. We stood that up last year and so 
far awarded a total of $58 million. Of course, COVID-19 only 
underscored the importance of telehealth. As the pandemic 
emerged, Congress passed the CARES Act, which provided the FCC 
with $200 million in additional telehealth funding. We used 
that to stand up a new COVID-19 program that built off the 
Connected Care model. We awarded all of that funding by July 
2020, and Congress then provided the agency with an additional 
$250 million. So far, the FCC has committed $80 million of that 
round two funding.
    All told, I have had the chance to visit with 44 health 
care providers in 22 states, including many of the FCC 
awardees, and those visits have brought home the unprecedented 
spike in telehealth over the last 2 years. In Parsons, Kansas, 
a provider just told me their visits jumped from close to zero 
before the pandemic to about 1,200 a month. At the University 
of Michigan, doctors there saw a 75 fold increase in telehealth 
visits.
    And just yesterday in Florida, a pediatrics department told 
me that their telehealth visits grew from 25 a day to 1,800 a 
day. The data also confirm the significant benefits from 
telehealth. Yet barriers remain from legal and regulatory to 
connectivity challenges. For instance, there have long been a 
range of licensing and reimbursement issues.
    HHS eliminated some of those hurdles last year through 
waivers, but those are set to expire when the pandemic ends, 
and we simply can't afford a return to the status quo. That is 
why I have supported many of the bills that members of this 
subcommittee introduced. Including the bipartisan Connect for 
Health Act that would extend those waivers. There is more the 
FCC should do too. For one, connectivity is key to telehealth, 
so we need to continue our work of closing the digital divide. 
That means more spectrum and further streamlining of 
infrastructure rules. For another, we need to ensure that our 
telehealth programs deliver on their important goals.
    This means quickly finalizing the award of the remaining 
portions of telehealth funds. We are taking another good step 
in that direction later this month at our open meeting, so I 
want to thank Acting Chair Rosenworcel for bringing a vote 
forward on that issue.
    This also means working with stakeholders on a long term 
solution to funding these types of initiatives, and this means 
ensuring that our rural health care program provides the 
sufficient and predictable level of support necessary to meet 
the needs of rural providers. It has fallen short before, and I 
have been working with my FCC colleagues on fixing those 
shortcomings. I look forward to making more progress on that.
    In closing, I want to thank you again for the opportunity 
to testify today. I look forward to taking your questions.
    [The prepared statement of Mr. Carr follows:]

        Prepared Statement of Hon. Brendan Carr, Commissioner, 
                   Federal Communications Commission
    Chairman Lujan, Ranking Member Thune, Chair Cantwell, Ranking 
Member Wicker, distinguished Members of the Subcommittee, thank you for 
the invitation to testify. It is a privilege to appear before you 
today.
    I would like to begin by commending the Subcommittee for convening 
this hearing on telehealth and for its Members' leadership in 
supporting these vital services as well as the broadband connections 
that are necessary to power these offerings. Expanding Americans' 
access to telehealth services has been a top priority for me at the 
FCC, and I can say that it is an endeavor that has long benefited from 
broad and bipartisan support at the agency and here in Congress. In 
fact, for years, the FCC has supported the buildout of high-speed 
Internet services to health care facilities through the Universal 
Service Fund, which Congress authorized through the Telecommunications 
Act of 1996.
    I have had a chance to see firsthand the benefits that these 
telehealth services can bring to communities across the country. New 
Mexico is just one example. On a visit to the mountainous Mescalero 
Apache Reservation last year, I met with the talented team at the 
Mescalero Indian Hospital. Thanks to a high-speed Internet connection, 
community members can now have one-on-one video sessions with world-
class mental and behavioral health specialists that are located 
hundreds of miles away in Albuquerque. Without that connection, this 
type of mental and behavioral health care--care that we need to expand 
access to in this country--would be out of reach for many people in 
that community.
    I have seen similar benefits in remote parts of South Dakota as 
well. In the southwest corner of the state, I visited Pine Ridge two 
years ago. That's where I toured a ``smart emergency room'' that 
connects via an Internet-powered video and audio feed all the way back 
to Sioux Falls, which is almost 400 miles away. A team of talented 
emergency room specialists located there at Avel eCare can walk the 
generalists at Pine Ridge through complicated, emergency procedures in 
cases where there is no time to transfer a patient to a larger or more 
specialized facility. The high-speed fiber enabling that connectivity 
was built with support from the FCC's Rural Health Care (RHC) Program.
    This important type of telehealth--connecting one facility to 
another or what is often referred to as a hub and spoke model--is 
vital. With rural hospitals closing, a lack of specialists in many 
remote communities, and the challenges and costs of traveling long 
distances for care, we must continue to support this form of 
telehealth. The FCC is committed to doing just that.
    At the same time, there is an emerging and complimentary trend in 
telehealth. The delivery of high-tech, high-quality care is no longer 
limited to the confines of connected, brick-and-mortar facilities. With 
remote patient monitoring and mobile health applications that can be 
accessed right on a smartphone or tablet, health care workers now have 
the technology to deliver high-quality care directly to patients, 
regardless of where they are located.
    I first learned about this new trend on a visit to the Mississippi 
Delta a few years ago. It's a part of the country with a deep and rich 
history. And it is not exempt from the many health care challenges that 
Americans face in communities around the country. Take Ruleville, 
Mississippi, which sees diabetes rates about twice the national 
average. It also has some of the highest poverty rates in the country, 
only adding to the difficulty in finding adequate health care.
    In Ruleville, I met Miss Annie, a patient at the North Sunflower 
Medical Center. Miss Annie woke up one morning with blurred vision, and 
after seeing her doctor found out she had advanced diabetes. She tried 
treating it through traditional methods of care but didn't see much 
progress. She then signed up for a ground-breaking telehealth program 
being run in conjunction with the University of Mississippi Medical 
Center (UMMC). She was sent home with a tablet and a wireless-powered 
blood glucose monitor. Every morning, Miss Annie's tablet would chime 
as a reminder, she would prick her finger, and the tablet would then 
display her glucose number, which was reported back via a wireless 
connection to her doctors.
    Based on that reading, an app on the tablet suggested appropriate 
actions--from a particular food or exercise, to watching a relevant 
video. If she forgot, she would get a call from a nurse. With this 
technology, her A1C levels went down, and Miss Annie says she has never 
felt better. I had the chance to visit Ruleville again just a few 
months ago with Senator Wicker and reconnect with Miss Annie. She is 
doing great and is a strong advocate for expanding telehealth.
    After that first visit to the Mississippi Delta a few years ago, I 
started working with my FCC colleagues to create a nationwide, $100 
million Connected Care Pilot Program that builds on the one UMMC 
pioneered. We were able to stand that program up in April of 2020. So 
far, we have awarded a total of $58 million to more than 50 entities in 
30 states and the District of Columbia.
    While there has long been value in telehealth, COVID-19 further 
underscored the importance of care at a distance. As stay at home 
recommendations spread across the country, everyday tasks that used to 
be carried out in person moved online. It became critically important 
that patients receive treatment remotely. In response, the FCC quickly 
waived certain telehealth rules and boosted funding to our RHC Program 
to make it easier for broadband providers to support telehealth during 
the pandemic.
    Congress also came together and passed the CARES Act, which 
provided the FCC with an additional $200 million in emergency 
telehealth funding. Within days of Congress passing that law, we used 
that support to stand up a new COVID-19 Telehealth Program. We awarded 
all $200 million by July 2020, and at the end of that year, Congress 
provided the Commission with an additional $250 million for a second 
round of funding. So far, the agency has committed $80 million of that 
Round 2 funding.
    I have had the chance to visit with many of the awardees and other 
health care providers that have greatly expanded their telehealth 
offerings, including in New Mexico, South Dakota, Washington, 
Mississippi, Florida, Kansas, Michigan, Ohio, and Pennsylvania.
    One thing these visits have brought home is the unprecedented spike 
in telehealth visits over the past two years. In Parsons, Kansas, I 
recently met with a health care provider that saw telehealth visits 
jump from close to zero before the pandemic to about 1,200 each month. 
At the University of Michigan, I met with doctors that saw a 75-fold 
increase in telehealth visits per month--increasing from 400 a month 
pre-pandemic to more than 30,000 at its height. Near Miami, Florida, 
one provider went from zero telehealth visits in 2019 to 90,000 in 
2020. All of these facilities said that they were able to ramp up their 
technology infrastructure to meet this surge in demand thanks to the 
FCC's congressionally-funded COVID-19 Telehealth Program.
    More broadly, the data on telehealth and remote patient monitoring 
show significant benefits too--both in terms of health outcomes and a 
reduction in costs. For instance, the Veterans Health Administration's 
remote patient monitoring program resulted in a 25 percent reduction in 
days of inpatient care and a 19 percent reduction in hospital admission 
for more than 43,000 veterans. It also cost $1,600 per patient compared 
to more than $13,000 per patient for VHA's home-based primary services. 
Another remote patient monitoring initiative showed a 46 percent 
reduction in ER visits, a 53 percent reduction in hospital admissions, 
and a 25 percent shorter length of stay. Analysts estimate that the 
widespread use of remote patient technology and virtual doctor visits 
could save the American health care system $305 billion annually.
    While the benefits of telehealth are clear, barriers remain--from 
legal and regulatory to connectivity challenges. For instance, there 
have long been a range of licensing and reimbursement issues that held 
back telehealth. In early 2020, the Department of Health and Human 
Services (HHS), with urging from Members of this Subcommittee, helped 
facilitate greater access to telehealth services through the issuance 
of key waivers. For example, HHS has allowed more types of providers to 
bill Medicare for telehealth services and granted waivers for the 
reimbursement of audio-only telehealth services. While these waivers 
are set to expire at the end of the COVID-19 public health emergency 
declaration, we cannot afford a return to the status quo once the 
pandemic ends. We have made too much progress to move backwards.
    For this reason, I fully support the bipartisan CONNECT for Health 
Act reintroduced this year by Senator Schatz, Ranking Member Wicker, 
and many other Members of this Subcommittee. This important legislation 
would take a number of steps to ensure that more people have access to 
telehealth, including by removing geographic restrictions on telehealth 
services, allowing health centers and rural health clinics to provide 
telehealth services on a continued basis after the pandemic ends, and 
giving the Secretary of Health and Human Services additional authority 
to waive telehealth restrictions after the pandemic ends. Similarly, 
the Telehealth Modernization Act and the Protecting Rural Telehealth 
Access Act--championed by Members of this Subcommittee--are valuable 
pieces of legislation that would extend many of these same waivers.
    Ranking Member Thune's bipartisan RUSH Act of 2021 would also take 
important steps to facilitate greater use of telehealth in skilled 
nursing facilities, like the one I visited in Lennox, South Dakota. 
This legislation would reduce unnecessary hospitals visits and stays 
and, in turn, decrease the risk of COVID-19 or other virus 
transmission.
    There's more the FCC can and should do, as well. For starters, 
connectivity is key to telehealth. And on this front, we have made 
significant progress towards the goal of ensuring that every American 
has access to an affordable, high-speed connection over the past few 
years. Since 2016, Internet speeds have more than tripled. Competition 
has increased too, with the percentage of Americans with more than two 
options for high-speed service jumping by 52 percent between 2016 and 
2018 alone. And the digital divide has been cut significantly as both 
new cell sites and high-speed fiber builds accelerated over the past 
few years.
    Yet there remain too many Americans without access to affordable, 
high-speed connections. And this prevents them from realizing the 
benefits that telehealth and other online services can deliver. So the 
FCC must continue to deliver results.
    On the spectrum front, we must keep moving the airwaves needed for 
5G and other high-speed connections into the commercial marketplace. On 
infrastructure, we need to build on the reforms we put in place over 
the past few years and continue to modernize and streamline our 
regulations.
    And there is more the FCC can do to ensure that our telehealth 
programs deliver on their important goals. For one, we should quickly 
finalize the award of the remaining portions of the COVID-19 Telehealth 
Program and the Connected Care Pilot Program funding. We are taking 
another good step in that direction later this month when we will vote 
on a new round of awardees at our October Open Meeting. So I want to 
thank Acting Chair Rosenworcel for moving that forward. For another, we 
need to work with stakeholders on a long-term solution to funding these 
types of initiatives. The Connected Care Pilot Program for instance is 
a three-year initiative. One goal for the program is to provide 
additional evidence regarding the value that flows from connected care 
technologies. In my view, the portions of the health care industry that 
benefit from these technologies and their associated reductions in 
health care costs should be the ones that support them in the long run. 
Now is the time to work towards that transition.
    Finally, the FCC needs to take additional steps to ensure that our 
RHC Program provides the sufficient and predictable level of support 
necessary to meet the needs of rural health care providers. I have 
worked with my FCC colleagues towards this goal over the past few 
years, including on the issuance of a January 2021 waiver that 
addressed anomalies in a rates database--anomalies that would likely 
have contributed to an inadequate and inconsistent level of support for 
Alaskan health care providers. I also worked with my colleagues to add 
additional rates into that database and otherwise on relief that 
ensures greater flexibility. There are additional steps we can take to 
improve the administration of the FCC's initiatives, including by 
imposing firmer deadlines on funding decisions, and I look forward to 
continuing to work with my FCC colleagues and stakeholders on those 
improvements.
                                 * * *
    In closing, I want to thank you again Chairman Lujan, Ranking 
Member Thune, Chair Cantwell, Ranking Member Wicker, and Members of the 
Subcommittee for holding this hearing and for the opportunity to 
testify. I look forward to continuing to work with the Subcommittee to 
accelerate the buildout of broadband networks to facilitate the greater 
use of telehealth services. I welcome the chance to answer your 
questions.

    Senator Lujan. Thank you very much, Commissioner Carr. 
Next, we are going to hear from Ms. Deanna Larson, the Chief 
Executive Officer at Avel eCare in Sioux Falls, South Dakota.

  STATEMENT OF DEANNA LARSON, PRESIDENT, AVEL eCARE; FOUNDER, 
  AMERICAN BOARD OF TELEHEALTH; EXECUTIVE SECRETARY, AMERICAN 
                    TELEMEDICINE ASSOCIATION

    Ms. Larson. Good morning, Chairman Lujan, Ranking Member 
Thune, and Ranking Member Wicker--good morning, Chairman Lujan, 
and Ranking Member Thune, and Ranking Member Wicker. Very happy 
to be here this morning. Honored to represent the many 
stakeholders and the providers of telemedicine who are using 
this modality to deliver health care across the Nation. Being 
based in Sioux Falls, South Dakota, for the last decade and a 
half, telemedicine has given us a lot of experience in rural 
care. We now have locations--sub-locations in Michigan and in 
Texas.
    I have the honor also of serving on the board of the ATA, 
so we hear a lot from many members across the Nation about 
issues and great outcomes as well. And by way of background, we 
began providing telemedicine services in 1993, really providing 
specialty care clinic to clinic for patients and individuals 
who couldn't make into the--out of the rural settings into 
tertiary. We now provide acute care for ICU, hospital medicine 
and emergency medicine, behavioral health services, specialty 
clinics, school health, as well as in skilled nursing 
facilities.
    So essentially, we are a virtual health care center, 
augmenting care in rural locations. So how did we get to use 
the FCC funds? We were very excited about the opportunity. 
During the pandemic, there was pandemonium in health care. It 
is usually a fairly very--excuse me, it is usually a very 
controlled environment, and all of a sudden all of the--
everything was not controlled. So overnight, we developed 
training and moved out. Telemedicine has been earlier described 
both to clinicians and residents. Brick and mortar closed. 
People were needing access to care. So, we know we are needing 
to extend those services using now--providing the funds from 
the COVID telehealth relief program. We were able to extend 
those services in emergency settings, skilled nursing 
facilities, and in home monitoring.
    84 communities in 7 states. We were very grateful to 
receive those funds. It all went directly to expansion of that 
equipment. On behalf of those customers, we were really 
grateful for all of that work, but we know that there are still 
a lot of opportunity. There are still underserved communities 
as it relates to broadband. We have experience where we haven't 
been able to get into communities for up to 2 years of time, up 
to 2 years of time in Montana, where individuals are seeking 
care, telemedicine services, and there is no access, there is 
no way for us to get to them. While we are very grateful, we 
know there is a lot more to do.
    So, it is really important broadband for us. It is the 
essential piece, as we really made a shift during the situation 
and the kind of pandemonium of telemedicine, we made a shift 
with providers. The paradigm moved. Clinicians all of a sudden 
understood the power of telemedicine. Patients were willing to 
accept it. Now we need that critical vehicle of broadband 
everywhere to make that happen.
    An example of that is, you know, the use of broadband too, 
I want to mention, it has been brought up before, you know, is 
it telephone? Is it video? Is it store and forward? You know, 
that is like asking a physician, you can't use--you can only 
use a flat X-ray or CT scan or MRI. Should we be making that 
decision, or should we leave that in the hands of physicians or 
clinicians who can make that decision? Which use cases most--
treats their patients in the best way?
    And we also are involved in the Federal initiative, the 
National Emergency Telemedicine Critical Care Network, that has 
been sponsored federally. It is called NETCCN. We are working 
with HHS, Asper, and the Department of Defense to provide 
critical care expertise to hospitals, municipalities struggling 
still with the COVID-19 surges. Over the last year, we have 
been deployed over a dozen times to care for thousands of 
patients in the communities, ICUs, community hospital units, 
and also in patients homes. We know we have been part of saving 
lives in those situations.
    We have supported health systems, alleviating bed 
shortages, and really supporting those vulnerable clinician 
workforce that now is out there. And there is a very big 
scarcity in the workforce situation. I know important strides 
have been made to improve access, and we are very grateful in 
the broadband situation. I would urge the committee to continue 
to support new and innovation projects and initiatives that 
might alleviate these physical challenges we see like in 
Montana. Let's keep an eye on Starlink and the satellite 
opportunities that might be coming around for us to have very 
affordable and continuous access.
    The Telehealth Flexibility Program, I urge every member on 
this committee in the Administration to continue to extend the 
telehealth regulatory flexibilities created during the COVID-19 
pandemic, or better yet, let is just make them permanent. 
Without this support, patients can lose access. We will go back 
to the great divide, if you will, or as ATA calls it, the 
telehealth cliff.
    We will create again underserved communities that will no 
longer have access. The ability to provide this modality-
neutral telemedicine, such as again, the phone only or 
asynchronous care, remote patient monitoring really has proven 
to be essentially valuable. We also are very grateful for the 
FCC funding USEC program. We use it very well in many of these 
remote and rural programs. They are very grateful to receive 
those funds.
    It has been my experience over the course of my career to 
find telemedicine makes a great difference. It improves the 
overall quality of care. They are reaching patients. It serves 
the community well. We often can keep patients in their small 
rural community. Keeping the money in that community. We are 
able to support and retain physicians, clinicians in that 
community. All of that immediate care where it is needed can 
de-escalate the illness and reduce the cost of that care 
overall.
    Again, I am very happy to be here and represent this and 
look forward to your questions.
    [The prepared statement of Ms. Larson follows:]

 Prepared Statement of Deanna Larson, President, Avel eCare; Founder, 
      American Board of Telehealth; Executive Secretary, American 
                        Telemedicine Association
    Chairman Lujan, ranking member Thune and members of the committee, 
thank you for the invitation to speak to you today on behalf on such an 
important topic--the state of telehealth. My name is Deanna Larson, CEO 
of Avel eCare based in Sioux Falls, S.D., and Executive Secretary, 
American Telemedicine Association. By way of background, Avel eCare 
began in 1993 as a means to take care of patients in very rural areas, 
providing these communities with 24/7 access to care using 
telemedicine.\1\ Since then, we have expanded and our services now 
reach patients served by more than 600 facilities in 32 states across 
the Nation.
---------------------------------------------------------------------------
    \1\ See Addendum (page 5)
---------------------------------------------------------------------------
How has Avel eCare Leveraged FCC COVID-19 Telehealth Program Funds?
    During the past year-and-a-half, Avel has developed new services 
and solutions for the challenges brought on by the pandemic. From 
ramping up virtual visits, to augmenting long-term care, to virtual 
physician rounding in the hospital, we have leveraged telemedicine to 
meet real needs and in doing so, have saved lives, reduced cost of 
care, and supported our clinical workforce.
    As part of this work, we applied for the Federal Communication 
Commission's COVID-19 Telehealth Program. The funds received--totaling 
nearly $804,000--supported eCare emergency services brought much needed 
care to emergency rooms, hospitals, senior care facilities, and patient 
homes, impacting 84 communities spanning seven states.
    On behalf of our customers and the hundreds of providers and 
companies around the country who received these funds, I want to thank 
this committee and the FCC for offering this important program. The 
dollars went directly to acquiring new equipment, ultimately, 
delivering exceptional care to patients and their families during a 
difficult time.
Importance of Broadband Access, Connectivity
    A critical component to providing telemedicine care is broadband 
connectivity and access. Telemedicine can help bring care to 
underserved communities by eliminating travel, accessibility, and 
scheduling concerns. This utilization of telemedicine services by 
underserved groups is significant, and depends largely on their access 
to reliable, high-speed internet. Without convenient access to 
broadband connectivity enhances, our ability to reach patients with 
augmented, high-touch care is greatly restricted.
    Take for example our work with COVID-19 patients. One life-
threatening symptom that requires immediate care is the shortness or 
loss of breath that can often accompany a severe case of COVID. This 
can be an unsettling and traumatic experience for patients and 
caregivers. By having access to video telemedicine services, clinicians 
can more fully assess the severity of illness to determine the best 
course of treatment. They can reassess frequently throughout the day if 
needed. Patients have direct visual contact with a trusted clinician 
who can talk through the treatment options, discuss alternatives, and 
provide a calming presence. The ability to effectively manage 
significant COVID illness at home has been invaluable to patients, the 
health care system and to payers. But, access to reliable, fast 
Internet is critical to the availability of these types of programs.
    In another federally funded initiative, the National Emergency 
Tele-Critical Care Network, or NETCCN, we are working with HHS and the 
DOD to provide critical care expertise to hospitals and municipalities 
struggling with COVID-19 surges. Over the last year, we have been 
deployed a dozen times to support the care of thousands of patients in 
community ICUs, COVID hospital units, and at patients' homes. We know 
we have saved lives, supported the healthcare system, and alleviated 
burnout of our vulnerable clinical workforce. The ability to deploy 
this telemedicine support to communities in stress requires speed, 
regulatory relief, and importantly, reliable broadband even during 
times of high network demands.
    Important strides have been made to improve access to broadband, 
and I urge this committee to continue to support new and innovative 
projects and initiatives which can alleviate the physical challenges to 
delivering broadband. For example, our work with a rural Montana site 
was delayed for more than a year due to the logistical and physical 
difficulties of bringing in fiber to this remote community. If our 
provider partner had an alternative method to access high-speed 
internet, they could have brought in this life-saving care much sooner.
Telehealth Regulatory Flexibility
    In addition to support for connectivity, I urge every member of 
this committee and the administration to continue to extend telehealth 
regulatory flexibilities created during the COVID-19 pandemic, or 
better yet make them permanent. Without this support, patients will 
lose access and we could run the risk going over the ``telehealth 
cliff.'' The ability to provide modality-neutral telemedicine, such as 
phone-only care, asynchronous care, and remote patient monitoring, has 
proven especially valuable. We have learned we can trust clinicians to 
choose the right modality to work with their patients effectively.
Conclusion
    In closing, I would again like to thank the committee for the 
invitation to speak, and express gratitude on behalf of telemedicine 
providers to the FCC for providing funding to support the delivery of 
care to millions of patients. The funding available through USAC and 
the COVID-19 Telemedicine Program have delivered much needed access, 
but there is still work left to be done to address the disparity that 
still exists in the system.
    It has been my experience over the course of my career that 
telemedicine improves overall quality of care while reducing cost. We 
serve patients in the communities where they live. We provide resources 
and access to help reduce rural clinician burnout and stabilize local 
workforces. Most importantly, we save lives. Again, thank you for the 
invitation to speak and I look forward to your questions.
Addendum



    Senator Lujan. Thank you so very much, Ms. Larson, and 
thank you for your challenge in our call to action as well. 
Next, we are going to hear from Dr. Sanjeev Arora, founder of 
Project Echo and Distinguished Professor at the University of 
New Mexico Health Sciences Center in Albuquerque, New Mexico. 
Dr. Arora.

           STATEMENT OF DR. SANJEEV ARORA, PRESIDENT

           AND FOUNDER, PROJECT ECHO/ECHO INSTITUTE;

       DISTINGUISHED AND REGENTS' PROFESSOR OF MEDICINE,

    UNIVERSITY OF NEW MEXICO HEALTH SCIENCES CENTER (UNMHSC)

    Dr. Arora. Chairman Lujan, Ranking Member Thune, and 
members of the Committee. My name is Sanjeev Arora, and I am 
the Director and Founder of the Project Echo at the University 
of New Mexico. Thank you for inviting me to testify. As we have 
seen in the pandemic, we have exposed what we all knew 
instinctively, we need to fundamentally reorient our health 
care system to enable patients to get the care they need, when 
they need it, where they live. Last year, I testified before 
the HELP committee and shared a patient is story from almost 20 
years ago.
    A 43-year-old widow and mother had been diagnosed with 
hepatitis C eight years earlier. Yet she was just now seeking 
treatment for the first time. When I asked her why she had 
waited so long, she said her doctor told her that the treatment 
would require her to make a dozen trips to Albuquerque over a 
year, and she couldn't afford to take the time off work. Now 
the pain was too much for her to bear, but it was too late to 
save her. She died 5 months later from advanced liver cancer. 
We had the medicines and the expertise to treat her, but she 
didn't have the resources to get to us, and no doctor in the 
community had the knowledge to treat her disease.
    That is why I started Project Echo, to get the right 
information to the right place at the right time, to save and 
improve lives. Now we must enable telehealth of all kinds. 
Improving broadband will support all three domains of 
telehealth: remote monitoring, telemedicine, and telementoring. 
All three can advance health equity in rural and underserved 
communities. Remote monitoring gives us a unique window into 
the life of a patient. Picture an elderly woman wearing a 
wireless remote device that can alert us if her gait is 
unsteady and allows us to intervene earlier and prevent a fall 
and hip fracture.
    Telemedicine allows us to bridge a geographic divide and 
connect a specialist with a patient who would otherwise be 
forced to travel a long distance or go without care completely. 
Both remote monitoring and telemedicine are critical and needed 
and will be significantly enhanced by ensuring broadband 
connectivity to every household in America. But an additional 
serious constraint remains. The lack of specialists is not just 
in rural areas.
    Most urban areas also have an insufficient number of 
experts. There are simply not enough experts anywhere to serve 
all that need their help, and patients everywhere have to wait 
weeks and months to see a specialist. And that is where the 
mentoring to build workforce capacity comes in. They all teach, 
all learn Echo model works like this. Teams of experts at 
regional medical centers called hubs use one to many video 
conferencing to engage with local health care providers, the 
spokes, in ongoing weekly sessions with knowledge sharing and 
case based learning to ensure that clinicians already on the 
ground in communities have the latest best practices mentoring 
and support they need to treat patients.
    Hubs and spokes learn from each other. Everyone is 
knowledge is constantly improving. Based on the tremendous 
need, Echo has grown and is now embedded at more than 250 
organizations in all 50 states across the U.S. Many of these 
are major academic health centers, like the University of 
Washington, University of Hawaii, M.D. Anderson, the University 
of Mississippi, and many, many more. And we know the model 
works. A study published in the New England Journal of Medicine 
on Hepatitis C work in New Mexico showed that patients got the 
same quality of care they would get if they went to a 
specialist.
    There are now more than 400 papers published to demonstrate 
the effectiveness of the model. We had long believed that the 
Echo model could be put to work in a pandemic, and in 2020 it 
was put to the test. Since the onset of COVID-19, we have 
deployed our entire national and global network in response to 
the pandemic. Here are two quick examples. We worked with the 
agency for Healthcare Research and Quality and Institute for 
Health Care Improvement to launch the Nation's most 
comprehensive and successful effort to reduce the spread of 
COVID-19 in nursing homes. More than 9,000 nursing homes and 
more than 30,000 health care workers participated.
    We partnered with the Assistant Secretary for Preparedness 
and Response at Health and Human Services to run a national 
program for frontline providers focused on COVID-19. Every 
week, some 400 to 1,700 clinicians log on to this virtual 
community. More than 50,000 have participated. How can these 
lessons help us reshape our health care system to move 
lifesaving information more quickly and efficiently?
    First, expanding access to high quality, high speed 
broadband connectivity is critical. It is a prerequisite for 
the success of any telehealth model in rural communities and 
urban underserved areas. Second, the FCC should explore any 
additional opportunities under its purview to support 
telehealth to improve care in rural and underserved 
communities.
    Finally, although mostly outside the purview of this 
committee, I hope Congress will commit to exploring longer term 
changes to health care financing for approaches like 
telementoring that can support our health care workforce. I am 
committed to working with you to help realize the promise of 
telehealth in our country. Thank you for this opportunity and I 
look forward to your questions.
    [The prepared statement of Dr. Arora follows:]

Prepared Testimony of Dr. Sanjeev Arora, President and Founder, Project 
ECHO/ECHO Institute; Distinguished and Regents' Professor of Medicine, 
        University of New Mexico Health Sciences Center (UNMHSC)
    Chairman Lujan, Ranking Member Thune and Members of the Committee. 
My name is Sanjeev Arora. I'm here today both as a practicing liver 
disease specialist and as Director and Founder of Project ECHO at the 
University of New Mexico, Health Science Center.
    Thank you for inviting me to testify at today's hearing focused on 
exploring the state of telehealth and removing barriers to access and 
improving patient outcomes, particularly in the context of COVID-19.
    The pandemic exposed what we all knew instinctively long before the 
first COVID cases were diagnosed. We need to fundamentally reorient our 
healthcare system. Instead of placing the burden on patients to find 
us--the medical experts who can treat and cure them--we need to bring 
the care to them.
    We need to enable patients to get the care they need, when they 
need it, where they live.
    And technology can help us get there. It can't do it all--but, 
increasingly, it's a critical underpinning to our work.
    In June of last year, I testified before the Senate HELP Committee 
at a hearing on telehealth, and I shared the story of one of my 
patients from almost 20 years ago.
    A 43-year-old widow and mother of two small children, she had been 
diagnosed with hepatitis C eight years earlier. Yet she was just now 
seeking treatment for the first time.
    When I asked her why she had waited so long, she said that her 
doctor told her that treatment would require her to make at least a 
dozen trips to Albuquerque over the course of a year--and she couldn't 
afford to take the time off work.
    Now the pain was too much for her to bear. But it was too late to 
save her. She died five months later from advanced liver cancer.
    We had the medicines and the expertise to treat her. But she didn't 
have the resources to get to us. And no doctor in her community had the 
knowledge to treat her disease.
    That's why I started Project ECHO. We have the knowledge to reduce 
so much human suffering, but we need to move it out into communities 
where it's needed most.
    Now flash forward two decades and imagine another rural patient 
diagnosed with COVID-19 last year. The first in her community. Was her 
local medical team ready? Did they have the knowledge they needed to 
treat her?
    We need to leverage telehealth to quickly move new information and 
best practices from top experts at academic health centers to providers 
at the frontlines caring for patients in communities. The COVID-19 
pandemic has only underscored the urgency with which we need to tackle 
this challenge.
    To enable telehealth of all kinds, we need to ensure that providers 
and patients in rural and underserved communities have access to 
broadband and high-speed internet.
    Improving broadband will support all three domains of telehealth--
remote monitoring; telemedicine; and telementoring. And all three have 
the potential to expand access to best practice treatment and advance 
health equity in rural communities and urban underserved areas.
    But telehealth is much more than technology.
    Technology can help us bridge wide geographic divides in ways we 
wouldn't have imagined possible twenty years ago. But technology is 
simply a tool that enables essential human interaction.
    For example, technology allows us to have the virtual hearing we're 
participating in today, but it's not the technology that makes this 
discussion valuable. What matters is what the technology enables--the 
discussion we're having, the expert testimony, the answers we provide 
to your questions, and, most importantly, how it all informs the 
decisions you make going forward. Likewise with telehealth, the 
technology enables us to interact in ways that ultimately improve 
health and save lives.
    In the case of remote monitoring, technology gives us a unique 
window into the life of a patient. Picture an elderly woman wearing a 
wireless remote device that can alert us if her gate is unsteady and 
allows us to then intervene earlier and prevent a fall and a possible 
hip fracture.
    In telemedicine, technology allows us to bridge a geographic divide 
and connect a specialist with a patient who would otherwise be forced 
to travel a long distance or go without care completely. The technology 
enables the communication to happen, creating the opportunity for a 
patient-physician relationship that might never have existed.
    Both remote monitoring and telemedicine are critical and needed and 
will be significantly enhanced by ensuring broadband connectivity to 
every household in America.
    But an additional constraint remains. In addition to the lack of 
specialists in rural areas, most urban areas also have an insufficient 
number of experts. Patients everywhere in the country have to wait 
weeks and sometimes months to see a specialist. Even if we can power up 
rural and underserved communities with high-quality, high-speed 
broadband or 5G, we're still woefully short of enough specialists to 
provide care, virtually, to patients in these communities. A workforce 
training and development solution is needed to enhance the capacity of 
the healthcare professionals.
    And that's where telementoring models come in.
    Efforts like Project ECHO leverage technology, including 
videoconferencing platforms such as Zoom, to ensure that clinicians 
already on the ground in communities have the latest best practices, 
mentoring and support they need to treat patients. They involve a 
specialist or team of specialists in a specific disease area connecting 
to many teams of community providers in an ongoing virtual learning 
community.
    Again, each of these telehealth approaches is needed and valuable. 
But for the purpose of my testimony, I will be primarily focused on 
telementoring, which is the area I know best.
    When I started Project ECHO to treat hepatitis C in my home state, 
I realized that in order to convince clinicians in rural clinics to 
treat this complicated disease, I needed to create something that 
mimicked the grand rounds experience of their residencies. We needed to 
bring the experts to these rural clinicians over video to share up-to-
date best practices--and the clinicians needed to present their own 
cases and get ongoing guidance and mentorship from experts.
    We launched 21 new centers of excellence to treat hepatitis C in 
rural communities across the state. Each center was run by a primary 
care clinician. We shared our treatment protocols with them, and they 
connected with us all together once a week on video to discuss cases. 
Soon they became experts and the wait in my clinic fell from 8 months 
to 2 weeks. Tens of thousands of patients got treatment. We knew we had 
an effective model, so we expanded it by training other academic health 
centers around the United States to deploy ECHO for a wide range of 
common and complex diseases and conditions. The ``all teach, all 
learn'' ECHO model works like this:
    Teams of experts at regional medical centers (called ``hubs'') use 
one to many videoconferencing to engage with local healthcare providers 
(the ``spokes'') in weekly ongoing knowledge-sharing, case-based 
learning, and telementoring.
    Hub and spokes learn from each another, Everyone's knowledge is 
constantly improving.
    Based on the tremendous need, ECHO has grown from addressing a 
single disease in a single state to over 600 training centers 
addressing over 75 different health conditions with learners connecting 
in from more than 180 different countries around the world.
    There are now ECHO projects at more than 250 organizations in all 
50 states across the U.S. . alone, many of these at major academic 
health centers like the University of Washington, the University of 
Hawaii, MD Anderson, the University of Minnesota, and many more.
    And we know the model works. A study published in the New England 
Journal of Medicine and funded by the Agency for Healthcare Quality and 
Research focusing on our hepatitis C work in New Mexico showed that 
patients treated by an ECHO-trained community provider got the same 
quality care they would get if they went to a specialist. There are now 
more 300 papers published on different aspects of the model, 
demonstrating that ECHO can help implement best practices at speed, 
scale, with fidelity, at substantially lower cost.
    We had long believed that the ECHO model could be put to work in a 
meaningful way in a pandemic. And in 2020, it was put to the test.
    Since the onset of COVID-19 we have deployed our entire national 
and global networks in response to the pandemic:

   Launched in October 2020, the National Nursing Home COVID-19 
        Action Network was the Nation's most comprehensive effort to 
        reduce and prevent the spread of COVID-19 in nursing homes. At 
        the time, COVID-19 was surging across the country, 
        disproportionately affecting people living and working in 
        nursing homes--which accounted for nearly 40 percent of all 
        deaths from COVID-19. Despite the terrible pressures under 
        which they were operating, more than 9,000 of the Nation's 
        15,000 nursing homes joined the Network, a partnership of the 
        Agency for Healthcare Research and Quality (AHRQ), Project 
        ECHO, and the Institute for Healthcare Improvement. More than 
        30,000 healthcare workers were mentored as part of this 
        initiative as part of one of 326 weekly virtual learning 
        communities.

   We partnered with the Office of the Assistant Secretary for 
        Preparedness and Response (ASPR) at HHS to run a national 
        program serving extremely rural locations for EMS and other 
        emergency frontline workers focused on COVID-19 that continues 
        to this day. With new best practices emerging every week we 
        used ECHO to get that knowledge into the hands of frontline 
        health workers across the U.S. Every week, some 400 to 1,700 
        clinicians log on to navigate the challenges of COVID-19 
        together.

   Our ECHO networks active with the Indian Health Service, the 
        CDC, and other Federal agencies all shifted to get up-to-date, 
        best-practice knowledge about COVID-19 into the hands of the 
        health workers in rural and underserved communities who needed 
        it most.

    In addition, to underscore the interconnection of different 
telehealth approaches, multiple ECHO projects are now using the ECHO 
model to train providers on how to do telemedicine effectively. We need 
ongoing learning communities to ensure that the doctors, nurses and 
other health professionals who were thrown into a world of virtual 
medicine, almost overnight, get access to best practices and the 
guidance to implement them.
    What does this all mean for going forward? How can lessons from 
COVID-19 and the experience of telehealth during this pandemic help us 
to reshape our healthcare system to move life-saving information more 
quickly and efficiently?
    First, expanding access to high-quality, high-speed broadband 
connectivity is critical. It's a prerequisite for the success of any 
telehealth model in rural communities and urban underserved areas.
    Broadband connectivity will help us address one of the biggest 
challenges in our healthcare system--that almost no one has access to a 
specialist on a timely basis regardless of whether they're being 
treated for COVID, cancer, or autism. And rural communities and urban 
underserved areas are at highest risk with either no access at all; 
long waits; or when they do get access, they have to travel long 
distances.
    Second, the Federal Communications Commission should explore any 
additional opportunities under its jurisdiction to support telehealth 
to improve care in rural and underserved communities.
    Steps that Congress and others have taken in areas like increasing 
broadband access in rural communities and expanding coverage for the 
virtual services clinicians can provide are critical--and we need to 
explore more pathways to making this happen quickly.
    But we also need to continue to move beyond the emphasis on the 
technology part of telehealth to the health part. Again, like the 
hearing today, it's what's being virtually delivered across the 
medium--and--how that allows us to take action that will optimize 
health outcomes.
    While mostly outside the jurisdiction of this Committee, I hope the 
Congress will commit to exploring longer-term changes to healthcare 
financing that would create sustainable and ongoing funding for 
effective telehealth approaches like telementoring that can bring much 
needed care to the people in communities who need it the most.
    If not continued COVID-19, the lives of rural and urban underserved 
populations will be disproportionately affected by the opioid epidemic, 
cancer, HIV, diabetes, autism or many other diseases or conditions.
    I am committed to working with you to help realize the promise of 
telehealth, and ultimately seeing the day when a mother's survival 
doesn't rest on her ability to take a five-hour car ride twelve times a 
year.
    Thank you for providing me with the opportunity to testify before 
you today. I look forward to answering your questions.

    Senator Lujan. Thank you, Dr. Arora. We will now move to 
questions of our distinguished panel. I recognize myself for 5 
minutes. At this moment, the U.S. Congress stands at a critical 
juncture. We are on the cusp of a historic bipartisan 
infrastructure package that invest $65 billion in broadband 
infrastructure and broadband affordability.
    This investment has the opportunity to improve connectivity 
and access to education, jobs, and critically lifesaving 
treatments. To start us off here, I have a simple yes or no 
question for each of the witnesses. Does access to high quality 
broadband contribute to better health outcomes? Dr. Ransone.
    Dr. Ransone. Yes, sir. Absolutely.
    Senator Lujan. Ms. Larson.
    Ms. Larson. Resounding yes.
    Senator Lujan. Commissioner Carr.
    Mr. Carr. Yes.
    Senator Lujan. Dr. Arora.
    Dr. Arora. Yes.
    Senator Lujan. Thank you. And I think we all agree here 
that we must connect every American and ensure those networks 
are built to live up to the critical role they will play in our 
health and well-being. Dr. Arora, you are the Director of a 
nationwide leader in telementoring project, but you are also 
still a practicing physician who has served the people of New 
Mexico for nearly 30 years. I am deeply grateful for your 
tireless work that you have done for our home State of New 
Mexico. You have touched thousands of lives in Albuquerque and 
across our state and across America, and skilled that knowledge 
to provide expert care across the world. Thank you.
    A state like New Mexico faces many unique challenges in 
accessing health care. Many of my constituents live hours from 
the nearest community health center or hospital. For many, 
telehealth is the only way they can get care without having to 
take a day off of work or find someone to care for their kids.
    Dr. Arora, how can we ensure future investments in 
telehealth meet the needs of states like New Mexico, South 
Dakota, and Mississippi--and Hawaii? I am going to get in 
trouble over here--and Kansas. So, I am going to get in trouble 
as I look around. Dr. Arora?
    Dr. Arora. Thank you, Chairman Lujan, for the question. The 
problem you have identified is present in every state in the 
United States. Many, many of our patients and health care 
providers in the most rural areas don't have access to 
adequate, high quality broadband. So, of course, that would be 
enabling every different aspect of health care and produce 
equity in a health care system, if we were able to fulfill the 
vision that you articulated of getting good broadband to every 
household and every health care provider in New Mexico. The 
biggest problem, Senator Lujan, that I see in the United States 
today is that in every state, there are such a long wait to see 
a specialist.
    Take the example of a dermatology consult in New Mexico. 30 
percent of our land area has no dermatologist, there are only 
33 dermatologists in the State of New Mexico, when we need more 
than 120. Even in Albuquerque and Santa Fe, the wait to see a 
dermatologist can be six to 8 months. It is not possible for 
this person to do a lot of telemedicine because he or she is so 
busy seeing patients all day long in Albuquerque and Santa Fe. 
And so telemedicine will overcome a geographic divide, but it 
does not overcome the biggest problem of a capacity constraint 
in our health care system.
    We need task shifting so we can enable physician 
assistants, nurse practitioners, primary care doctors, family 
doctors to provide fundamental dermatologic care in their local 
communities. In a state where we have one of the highest skin 
cancer rates, our patients cannot access dermatology care.
    And so I think the combination of all three types of 
telehealth that we talked about, remote monitoring, 
telemedicine, and telementoring with projects like Echo can be 
a solution not just for New Mexico, not just for every rural 
state, but for the entire United States.
    Senator Lujan. Thank you so much, Dr. Arora. Commissioner 
Carr, the Connected Care Pilot Program identified a critical 
need within the telehealth system. The Connected Care Program 
is designed to serve a critical need by targeting telehealth 
funding to communities that most need support. What is the 
future of Connected Care with the program, and do you recommend 
we move it beyond a pilot into a permanent program?
    Mr. Carr. Thank you--thank you--I always do that. Thank 
you, chairman, for the question. The Connect Care Pilot is set 
to run for 3 years, and part of the original idea was to get 
more data on how beneficial telehealth is. Well, the reality is 
with COVID, we stood up before it, the emergency COVID-19 
program, so we have even more data now. So long term, yes, we 
need to make sure that this type of service is available. There 
are questions about how to fund that, but absolutely, we need 
to make sure we maintain support for these types of telehealth 
services.
    Senator Lujan. I look forward to hearing more about that 
during the hearing today and in the future. Appreciate that. I 
now recognize, Mr. Thune, for five minutes.
    Senator Thune. Thank you, Mr. Chairman. Ms. Larson, how did 
the FCC's COVID-19 telehealth program help expand the reach of 
Avel eCare, and I used to know it as Avera eCare, but Avel 
eCare Telehealth services? And is there anything that we should 
know as policymakers about the program? What worked well and 
what didn't?
    [Technical problems.]
    Ms. Larson. We used the funds to create another situation 
of telehealth and more emergency settings, more skilled nursing 
facilities, and specifically in that home settings. So, the 
funding really works very well for us. Some of the things that 
worked very well and were difficult at the same time, was very 
quick notice. You know, it seemed like we had to be first in 
line. And so, we applied within 24 hours, which is no small 
feat when you are trying to collect all of those tools. But 
nonetheless, we were very happy to apply. I think that worked 
very well. We were able to get equipment out and we were 
actually able to get equipment out quickly.
    The reimbursement for that equipment took nearly 12 months. 
So due to the paperwork and processes that are in place--and 
again, it wasn't, you know, could have been part of our issue 
too, but that is part of how do we streamline that so that we 
aren't using extra time to try to make those things work very 
efficiently. I do believe it was a great program and it funded 
what we needed to have to extend our programs. We did not apply 
for the second one. Not sure. Remember, there was a lot of 
unknowns during that time. Not sure when funding the 
reimbursement would be coming.
    And then again, the notice to get ready so quickly. We 
deeply appreciated in that we are able to impact hundreds and 
hundreds of lives through the funding we received.
    Senator Thune. Well, it seems like we ought to be able to 
improve on a 12-month reimbursement rate, even for 
organizations as inefficient as the Federal Government. 
Commissioner Carr, can you talk about some of the lessons 
learned from the COVID-19 telehealth program and what other 
initiatives are underway at the FCC to support telehealth 
services?
    Mr. Carr. Well, I think one the most interesting lessons 
learned is how much uptake there was for these services. We 
talked about the 75fold increase, depending on the facility. 
People found this very easy to use, preferable to use. Health 
outcomes improved. So, we do need to move down this path, and I 
think finishing the award of funds from our existing programs 
would help. And looking at how do we sustain this from a 
payment perspective long term are some important steps we need 
to take.
    Senator Thune. Tell me about--we know telehealth services 
have dramatically expanded with the improvement of broadband 
services in rural America. You all have testified to that. What 
steps has the FCC taken to expand reliable and affordable 
broadband services to unserved areas? And what needs to be done 
to make sure all the broadband funding provided by Congress 
goes to truly unserved areas?
    Mr. Carr. Well, there are a lot of steps we took over the 
last couple of years to streamline infrastructure rules. A lot 
of it was looking at some of the legislation that you all have 
been working on. We pushed a lot of spectrum out, building off 
of the MOBILE NOW bill that you all introduced. And going 
forward, we need more of the same. One, we need to continue to 
streamline infrastructure rules. Two, we need to continue to 
get spectrum out there, put a spectrum calendar out that would 
make sure we do that.
    And importantly, we have a lot of funding right now in the 
pipeline that we need to get out the door, whether it is RDOF 
phase one, which we will have a couple of percentage points of 
the total award moved out the door yet. So we have funding in 
the pipeline that we need to get going, because as I did a 
visit with Senator Wicker, there is broadband builders that won 
funding that are ready to go, they are just waiting on those 
dollars to get to them.
    Senator Thune. And what does it take to get them going 
faster?
    Mr. Carr. Well, I am not sure. We are behind schedule in 
terms of the CAF II, which is an analogous program, in terms of 
the percentage of funds that we got out the door. So, we have 
got to keep moving on that. Obviously, long term, the maps are 
going to be key. We have got to complete those maps. That is 
what is going to let us go to RDOF phase two, 5G fund, and get 
more support for broadband builders in rural communities.
    Senator Thune. It comes always comes back to the maps, 
doesn't it? Been working on the maps for a long time. Ms. 
Larson, how have you seen expanded broadband services improve 
patients' and health care providers' experience in areas that 
have lacked sufficient health care services, particularly 
specialty care services? Can you talk about that?
    Ms. Larson. You know, I think a great example of this is 
the care and services, especially to the opportunity with the 
COVID relief pieces. We were able to provide, in two of the IHS 
areas, both the Billings area and the Great Plains area. 
Previously, you know, there hadn't been enough access for us to 
provide care. And having broadband available, the last one was 
in the Billings area, we were actually able to reach another 
tribal location and a service unit area. We increased--through 
the relief, we were able to increase the behavioral health 
services response. So able to provide care in the home through 
behavioral health versus having to go to a clinic. The no-show 
rate of those individuals reduced by up to 40 percent.
    So now, we are reaching 40 percent more of the individuals 
coming on a telehealth visit, receiving behavioral health 
services. So, you know, the availability of that in the home 
setting and because broadband was now brought out there, they 
could actually use their phones in their home situation to have 
behavioral health services. Huge extension. And the clinicians 
and the behavioral health arena specifically are very 
comfortable on video or on phone.
    I mean, we have many physicians in many specialty areas 
that are comfortable at this point, but it is especially 
interesting that individuals with behavioral health needs are 
more comfortable in a location, not always in a clinic setting, 
maybe in their home setting. Also, the providers and behavioral 
health are telling us they can learn more. The patients are 
more comfortable in their home setting. They also can see the 
environments behind them or around them to help them understand 
maybe what is happening with the individual, which is not 
something you can get if the individual comes in and is not 
able to really communicate easily in the clinic setting.
    So taking broadband out across the reservation areas has 
enabled physicians. I have mentioned behavioral health. There 
is also dermatology. There is endocrinology. We know the 
situation with diabetes in that population. Able to manage and 
control that with individuals not always in the clinic setting 
but making broadband available in that setting also gives our 
specialists the ability to be in the clinic and work remotely 
with those clinic physicians.
    Senator Thune. Thank--thank you. Thank you, Chairman.
    Senator Lujan. Thank you so much. Next will recognize, 
Senator Schatz, for questions.

                STATEMENT OF HON. BRIAN SCHATZ, 
                    U.S. SENATOR FROM HAWAII

    Senator Schatz. Thank you, Mr. Chairman. And thank you to 
the Chair of the whole committee for deferring to me. Mr.--Dr. 
Ransone and Ms. Larsen, as you know, we are facing a telehealth 
cliff because the authority that has expanded Medicare's 
coverage of telehealth expires when the COVID-19 public health 
emergency ends.
    And unless Congress acts, we will go back to the stone 
ages, with very limited access to telehealth, and I think 
people are sort of underestimating the shock that will occur 
across communities if we don't deal with this cliff. I have 
introduced a bill, the Connect for Health Act. It has the 
support of more than 60 Senators on a bipartisan basis that 
would make this expanded coverage permanent.
    So Dr. Ransone, first and then Ms. Larson, could you speak 
to the disruption in health care delivery if we don't fix this?
    Dr. Ransone. Thank you, Senator. There will be an 
incredible disruption in my ability to take care of my patients 
when we reach this cliff. For family physicians nationwide, 
prior to the pandemic, about 15 percent of our members provided 
telehealth services. And because we were concerned about the 
safety of our patients at the beginning of the pandemic, we 
quickly transitioned to approximately 6 weeks later, over 90 
percent of our members provided telehealth services to our 
patients.
    It is critically important that we are allowed to have 
funding to help us take care of these patients in a virtual 
environment. The concerns that I have are multiple should that 
funding evaporate. Number one, virtual care has allowed me to 
expand my house call services. I have done physical house calls 
for years. However, because of patient safety, because of 
distance, and because of I am in a rural area, allowing me to 
access the patients that I have known for years in their home 
has allowed me to keep many of my patients out of the hospital. 
So this is a big cost savings for our entire health care 
system. When we can go, we can monitor our patients closely.
    We can keep them from going downhill and we can keep them 
out of the hospital. So continued funding is incredibly 
important. I would also like to put in a little push for 
continued funding of audio only telehealth services. I see many 
geriatric patients. And rarely do I see a patient over 75 who 
is not there with someone who is younger. Typically, they have 
a family member who is there helping them bridge that digital 
divide, helping them use the technology that is there.
    And more frequently, my patients 80 and over just don't 
have that technology. A flip phone is considered very advanced 
for them. So, they have used audio only telemedicine services, 
and I use that to help monitor them and help keep them healthy. 
I think keeping that availability of audio only telemedicine 
services and funding thereof is incredibly important to help me 
take good care of my patients. Thank you.
    Senator Schatz. Ms. Larson.
    Ms. Larson. So I would echo a few of those comments. It is 
very important to us that the geography is not limiting where 
we can really see individual patients. Workforce is an issue. 
You know, we have to remember that physicians are clinicians 
having to travel to locations to see--in our rural states, they 
may travel 60 miles 1 day or more just to get to a clinic to 
see patients. Can I not do--can I have that in a skilled 
nursing facility? You know, really making sure that location is 
not a barrier. And in the home, ensuring that that same 
clinician doesn't have to take the time, unnecessary time to 
travel where they can actually see the patient in their home.
    Not to mention, remember, many of these individuals don't 
have the ride that was just earlier mentioned. They will forego 
it. They won't ask their daughter or their son to take the day 
off, to take them to the nearest setting, when we can be right 
in their home with them. That is a huge and important--it 
will--absolutely, people will fall through the cracks if we are 
not able to continue to see them in their home.
    Senator Schatz. Right. And for the technicians, you know, 
who develop these statutes and the people who work at CMS, and 
people on the Finance committee, we talk about that as the home 
as an originating site. But the practical implication is really 
significant. It is a matter of life and death. It is a matter 
of whether or not you can get care. Because if you still have 
to go to your car and get into some--either public 
transportation or get a ride, and schlep someplace, it defeats 
the purpose, at least partially of telehealth in the first 
place.
    Ms. Larson. It absolutely does. And you know, the 
spiraling--remember that since COVID too, many families are 
trying to care for their senior family members in their home, 
which means they are not in skilled nursing facilities today. 
So even in skilled nursing facilities, but now in the home, we 
see escalation of illness that there is delay.
    So, what does that cost--what does that cost us? So if we 
can't immediately see an individual when they start to feel ill 
or have a situation going on, if we are waiting, now that 
individuals is going to be seen probably in an emergency 
department with an escalated illness and maybe even 
hospitalized. We can prevent much of that.
    Senator Schatz. Thank you. One final question I will submit 
for the record, but I am very interested in the behavioral 
health piece, especially for adults in the community with 
severe and persistent mental illness. I used to run a nonprofit 
that provided services to people with severe and persistent 
mental illness, and a lot of our case management was just 
finding the client--physically locating the client. And 
technology has advanced to the point where we can make sure 
that those--and oftentimes it is billable hours.
    It is a fee-for-service arrangement, but a lot of those 
billable hours we are chasing someone and trying to locate 
them. And this is a problem that telehealth can solve and make 
sure that the system is efficient and delivering care, not just 
activities related to trying to deliver care. So thank you. I 
will submit that for the record. Thank you.
    Senator Lujan. Thank you, Senator Schatz. Next, Ranking 
Member Wicker.
    Senator Wicker. Thank you very much. Commissioner Carr, 
when do you think the FCC will have the new maps ready?
    Mr. Carr. Well, it is a good question. It is a bit of a 
black box, but I don't think it should be. Back in March, I 
said we should get them done by this fall, at least a targeted 
set of maps that lets us go forward with RDOF II and 5G fund. I 
heard that they may get done this summer, but there are no maps 
at this point.
    Senator Wicker. Is there a sense of urgency in the FCC?
    Mr. Carr. I am sure there is. And so I don't know what the 
difficulty is. Obviously, getting these maps together is a very 
complicated process, but we obviously do need to get them done.
    Senator Wicker. OK, so is this a staff problem or do you 
need to get back to us on that?
    Mr. Carr. I am happy to--you know, we obviously got almost 
$100 million from Congress at the end of last year to get this 
done, and we need to because it is holding up the distribution 
of funds that could further bridge the digital divide.
    Senator Wicker. OK. Well, pass along that I would like to 
see a sense of urgency from everybody within the FCC, and I 
hope I get some amens up and down the dais on that. 
Commissioner, USF is funded by contributions from 
telecommunications providers who pass the cost to consumers.
    The contribution rate, which is a tax, has climbed. I have 
a bill called the Fair Contributions Act, which directs the 
FCC, which would direct the FCC to study whether big tech 
should also contribute to the USF fund because these companies 
overwhelmingly benefit from broadband. So how can--do you think 
that would be a good way to ensure that Universal Service Fund 
is on a stable and sustainable path?
    Mr. Carr. Well, thank you, Senator. I think that is a great 
bill and it tackles an important issue. There is a 30 percent 
charge that we add to the telephone portion of consumers' 
bills. A study that came out a couple of weeks ago said that 
that could spike to 75 percent if we don't do something 
different.
    And your legislation would have us to look at what I think 
is a much more fair way of doing that. Just looking to the 
large tech companies that benefit to the tune of trillions of 
dollars from these investments in the network, they should 
start contributing a fair share. So I think the FCC should move 
forward, consistent with that legislation.
    Senator Wicker. Seems to me we ought to just use that bill 
this afternoon. Members of the Senate can get back to me on 
that. One other thing Commissioner, the FCC has reviewed 
applications for both COVID-19 Telehealth Program and the 
Connected Care Pilot Program beginning in April 2020. The 
applications were either granted or denied based solely on FCC 
staff review, without public comment on their applications. 
Commissioner, is this a fair criticism, and has the selection 
process for both COVID and Connected Care Pilot Program been 
open and transparent?
    Mr. Carr. Thanks for the question. It sounds like there is 
room for improvement on that front. We have tried to put some 
guardrails in place at the Commission level and then move 
quickly at the staff level to move those through. But I take 
the point that we could bring some greater transparency to that 
to make sure that we are getting the dollars where it is needed 
most.
    Senator Wicker. OK, so what needs to be done? What would be 
the next step there?
    Mr. Carr. We can work with my colleagues and see if there 
is more that we need to do to get common input on those 
applications that are pending.
    Senator Wicker. OK, well, you know, I will tell you what I 
think I would like to ask you to do is check with your 
colleagues and maybe you can respond on the record. A 
comprehensive answer there. Ms. Larson, you agree with me about 
maps. We don't we don't want to duplicate where we already have 
service. We need to make sure where the new broadband is 
needed. Do you agree on the importance of maps?
    Ms. Larson. Absolutely agree on the importance of maps. 
What I want to make sure and maybe indicate here when we--the 
comprehensive maps. There are urban settings where there is not 
enough access. So, you know, let us be sure it is comprehensive 
and that we really understand where this broadband is 
absolutely needed for access for all.
    Senator Wicker. Well, you have a young man sitting right 
next to you there, who I am sure is listening. Besides the 
existence of broadband, are there regulatory barriers in 
telehealth that you would like to bring or other barriers 
besides just the availability of broadband you would like to 
bring to our attention?
    Ms. Larson. So I will start with broadband. You know, it is 
interesting when we go to different locations, you know what 
the cost of broadband access is for a different remote 
location. And certainly the USAC funds have tried to address 
that. And you know, it is--I think we have talked about this 
before. I know I have talked it with Commissioner Carr. 
Application is--when you are a small critical access hospital, 
and you know, you have--the IT person is also the quality 
control person, maybe infection control and a few other things, 
the application process is difficult and that can actually--and 
it is not that it is not accurate.
    It is not that it is not--that the information is not 
needed, but it is a lot of due diligence that we often try to 
help with. So that piece of access again and the funds that are 
available, if there is any way we can make that more readily 
available for those most in need. We have come into 
organizations who just a small critical access facility who 
site monthly fees of up to $15,000 for broadband access.
    You know, that is it is an incredible amount of money when 
you are that size of the facility. But with USAC, we typically 
can, you know, cut that down to much, much, much less than 
that. So, that is an important feature.
    Senator Lujan. Thank you, Ranking Member Wicker. And I 
think there is a lot of interest in what you have identified, 
not just with legislation you have introduced, but looking at 
modernizing how we are able to fund these initiatives. And also 
the editorial piece, the opinion piece that was written by you, 
Commissioner Carr, which I know received a lot of attention. I 
certainly appreciate it as well. Next, we are going to hear 
from the Chair of the Full Committee, Senator Cantwell.

               STATEMENT OF HON. MARIA CANTWELL, 
                  U.S. SENATOR FROM WASHINGTON

    The Chair. Thank you, Mr. Chairman. Thank you for this 
important hearing. You and Senator Thune have done a good job 
of outlining these important issues. Senator Thune and I both 
serve on the Finance committee, and I guarantee you these are 
constant issues before the Finance Committee, and we just have 
to figure out solutions. But thank you for your leadership 
because your understanding of our infrastructure as it relates 
to the utility sector and these solutions is very, very much 
appreciated.
    And I want to--I think the Ranking Member is reminding us 
how important it is that we actually get the information on 
these maps now. I have seen a lot of data provided by the 
private sector already on this, and I think that some of the 
private sector data is outlining just what Ms. Larson said, 
that while access in some parts of the United States is 
challenging, affordability is a bigger problem. It is in sheer 
numbers what is preventing us from delivering something on 
telehealth. So, we need to do both, and hopefully we can do 
both. And hopefully this committee can play a larger role in 
communicating to our colleagues what are some burgeoning 
technology solutions that I think could expedite us, obviously, 
once we see the data and information.
    Although I think there is a lot of data and information 
that is already there that should point us in the right 
direction. On this specificity this morning, Commissioner Carr, 
I think you recently visited the Whitman-Walker Health Center 
in D.C. Acting Chair Rosenworcel happened to be in the 
Northwest in 2019, where we visited an actual stroke victim 
gentleman, one of the San--basically had been on the San Juan 
Islands. Was able to then be helicoptered, I think, over to one 
of the Bellingham hospitals.
    And then because of tele-stroke care, immediately, they 
knew--they knew, immediately. Actually, it might have been even 
before he left one of the San Juan Islands, they knew, and they 
said, get him down to Seattle for care. So, that is the kind of 
system that we want, and obviously we have to have that 
connectivity to help in making those kinds of assessments in 
those rural areas. But I am also interested in this issue of 
the system just in the availability of specialists. It is 
almost as if we could open up rural parts or hard-to-serve 
parts of our health care delivery system to the kind of care 
you don't have to drive to Seattle to see the specialist or you 
can get some of the information or the help and support.
    The reason I mention that is because we have so many 
shortages in primary care physicians, unbelievable amounts of 
shortages of primary care, and hopefully we can do something 
about that. But we also have tremendous shortages in specialty 
care.
    So Ms. Larson, what do you think we should be doing to try 
to identify and help? What kind of savings we would have in the 
health care system if we were able to hook up some of our most, 
you know, I think places in my state, north of Spokane, in 
other parts that are just hard to get to see a specialist?
    Ms. Larson. It is a great question. And workforce is an 
issue. You know, we have to understand, and I have been saying 
for a long time that telehealth is part of the solution of 
workforce. You know, we don't have enough specialists. And 
where they are located may not--they may, even as a 
subspecialist, not have enough population to even fill their 
profiles.
    So we need to think about a broader cast of network of 
providers who can cross State lines. You can have access to a 
child in rural South Dakota who has rheumatoid arthritis. There 
is no reason for a peds rheumatologist to be in South Dakota. 
There is not enough patients for him to take or her to take 
care of. But in a neighboring state, maybe two or three of 
those States in the Midwest, they could do a great amount of 
care if they were able to get through the licensing issues to 
provide telemedicine support to the family practice provider, 
who would collegially take care of that individual, that child 
through that growth over time.
    It is a--you know, today medicine, they are trained to work 
collegially. Primary care providers are trained through their 
residency to understand the specialties and how to work with 
them. But if they work in a remote location, that is not 
available to them or the individual's family. And as you say, 
you know, sometimes it could only--it could be close by, but it 
is still not available to them because of a distance travel. 
You talk about Spokane and some of the places, you are talking 
about airlifting. You know, and it is just not available for 
everyone. But telehealth can be available.
    And what we find in our environment--you know, we are often 
working with nurse practitioners where through telemedicine, we 
are intubating patients who are at the end of their life, 
guiding the hands of the nurse practitioner, placing chest 
tubes. These are very technical types of things. So take that 
and move that over to a peds rheumatologists working with the 
primary care in a very calm clinical setting. These clinicians 
know how to do this. They know how to work collegially.
    We need to give them the tools set, move some of the 
restrictions in the licensing across the states, and let them 
build a broad network to help each other and support the 
constituents.
    The Chair. I think this is why I say there is overlap here, 
particularly with the--well, not just with us at the Federal 
level like on the Finance Committee, but states too, because a 
lot of these licensure issues are at the State level. And so, 
then how do you figure out how to get some sort of global 
agreement?
    And so, I would like for the record, if you could, just 
tell me, you can submit it for the record, what are those, you 
know, top three or four areas that you think would best be 
served by having--you mentioned rheumatoid arthritis, but like 
what are the three or four things where we are seeing a lot of 
activity, where a licensure and telehealth delivery system 
could make a big dent in delivering care? And you can take that 
for the record, but--unless, you know, right off the top. But I 
don't want to----
    Ms. Larson. Well, I will take it for the record, but I will 
also mention you will for sure see behavioral health.
    The Chair. Pardon me?
    Ms. Larson. You will for sure see behavioral health be a 
part of that.
    The Chair. Behavioral health. Yes. Well, my colleagues, I 
am sure every one of my colleagues could go a long time on 
sections of their State who have like no behavioral health 
services, like counties and counties. Thank you. Thank you, Mr. 
Chairman.
    Senator Lujan. Thank you so much, Chair Cantwell. And Dr. 
Arora, I think it would be important to hear from you on that 
question from Chair Cantwell as well. So we will make sure we 
submit that to the record for you as well. And next, we are 
going to hear from Senator Moran.

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Chairman Lujan, thank you very much and 
thank you to our witnesses for their participation today. Let 
me start, I think, with Dr. Ransone. First of all, I want to 
highlight a piece of legislation as many of my colleagues have 
done. And also second, what Senator Wicker said about maps, 
Commissioner Carr. We have introduced, several of us have 
introduced Protecting Rural Health Telehealth Access Act. It 
is--there is a number of pieces of legislation.
    I am involved in most of them, but this is the only one 
that includes a provision to allow payment parity for audio 
only telehealth. And I wanted to ask you, doctor, from a 
physician's perspective, why is the continuation of audio only 
telehealth important, particularly as it relates to rural 
communities?
    Dr. Ransone. Thank you, Senator. I can say that AAFP did 
support that piece of legislation. It does support it. Audio 
only telehealth is incredibly important, especially for my 
older and geriatric patients. There is a in the--part of the 
digital divide is just a competency and confidence in using 
technology.
    And a lot of my older patients just do not feel confident 
in using it. A lot of them feel that if they do anything to the 
computer, it will break and they won't have the availability to 
do it, and so they don't feel confident in doing it. And we 
need to meet--we need to meet these patients where they are. A 
lot of them don't have computers or tablets or anything in 
their home, and what they have is a telephone. They feel 
confident with that type of technology, and they know how to 
use it.
    So because they have been using it for 90 years. So, when 
we see those folks, a way that we can get to them is the audio 
only or telephonic consultation. In the time of the pandemic, I 
spent a lot of my time trying to keep my patients into an 
environment that was safest for them and frequently that was 
not going out in public and potentially exposing themselves to 
the virus. So I needed to find ways that I could get to them to 
help manage their chronic disease.
    Telemedicine was my answer for a lot of patients to be able 
to get to them to give them the best quality of care, and I 
continue to use that. I think that in the future, after the 
public health emergency has abated, I will still use and will 
still need to use audio only services in order to reach those 
patients. Thank you.
    Senator Moran. Thank you for that testimony. That 
confirmation of the value. Commissioner Carr, you mentioned 
audio only. Anything you want to add to the doctor's response 
to my question?
    Mr. Carr. I think he is exactly right. And as my testifying 
friend here said, we need to give doctors every tool in the 
toolkit and audio is a big piece of that. I think your 
legislation would make a lot of progress on telehealth.
    Senator Moran. Commissioner, thank you for your recent 
visit to Kansas. Parsons may be the most per capita the 
Commissioner visited community in the country. And I was not 
able to join you on your visit, which only means that you have 
to return to Kansas in the near future. Commissioner, you are 
aware that the FCC, USDA, and NTIA announced a memorandum of 
understanding to share information and coordinate the 
distribution of broadband deployment Federal funds. Can you 
bring us up to date on what has transpired? Is there the 
necessary coordination occurring?
    Mr. Carr. I am concerned there is not the necessary 
coordination for a couple of reasons. One, the agreement that 
you referenced only covers some agencies that have broadband 
dollars and then some of the broadband dollars at the agencies 
that signed it have. If you step back, you can argue that there 
is about $800 billion across various agencies right now that 
could go to broadband infrastructure. It could go to other 
infrastructure as well. And I am not confident that we are in a 
situation where we are coordinating across agencies.
    And unfortunately, we saw what can happen back in 2009, we 
had the BTOP program, which is a lot of people here probably 
remember, was plagued by waste, fraud, and abuse. And I am very 
worried that we have hundreds of billions of dollars right now 
that we aren't focusing enough on implementing those existing 
dollars, because there is enough money now potentially to 
bridge the digital divide, and I don't want to see that money 
go to waste.
    So, we need more focus on coordinating across agencies that 
have portions of these hundreds of billions of dollars.
    Senator Moran. I think that is a really important comment 
that you made, and I share the concern. We do spend a lot of 
time talking about the importance of maps so that we are 
putting the money where it belongs. But if the consequence 
because of lack of coordination between various Federal 
agencies and others is so lacking, the coordination is lacking, 
that we are spending money that doesn't need to be spent, that 
is also a sin as well. And so, we need to make certain that 
that coordination is occurring.
    And I would encourage you to ask us, ask Congress, for any 
assistance that would be helpful in that regard. I would 
highlight for you, Commissioner, there was another memorandum 
of understanding for planning a rural telehealth initiative. I 
would be glad to hear any update on that. I don't have enough 
time to take your answer.
    The last thing I wanted to say is--actually the second to 
last thing, but I only have time for one more. That is, I have 
some responsibilities in the world of the Department of 
Veterans Affairs, and they have a significant telehealth 
program.
    Any of our witnesses have any suggestions or comments that 
we should know, as we try to improve the access of care within 
the Department of Veterans Affairs for those who served our 
nation?
    Mr. Carr. Well, for my part, I will add that the VA has 
been on the front edge of a lot of telehealth adoption, and 
that has been very good to see. Digging beneath that 
observation, I would leave it to others.
    Ms. Larson. You know, we still experience latency in 
getting local providers eligible to provide specialty service 
at the VA. If they are not members of or getting again, a 
credential to be on, VA staff as a provider is difficult. And 
so, we still have that barrier.
    Senator Moran. Ms. Larson, I am not sure, and my time is 
expired, but I am not sure what you are telling me because the 
VA has the opportunity to provide, in fact, as the requirement 
to provide, community care in the community for those veterans 
who can better be cared for in the community. And I don't know 
whether you are telling me--that those providers are not being 
allowed to provide care in the community or you are not being 
able to get the necessary credentialed people at the VA?
    Ms. Larson. Yes, I am telling you physicians have 
difficulty meeting the requirements to be credentialed at those 
facilities.
    Senator Moran. Community facilities or the VA hospital 
itself?
    Ms. Larson. All VA settings.
    Senator Moran. Thank you. Thank you, Chairman.
    Senator Lujan. Thank you, Senator Moran. And Dr. Ransone 
and Dr. Arora, Senator Moran's questions is very important. If 
we could hear from both of you as well in regards to care for 
veterans in that VA setting.
    Dr. Ransone. Thank you, Senator. I see numerous veterans in 
my clinic, and I share many of my veteran patients with the 
nearest VA hospital. I have two, each of which are probably 1 
hour and 20 minutes to an hour and 30 minutes drive from my 
office.
    I have not heard of any program where I am able to access a 
VA Administration specialist via telemedicine. I think that is 
a wonderful idea. I take care of these folks and I try to keep 
them out of the hospital. But any time that I could teleconsult 
with a specialist in the VA system, it would be beneficial for 
our veteran patients. Thank you.
    Senator Lujan. Dr. Arora.
    Dr. Arora. Thank you, Mr. Chairman. You know, the VA has an 
extraordinarily great shortage of specialists to take care of 
veterans. Most veterans living in rural areas don't have 
adequate access. We at Echo, have partnered with the VA system, 
and they have run more than 30 networks on a variety of 
diseases, including mental health disorders, hepatitis C, etc. 
But there is the same problem that exists in nursing homes in 
the VA hospitals, that is in our health care system financing, 
there is no real methodology to incent specialists to 
democratize their knowledge and enable primary care clinicians 
across this country and in the veterans admission system to 
operate at the highest level of their license.
    All VAs that I am aware of have very long waits for 
specialists and therefore these veterans have limited access. 
But this can be solved if we were able to measure productivity 
in the health care system differently. For example, could we 
account for a time a specialist at the VA spends in mentoring 
other primary care providers in rural areas in the VA system, 
in the VBOCs, outpatient clinics to provide the care locally.
    That is not happening because our measurement systems are 
all outside the VA and inside the VA focused on a fee for 
service system where the specialist only gets reimbursed for 
seeing the patient themselves. And that, in turn, exacerbates 
this enormous shortage of knowledge that exists in rural areas. 
And I think there is a potential in the VA system to change 
that.
    Senator Lujan. Thank you, Doctor. And Senator Moran to 
respond. And then, we will go to Senator Blumenthal.
    Senator Moran. Chairman Lujan, thank you for highlighting 
the importance and allowing the other two witnesses to testify. 
I appreciate your interest in this topic. The Mission Act, 
which many of us were intimately involved in, allows for the 
Department of Veterans Affairs and I said earlier requires 
where it is in the best interest of a veteran, he or she is 
entitled to have care outside the VA. It is not really outside 
the VA, it is within the VA, but it is a community care 
provider network. And I just would highlight for particularly 
both of the doctors and what they just said.
    First of all, we expect the VA--and they tout their 
capabilities within the capability of providing telehealth to 
veterans across the country. What you are telling me is they 
lack the necessary professionals, particularly in specialty 
areas, to meet the needs. That is one area in which the 
Department of Veterans Affairs can reach veterans is through 
their own telehealth program.
    But the other is community care authorized, required by the 
Mission Act, which says if it is in the best interests of a 
veteran, determined by his or her--him, her, the veteran and 
his or her provider, then the VA must provide that care within 
the community. It doesn't solve the specialty care, probably 
because there is not that many specialists--we don't have the 
necessary specialists in our communities, but particularly when 
it comes to primary care, there is an opportunity for veterans 
to be cared for in the community separate from telehealth.
    And this is not a feature that should be forgotten and 
needs to be highlighted within our physician community.
    Senator Lujan. Well, said Senator Moran. Thanks so much. 
Senator Blumenthal.

             STATEMENT OF HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thanks very much, Mr. Chairman, and 
thank you for having this hearing during National Digital 
Inclusion Week. Very fitting time to have it. Broadband, in 
other words, high speed, affordable broadband is really an 
essential need. It is not a convenience or a luxury. I think 
every one of our witnesses knows the COVID-19 pandemic has only 
increased digital divide, including the homework gap. But that 
divide can mean a life or death difference to underserved 
communities. On Monday, I visited East Hartford to join in the 
announcement of East Hartford Fiber City, a project that will 
bring in all fiber Internet networks to every home, business, 
and town owned facility. It can reach speeds of 10 gigabytes 
per second.
    I want to highlight this project in particular because it 
brings broadband to an underserved urban area. It is not the 
solution for the whole State of Connecticut or the whole 
country because it relies primarily on private money, even 
though it is a public-private partnership, but we do need more 
projects across the state and country that provide that kind of 
Internet access, including telehealth. So I wonder whether our 
witnesses can explain how underserved communities really suffer 
as a result of the digital divide, and in particular, low 
income communities and communities of color, which face the 
largest barriers in accessing telehealth? I will begin with 
you, Commissioner Carr.
    Mr. Carr. Thank you, Senator, for the question. We have 
done some mapping historically at the FCC, and you are exactly 
right. We see poor health outcomes, lack of affordable access 
to internet, low income. Those things tend to cluster together.
    And that is why if we can get affordable Internet 
connectivity out there, we can extend the benefits of 
telehealth and it literally can save lives. That is why the 
Connected Care Pilot we have been working on focuses on low 
income Americans and veterans. To your point, COVID-19 only 
underscored the value of Internet connection and the value of 
telehealth, and we can't afford to go back to the way we did 
telehealth before COVID-19.
    Senator Blumenthal. Ms. Larson.
    Ms. Larson. You know, I think it is really essential to say 
that communities do need health care. And the connectivity with 
telehealth, what it does is actually helps us keep dollars in 
that community, commerce in the community, as we can retain 
patients in that local clinic setting, have all of their lab 
work and other follow up care retained in the small rural 
community versus going to the next level of care. We are 
keeping commerce in that community, helping it stay alive.
    Senator Blumenthal. I want to ask a question that troubles 
me after hearing that we had yesterday in this committee about 
data security. It was the second in a series of hearing that is 
focused on finding a path toward consumer privacy and 
protecting that privacy. I think that my colleagues and I all 
agree that we need to see real change to protect consumer 
privacy rights.
    And I wonder if you could tell me, and I am going to ask 
Dr. Arora, Dr. Ransone, and Ms. Larson, what specific actions 
do you think ought to be taken to ensure privacy? And then 
Commissioner Carr may not have time, so I may ask you to 
provide the answer in writing, what the FCC does to verify 
telehealth providers in the area of privacy? Ms. Larson, maybe 
begin.
    Ms. Larson. So there are several options, as you know, 
for--especially during the early COVID time where clinicians 
were allowed some opportunities to go on different aspects of 
providing telemedicine. As a health care provider, we do not 
allow that. So all of our--all of the connectivity we have is 
HIPPA compliant and we do, of course, comply with that as a 
health care requirement.
    Senator Blumenthal. Dr. Arora.
    Dr. Arora. Mr. Chairman, Senator--Mr. Chairman, Senator 
Blumenthal in the Echo Project, your state has taken a 
leadership role in democratizing the knowledge of the Yale 
University Community Health Center Inc. and many other 
organizations. We have taken special precautions for data 
security that when a patient is presented on the Echo project 
as a telementoring case study, no patient identifying data is 
ever shared. So, the Echo model inherently protects the data of 
individuals.
    Let me give you an example of the nursing home project that 
we recently launched. You know, we had almost 500,000 deaths at 
one point in the pandemic and 30 to 40 percent of them were in 
nursing homes in the United States. So, we at Echo launched 326 
networks to connect many in Connecticut to connect these 
nursing homes in cohorts of 30 to these academic medical 
centers and other organizations.
    So, in South Dakota, what happened was there was a nursing 
home where there were 40 people residing and 30 got infected 
with COVID-19. Two of them were over 100 years old. We had 
taught this nursing home using Echo how to use the antibody and 
bam, and essentially, of the 30, 28 survived. Two of them who 
were over 100 survived. This was almost unheard of in nursing 
homes where COVID-19--but the right knowledge at the right 
place saved their lives.
    And no data security issue came along because no patient's 
name was ever discussed, ever in this entire network. Thank 
you.
    Senator Blumenthal. Thank you. Dr. Ransone, do you have 
any----
    Dr. Ransone. Yes, sir. I would like to say that we take the 
digital privacy and security--we think that is incredibly 
important. The concern that we have is the affordability of 
HIPPA compliant platforms. Typically, they tend to be more 
expensive, and trying to support the smaller, rural practices 
is difficult just because of the cost issue. One thing I would 
like to jump on that you said earlier, Senator, was regarding 
your all fiber network. I only got wired Internet in my home 
about 3 years ago, and this was after 2 years of fighting with 
a company in order to get it to our area.
    Before that, I was considered to have broadband because I 
had a cell phone and I had 3G coverage. Unfortunately, that 
type of coverage is not anywhere near good enough to allow me 
to access my advanced electronic health record at the office. 
And so there, I might have been considered to have broadband. 
But it was not broadband that was usable and affordable for 
most folks. So thank you very much.
    Senator Blumenthal. Thank you. Excellent testimony. Thanks 
again, Mr. Chairman, for having this hearing.
    Senator Lujan. Thank you so much, Senator Blumenthal. Next, 
we are going to hear from Senator Blunt.

                 STATEMENT OF HON. ROY BLUNT, 
                   U.S. SENATOR FROM MISSOURI

    Senator Blunt. Thank you, Chairman. On the topic of how we 
deliver, Commissioner Carr, you said in your testimony that all 
the benefits of telehealth are clear. Barriers remain from 
legal and regulatory to connectivity challenges. We seem to be 
moving as quickly as we are able to, though seems slower to 
most of us than it should be for connectivity. But on the other 
authorities, I am concerned we are not moving as quickly as we 
need.
    Senator Murray and I, along with the House Representatives 
Lara and Dingell, introduced a bill, the Treat Act, to try to 
deal with some of the regulatory challenges. You know, Missouri 
is--we have seven states that touch our state. Our two biggest 
population centers are right on the edge of the state. Lots of 
people drive from other states to come to Missouri for health 
care.
    But when it is telemedicine and they are dealing with the 
doctor they have always dealt with, they are in a state where 
that doctor may not have--may have some challenges because of 
the barriers to becoming licensed in that state. Do you--any 
anybody on the panel, starting with Commissioner Carr, have any 
thoughts on that problem and the importance of solving it?
    Mr. Carr. Well, thank you, Senator. I think the Treat Act 
is a great step in the right direction to eliminate some of 
those geographic restrictions that are unnecessary in a 
telehealth world. Speaking of Missouri, though, I also want to 
say that you know, one of the challenges on the connectivity 
side is workforce and make sure we have the telecom crews 
capable of building this out.
    And I just had a visit to Lynn, Missouri. They have got 
State tech there, which is a wonderful program, training up 
young people to get good paying jobs building out this 
infrastructure. And as a country, any infrastructure plan that 
doesn't include a plan for workforce shortage that we have is 
itself falling short. I think that type of a program in Lynn, 
Missouri is a great model we need to continue to build on.
    Senator Blunt. Right. Well, I agree with that. But in fact, 
in our state, the University of Missouri has had extension 
opportunities. Early on, very much Ag focused, but later that 
focus expanded in every single county. And one of the things 
they are doing right now is trying to be sure that there is at 
least one location in every county that someone could go to for 
a telemedicine opportunity. Often your behavioral health 
provider is further away than your other health provider.
    And you know, that is something you don't want to let get 
away. But if anybody has any thoughts on the challenges. Last 
year we saw kids in college in a different situation than they 
had been before. Maybe these were people that had had a 
behavioral health, people that they would relied on at home, 
but suddenly they are five states away. How important is it 
that we figure out how to deal with that problem? Ms. Larson.
    Ms. Larson. You know, I would speak to licensing is really 
a barrier. As you talk about these specialists, they can 
provide--there is always a place that is needing them. And you 
know, if there are a lot of barriers to getting not only 
licensed in the State and the time that that takes--some states 
require them or want them to come into the State and be 
fingerprinted.
    You know, the duplication of that for an individual 
physician who is very busy to get all of that done across 
several State lines is difficult. Not to mention, typically at 
least the way we provide telemedicine, we become--we did a 
credentialing or appointment, if you will, with whoever the 
local providers are. That means that medical staff, through the 
conditions of participation, are required to have medical staff 
appointment criteria.
    Each of them are different. I have ED, emergency physicians 
who are appointed in 200 locations across the U.S., 200 
different sets of bylaws that they have to be accountable to 
achieve and accomplish and keep up in 200 different facilities. 
That is just the governance at the local site that is required 
by the conditions of participation.
    Senator Blunt. Well, I think I am running out of time here. 
We are--I think this is something we have to deal with. I had a 
meeting, a Zoom meeting this week with a group, the American 
Connection Project, 170 different members, big companies and 
others. The Treat Act is the first piece of legislation they 
have ever endorsed, and so they endorsed it this week.
    And I hope we can deal with that because if we have 
telemedicine, we are going to have to have connection to the 
doctors and other health care professionals that you want to be 
connected with and that you often are connected with when you 
get in your car and drive.
    But all of our--every state has somewhere in the State that 
someone from another state drives to see their doctor now, and 
we need to figure out how they can have that telemedicine visit 
as well with the--I think you can make considerations as the 
Treat Act does, for State regulators to still have authority if 
things are not going the way they should, but some sort of 
understood reciprocity or something is really important here. 
Thank you, Chairman.
    Senator Lujan. Thanks, Senator Blunt. Next, we are going to 
hear from Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Chairman Lujan. I like the sound 
of that. You know, Commissioner Carr, before I get into my 
remarks here, I just want to say, I hope you heard what Dr. 
Ransone said. And at that, you know, we give a lot of money out 
to folks who are supposed to put broadband in the ground, and 
they turn around and say, you know, he has already got 
coverage, when he has got crap for coverage. I mean, this is 
unbelievable.
    And so I think depending on you, Commissioner, to put the 
boost of these guys when they don't do what they say they are 
supposed to do because we are putting out billions of dollars. 
And telehealth is really important. I live in Montana. Weather, 
distance, those all make telehealth a winner. And I have heard 
from patients that they believe it is a winner. And quite 
honestly, I wasn't sold on it from a mental health standpoint 
in the beginning.
    But I have heard from veterans because I serve as chairman 
of the Veterans Affairs committee--from veterans that say 
telehealth is actually better than in-person visits in a lot of 
cases. So, there is just a lot of positive things out there for 
telehealth, and we have done a lot to help push the ball 
forward as the Senators know, through the CARES Act and through 
the December Consolidated Appropriations Act that we passed in 
2020. Montana health care providers received nearly $1.9 
million. That is real money. And it came through Commissioner 
Carr's FCC telehealth program, to purchase telemedicine 
software devices, remote monitoring equipment, and more--
ultimately delivering more quality care to Montanans.
    Because of this funding, Montanans, you know, they can do 
it at home. They can do it at a local hospital that may not 
have the kind of level of expertise there that some hospital 
always away would have. So, it is a real positive thing in a 
State like Montana. And I know that for those folks who don't 
know how to use a computer or don't want to use a computer or 
don't have the up to date computer, there is also audio 
options. And quite honestly, those provide some benefits too.
    I am going to start with you, Dr. Ransone. From an audio 
standpoint, I don't know if you do any audio telehealth, but if 
you do, could you talk to me about its effectiveness, because I 
do know the video telehealth is very effective. And correct me 
if I am wrong on that. You are the pro.
    Dr. Ransone. No, sir. The video is very effective. And 
being able to see a patient and being able to have them hold 
their broken finger up or whatever it might be in front of a 
camera, it is quite beneficial for me and making a diagnosis 
and developing a treatment plan. Audio only is quite effective. 
Especially the most effective tool is one that we can use, 
right. And so, if my patient can't use video, it is of no good 
to me and their care. So, the most effective thing is what they 
can use. And audio only is incredibly effective, especially for 
my older patients. I can ask a lot of questions, and a lot of 
times I can decide, do I actually need to bring this patient 
down to see me?
    And an audio consultation can give me the needed data that 
I have in order to do that. I would like to jump in and just 
say that, when my patient--we know that the best care of these 
patients is in the patient-centered medical home. And when we 
have our patients who travel, they go to college, they do other 
things like you mentioned, specifically if they are out of 
state, I think I can give them the best care because I have 
known the patients since they were an infant.
    Frequently, when my patients go to college, I can call 
them. We can do mental or telehealth visits regarding 
behavioral health, frequent medication refills and things like 
that. So, we do think we need to crack that-of interstate 
commerce or interstate consultation, but we support the 
Interstate Medical Licensure Act.
    We think that it is incredibly important that there is 
still some state control for safety reasons over the physicians 
in that Act, though we think it needs to be less burdensome to 
apply in other states and less costly to apply in other states. 
We think it is incredibly important to allow that patient to 
stay within their medical home so we can give them the best 
services, be it audio or video. Thank you.
    Senator Tester. No, thank you for that input. This is a 
very simple question, and because I only got about 40 seconds 
left. And we put it in a bunch of waivers because of the 
pandemic on telehealth. Number one, do you think that those 
waivers should be made permanent, or should we just extend 
them? What is your view on the waivers, and have they been 
effective?
    Dr. Ransone. I think the waivers have been effective and I 
would be supportive of making them permanent. I think that we 
have entered a brave new world of virtual communication, and 
this is the best way for me to help take care of my patients in 
their medical home.
    Senator Tester. Alright, thank you, Mr. Chairman. I want to 
thank you all. It is a good hearing. Thank you very much.
    Senator Lujan. Thank Senator Tester. Next, Senator Cruz.

                  STATEMENT OF HON. TED CRUZ, 
                    U.S. SENATOR FROM TEXAS

    Senator Cruz. Thank you, Mr. Chairman. Ms. Larson, the 
Biden Administration has issued a number of COVID-19 vaccine 
mandates. One of them compels Medicare and Medicaid providers, 
such as hospitals and medical practices to in turn force their 
employees to get vaccinated or risk losing their job. These 
mandates violate individual liberty, they violate the health 
care privacy of the employees, they are not authorized by law, 
and they could force people to receive a vaccine, even if doing 
so is contrary to the medical advice of their own doctor.
    For the first 12 months of the pandemic, Republicans and 
Democrats together praised health care workers, praised 
doctors, nurses, physicians, assistants, technicians, 
pharmacists, other medical professionals for working 
tirelessly, and despite personal risk for their own safety and 
health, to treat Americans who contracted COVID-19. We all 
agreed that medical professionals were heroes.
    But for President Biden and for Senate Democrats, 
yesterday's heroes are today's Government subjects who must 
submit. The message from Joe Biden and Senate Democrats is, do 
as the Government says with your own health care or lose your 
job. Lose the ability to make a living, lose the opportunity to 
provide for your family. That is the Biden Administration's 
unlawful vaccine mandate. It is ironic that Senate Democrats 
are holding a hearing today about access to care, even though 
they are perfectly willing to let President Biden impose a 
policy that will cause medical professionals to lose their jobs 
and in turn diminish America's access to care.
    Ms. Larson, what are you hearing from medical professionals 
about their intention to submit to this mandate? And are there 
medical professionals who are not going to comply with this 
Government mandate?
    Ms. Larson. What I would like to speak to is the 
application of telemedicine within this. So what I do hear from 
individuals are because we are reaching patients a thousands of 
miles away, and it is the same clinicians, physicians, nurses, 
pharmacists, will we be requiring--you know, the question is, 
what are we doing? And you know, we will be in compliance with 
what our customers in this case want.
    So, in some cases, a receiving facility of telemedicine is 
saying all clinicians who are accepted on the medical staff 
need to be in compliance. And so, it is interesting in that 
situation we have to be careful that we aren't subduing care, 
taking care away from them by not being compliant with the 
bylaws of the medical staff. And individual physicians will be 
taken off medical staff if they aren't compliant with the 
requirements.
    So right now, you know, we are hearing a mix. There is--you 
know, just like the Nation, there is a mix of who is doing--you 
know, who wants to provide care or who wants to get a COVID 
vaccine and who doesn't. And we are in this situation of trying 
to be in compliance so that we aren't taking care away from any 
organization.
    Senator Cruz. Dr. Ransone, do you know how many doctors, 
how many nurses, how many health care providers have been fired 
because of the Biden Administration's vaccine mandate?
    Dr. Ransone. No, sir. I don't have any numbers as far as 
termination of employment. The American Academy of Family 
Physicians does support the vaccination of health care workers 
for----
    Senator Cruz. The mandatory vaccination, regardless of 
whether they want to or not?
    Dr. Ransone. We support what is best and safest for our 
patients, Senator.
    Senator Cruz. Does that mean the mandatory vaccination, 
whether they want to or not, and whether their own doctor 
advises it or not?
    Dr. Ransone. I think in a health care environment, each 
office, each hospital should be able to make their own decision 
about what is safest for the patients that come into their 
building or interact with their staff. And I support their 
freedom to make a decision on what, how they want their 
building or system to operate.
    Senator Cruz. So I agree with you they should have that 
freedom and they are not being given that freedom right now 
because the Biden Administration is forcing them upon it. I 
will read to you a headline from the New York Times this week. 
This week, on October 4th of this week, New York's largest 
health care provider fires 1,400 unvaccinated employees.
    It is astonishing, after we spent a year celebrating the 
heroes of health care, the Joe Biden solution is we are going 
to use Government power to force you to submit, and as a 
consequence, fire any doctor, fire any nurse who dares make a 
different decision. That is an abuse of Government power. It is 
contrary to law, and it is bad policy for America.
    Senator Lujan. Senator Peters.

                STATEMENT OF HON. GARY PETERS, 
                   U.S. SENATOR FROM MICHIGAN

    Senator Peters. Well, thank you, Mr. Chairman. And thank 
you to each of our witnesses for a very insightful hearing. 
Thank you for being here today. You know, I live in a very 
diverse state. The State of Michigan has some densely populated 
areas, as well as some incredibly beautiful rural areas in 
Northern Michigan in particular, in the Upper Peninsula. And 
what all of my folks require is access to quality health care 
that they can afford. And certainly telehealth brings state-of-
the-art technology into homes, regardless of where they live. 
It is incredibly transformative. But the University of Michigan 
recently put out a report that found that patients who are 
African-American or folks who may need an interpreter or use 
Medicaid as a primary insurance, or certainly if they live in a 
low broadband area, are much less likely to access video 
visits.
    For example it has been estimated that only 10 percent of 
African-Americans and 12 percent of Medicaid beneficiaries were 
less likely to access video visits compared to audio only 
visits. So, we have seen these kinds of health disparities 
certainly play out across the pandemic.
    And my question for you, Dr. Ransone, is in what ways can 
we support telehealth services to our underserved communities 
that currently are not able to utilize these technologies or 
for various reasons may find it difficult to use these 
technologies?
    Dr. Ransone. Thanks. I think that the connectivity issue is 
twofold, it is access and affordability. I think that we need 
to work on digital literacy for a lot of our patients, 
especially the elderly. And I think that potentially putting 
out pilot programs or things such as digital health navigators 
to help people understand the technology will be incredibly 
beneficial to help them be able to interact with me as their 
physician. I think that we have seen that non-native English 
speakers and folks who have limited English proficiency don't 
use telemedicine platforms to access their physicians.
    A lot of it has to do with just the inability to understand 
the instructions on their iPad or their phone. And I know that 
with when we first started with a telemedicine program to reach 
out to our patients at the beginning of the pandemic, I had to 
have extra staff time in order to help my patients learn how to 
connect with a digital platform.
    One of my front office staff would spend approximately 25 
to 30 minutes with each patient just trying to get them to 
connect so that I could have my office visit, and that takes 
time away from their regular duties in the office. So I think 
any type of digital health navigators to help these patients 
access and bridge that digital divide would be incredibly 
beneficial for them. Thank you.
    Senator Peters. Well, I appreciate that. And a follow up 
question, you mentioned also the ability to have resources to 
pay for these services so that it is available. You said access 
is about technology, but it is also affordable. We know that 
during the pandemic, HHS allowed certain services to be covered 
under Medicare, but those waivers are about to expire. Could 
you tell this committee why it is important to have both 
flexibility for billing, for telehealth services, why we need 
to continue to be focused on that going forward?
    Dr. Ransone. Thank you. Well, I spend a lot of time with 
each visit, be it an in-person visit, be it a video visit, be 
an audio visit beforehand, reviewing charts or viewing patient 
history and trying to prepare in order to see that patient to 
give them the most efficient and best care that I can give 
them. Once these waivers run out, I will be doing a lot of work 
for services for which I am not going to be reimbursed.
    So, it is pushing people more toward an in-person visit 
because that is the old paradigm in patient care, as you see a 
patient in person and you treat them. Where when we get to more 
advanced ways of seeing patients for some of the advanced 
models of patient care, it is--when we, let's say we were to 
make global payments to physician offices, we can allot our 
time.
    We can be paid for what we do to get ready for these 
visits. But it takes a lot of time to prepare and then follow 
up from any of the three types of visits mentioned. Thank you.
    Senator Peters. Alright, well, thank you, doctor. Thank 
you, Mr. Chairman.
    Senator Lujan. Thank you so much, Senator Peters. Senator 
Rosen while you are next, we don't have any other Republicans 
that are currently in the queue. Senator Warnock does have to 
leave now at noon, and I was just checking to see if we might 
be able to go to Raphael next----
    Senator Blackburn. Mr. Chairman, you do have a Republican 
in queue virtually.
    Senator Lujan. I appreciate that, Senator Blackburn. So, 
Ms. Rosen, you would follow Ms. Blackburn. But just checking to 
see if that might be OK.
    Senator Blackburn. OK. Are you ready for me, Mr. Chairman?
    Senator Lujan. No, a Democratic member is next, Ms. 
Blackburn.
    Senator Blackburn. OK.
    Senator Lujan. Or I apologize. Ms. Blackburn, you are next.

              STATEMENT OF HON. MARSHA BLACKBURN, 
                  U.S. SENATOR FROM TENNESSEE

    Senator Blackburn. OK. Thank you, Mr. Chairman, and thank 
you for the hearing. As you all can see, there is a lot of 
interest in this hearing. I enjoyed sitting in the hearing room 
until I had to step out and move on to another quick little 
meeting. Commissioner Carr, I wanted to come to you first. Last 
year, the FCC did such a good work setting up the telehealth 
program, the Connected Care Pilot Program that you all did. So 
we have talked a little bit during the course of this hearing 
about, you know, funding and grants and workforce, and a little 
bit about regulation, things that would inhibit moving forward 
with this program, growing it.
    And of course, we have talked about using it for veterans. 
And Dr. Ransone, thank you for your comments that are there. 
Ms. Larson, you have talked some about serving the underserved. 
So let me know if there are any legislative or legal hurdles 
that we need to move out of the way so that we can continue to 
grow this program. What do you see?
    Mr. Carr. Well, thank you, Senator, for your leadership on 
telehealth. First, I would say the Connected Care Program is 
funded out of the FCC's Universal Service Fund. And as a 
statutory matter, there are some threats to the stability of 
that fund, and that is why I have put forward the idea of 
looking for legislation that would help us expand the base of 
contributors into that to include big tech. I think the other 
statutory issue that comes to mind is the HHS waivers. I know 
you personally were involved in helping to secure those waivers 
last year that paid dividends for really so many Americans. I 
think statutorily addressing those waivers and sometime of 
longer term basis is a key step going forward.
    Senator Blackburn. OK, thank you for that. And Ms. Larson, 
as we were discussing the waivers with Senator Tester, I could 
see you wanted to weigh in on that. And as Commissioner Carr 
just said, this is one of the first things I did when we had 
the pandemic at its beginning, in the earliest stages, I asked 
President Trump to give that temporary relief and those waivers 
for telehealth provisions.
    We had had this legislation for about 3 years and people 
didn't seem to think it was a necessity. But of course, COVID 
has proven that it is a necessity for individuals with complex 
medical conditions and who are not in proximity to a health 
care provider. So, I want to give you an opportunity to weigh 
in on why these waivers need to be made permanent.
    Ms. Larson. Well, thank you for your leadership in all of 
those waivers. It has been essential for us to be able to 
provide the telehealth services in many locations. And I will 
just emphasize, you know, if HHS were able to untie their hands 
a bit to determine appropriate telehealth practices and 
services and providers, it would be tremendous--you know, the 
many of the rules and regulations are written prior to this 
type of technology.
    And so, if we could look at that in a more global way and 
untie their hands, allowing them to do what is appropriate 
today. And then also, you empower the safety net providers, the 
federally qualified health centers, as well as rural health 
clinics, making sure that we can have telehealth services 
continue in those locations, in those remote geographies.
    Senator Blackburn. OK. Yes, we have the legislation that 
would allow the across state line utilization of telehealth. 
Tennessee is a state that borders eight states, and we have 
areas where those physicians are located inside Tennessee, and 
then other areas against the state line where it is across that 
state line. So, we do think that that is vitally important.
    Dr. Arora, one quick question for you on the Echo program. 
Vanderbilt has done a really admirable job on its own Echo 
program, which really does help in training those providers on 
caring for our adults on the spectrum, as well as providers to 
treat patients with opioid abuse, disorders, pediatric 
behavioral health.
    So talk for just a moment about flexibility, why 
flexibility is important to the success of this program and the 
role that you see for public-private partnerships as we look to 
grow this program.
    Dr. Arora. Yes, Mr. Chairman and Senator Blackburn, thank 
you for your question. In addition to Vanderbilt and all of 
their amazing Echo programs East Tennessee State University 
also runs an Echo program for children's care. And these 
programs have an extraordinarily powerful impact on bringing 
care for children with autism in all over Tennessee. But there 
is a challenge for Vanderbilt and East State University. All 
our current Echo programs are funded through one time grants or 
support from the Executive Branch through a short amount of 
money or funding or philanthropic support is a very major way 
Echo's--we currently have close to 800 such networks operating 
in the United States.
    And in the United States alone, in 2020 alone, more than 
500,000 health care providers participated. Yet the entire 
network is operating on philanthropy or Federal grants, et 
cetera. We need policy change so that each of these academic 
medical health centers, large not-for-profits are actually 
incented and funded to democratize their knowledge so every one 
of the members of Dr. Ransone's community of family physicians 
has the ability to be mentored to provide best practice care in 
their local community, and that requires significant policy 
change.
    And Senator Blackburn, I would greatly enjoy the 
opportunity to work with you to bring this policy change so 
such universities can be supported.
    Senator Blackburn. My time has expired. We will follow up 
with you. And Mr. Chairman, thank you.
    Senator Lujan. Thank you, Senator Blackburn. And I also 
want to thank Senators Rosen and Hickenlooper for their 
indulgence. Senator Warnock, you are next.

              STATEMENT OF HON. RAPHAEL WARNOCK, 
                   U.S. SENATOR FROM GEORGIA

    Senator Warnock. Thank you so very much, Chairman Lujan. 
And it is great to serve alongside you on your subcommittee. 
COVID-19 has put a strain on all of us, and it has been 
particularly challenging to our health care systems. But one 
consequence of that is that it has forced advances in 
telemedicine that otherwise would have taken decades. In 
response to the pandemic, for example, CMS allowed telehealth 
flexibilities and encouraged Medicaid programs to follow suit.
    So, this is some innovation that is a consequence of the 
challenge. This has allowed patients to remain in the safety of 
their homes while receiving care. It has allowed providers to 
safely provide high quality care and to be reimbursed for it. 
However, due to the politics of health care coverage in our 
country, Medicaid nonexpansion states like Georgia have left 
some 4.4 million Americans in the coverage gap.
    And in the case of Georgia, there are 500,000 Georgians who 
cannot access these services. This means that Georgians are 
forced to delay lifesaving treatment in the midst of a 
pandemic. Dr. Ransone, can you tell me what it would mean to 
patients and providers and hospitals--by the way, we have had 
10 hospitals in Georgia close in 10 years because of our 
refusal to expand Medicaid.
    What would it mean for these communities and other--the 
other 11 nonexpansion states were we to expand Medicaid?
    Dr. Ransone. Well, thank you for the question, Senator. I 
am from Virginia, and we were a state that delayed expansion of 
Medicaid, and when we eventually did expand it. It allowed us 
to see over 400,000 new patients in our health care systems 
across the Commonwealth. By allowing these folks to receive 
coverage, we have been able to save lives. We have been able to 
initiate care sooner and we have been able to prevent the 
disease. Medicaid expansion has been essential for us to 
deliver equal and equitable care across the citizens of our 
Commonwealth. Thanks.
    Senator Warnock. Can you speak specifically to the impact 
of this for rural communities in your state? When I moved 
around Georgia, especially with the refusal to expand Medicaid, 
it seems to me that it is the rural communities that have been 
most hard hit by the politics of health care. Can you talk 
about the impact, particularly on rural communities?
    Dr. Ransone. Yes, sir. Living in a rural community, I have 
gotten many patients who were uncovered prior to the expansion 
of Medicaid. One patient in particular, his name was Sam, 
delayed coming to see me after he lost his job. He did not have 
Medicaid because his wife worked, and he delayed coming in to 
see me by approximately 9 to 10 months. By the time he came in, 
he was quite jaundiced or yellow in color, and we got him in. 
We got the services done under some--under some provisions of 
care for folks who were uninsured.
    But unfortunately, he ended up passing away from a 
cholangiocarcinoma, which is a cancer of the gallbladder and 
gallbladder duct. I think if we had been able to get him in 
sooner when he first had symptoms, we would have been able to 
save his life or at least ease a tremendous amount of suffering 
that he had near the end of his life. Medicaid expansion in our 
area has been incredibly important to get folks into our 
office. My wife, as I said, is a pediatrician. About 50 percent 
of her patients have Medicaid.
    I have probably doubled the number of Medicaid patients 
that I have been able to see in my office since we have had 
expansion, and it has enabled me to give them better care 
because they will actually come in when they first start seeing 
symptoms. Thank you.
    Senator Warnock. Thank you. So you see firsthand, given 
your position as President of the American Academy of Family 
Physicians, the ways in which this is an equity issue around 
health care. Generally, we have got Medicaid in 38 states. 
Imagine having Medicare in 38 States or Social Security in just 
38 states. But this issue around the digital divide is also an 
equity issue. About 1 in every 11 locations in Georgia lacks 
reliable broadband services, and 75 percent of these unserved 
locations are in rural areas.
    Commissioner Carr, we are working right now, and I was 
proud to join Chairman Lujan and others to champion increased 
broadband funding in the bipartisan infrastructure package. I 
hope the House will pass it soon. But even if that bill were 
signed into law today, it could take many years before some of 
these areas are served with high speed internet. Commissioner 
Carr, what are some short-term solutions that Congress, and the 
FCC can pursue to expand telehealth access in areas that 
currently lack broadband?
    Mr. Carr. Well, one thing we can do very quickly is we have 
about $326 million that is slated to come to Georgia as part of 
our RDOF initiative over 10 years. That could bring service to 
about 179,000. We need to accelerate the process of getting 
that money that Georgia broadband builders who won at the end 
of last year actually out the door. So, I think implementing 
the existing funds because there are billions and billions out 
there that we can put into the ground. I think that is 
important while the discussions go on about additional 
broadband funding.
    Senator Warnock. Thank you so much. Thank you, Chairman.
    Senator Lujan. Thank you, Senator Warnock. And again, 
Senator Rosen, thank you so very much. You are next.
    Senator Warnock. Thank you, Senator Rosen.

                STATEMENT OF HON. JACKY ROSEN, 
                    U.S. SENATOR FROM NEVADA

    Senator Rosen. Of course. Of course. Thank you both, the 
chairman--all the gentlemen for being here, women for being 
here, everyone, all the witnesses for being here today. It is a 
really important topic. Senator Peters, Senator Warnock, and 
others have talked about rural areas. I just want to add that 
in Nevada, 280,000 citizens of Nevada, my constituents that 
live in rural areas, barely 10 percent of our population.
    So it is really, really important to us. But I want to 
actually talk a little bit about provider shortages because 
earlier this year, Senator Murkowski and I introduced the 
bipartisan Improving Access to Health Care in Rural and 
Underserved Areas Act. It is going to bring specialists in 
person or through telemedicine like we are discussing today to 
health centers and rural clinics. So, Dr. Ransone, can you talk 
to me about how we can use telemedicine to leverage the 
providers that we have now, because we are facing severe 
provider shortages.
    And what can we do actually in conjunction with that, maybe 
having our EMTs, our mobile clinics, home visits by nurses, but 
there are shortage of providers everywhere we go, and we know 
we need to increase them. But how we can--how can we potentiate 
with other things we do in rural or remote underserved areas?
    Dr. Ransone. Well, Senator, I am a big believer in team 
based care. And I am a believer that the physician-led team 
based care consisting of nurse practitioners, physician 
assistants, potentially EMTs and so forth can greatly expand 
our access to patients in need. I have had telemedicine visits 
where I had a home health nurse in the home of one of my 
patients, where I could connect via a virtual video visit where 
the RN in that patient's home acted as my eyes and ears in 
looking at the patient.
    The reason we had to do that is because the patient was 
about an hour away and wasn't able to be transported. We don't 
have--in our rural environment, we have no public 
transportation. And they had no way to get to me, but I could 
get on the services to them. And that allowed me to take what I 
consider to be great care of that patient. And again, it was 
within our medical home. We could have people acting as our, 
again, our eyes and ears to help take care of that patient. One 
thing that--when you were speaking, it made me think, wouldn't 
it be a great thing--we know that physicians tend to settle 
within a certain radius of where they train.
    Wouldn't it be a great thing to be able to get young 
physicians, potentially rather than physicians out into rural 
and underserved areas where they are able to communicate with 
their attending physician via medicine, via telemedicine, so 
that they know in the area we can get them there before they 
have completed their training and potentially keep them in 
those underserved areas after they graduate.
    Senator Rosen. Yes. I couldn't agree more, and I agree with 
you on the team approach. We talk about connectivity or 
technological issues. Maybe people don't have an iPad, or they 
don't have the right technology to connect. This is where 
someone coming to their home can really help and get the 
services that they need. And speaking of other services we are 
talking about, so many of my colleagues, the access for mental 
health for our K-12 students. They really suffered so much 
during the pandemic with tele-education, trying to learn, 
missing their friends, all of that nationwide.
    We just know that there are in rural areas in particular, 
there is no licensed psychologist or there is such a shortage. 
94 percent of counties actually have no licensed psychologists. 
So, telemedicine again can help fill this provider gap.
    And so, what other things do you think, Dr. Arora, that--
what we can do about pediatric mental health care, access 
again, using this approach to get into people's homes somehow 
with maybe a provider on the other end of the line?
    Dr. Arora. Yes, Mr. Chairman, Senator Rosen, thank you for 
your question. Your State of Nevada, University of Nevada, Reno 
has done a tremendous amount of work with the Echo model to 
bring access to care to rural and underserved areas. They work 
in the area of opioid use disorder, medication assisted 
treatment, mental health, antimicrobial stewardship, and even 
in sports medicine. And I think that the problem you 
highlighted is one of the biggest problems of the health care 
system, the shortage.
    One potential way to ameliorate the problem, not completely 
solve it, is the idea of what we call task shifting. Dr. 
Ransone mentioned this briefly, but there are physician 
assistants, nurse practitioners, nurses. If they are mentored 
in a telementoring model in which all teach, all learn, we have 
demonstrated in hundreds of publications now that we can 
upskill them so that they can provide the care where patients 
live. Now this upskilling occurs in a method which we call 
``all teach, all learn,'' where these physician assistants and 
nurse practitioners learn from each other, they learn from 
experts at the university, and together discuss cases 
ultimately with the idea that they become experts in this 
situation.
    I will give you an example, out of this country in India, 
where the leading academic center in Punjab in India was 
treating 1,500 hepatitis C patients and they adopted the Echo 
model in every district hospital, and now have treated more 
than 90,000 patients with a cure rate of 93 percent just by 
upskilling and task shifting of the kind that you can do.
    Effective task shifting requires three things: a 
multidisciplinary team of experts, case-based learning, and 
mentor/mentee relationships. And with current expansion of 
broadband capacity that we are talking about here, we can 
achieve those objectives in this country. Thank you, Senator.
    Senator Rosen. Thank you. I really appreciate all the 
thoughtful answers today and look forward to working with you 
on positive solutions. Thank you.
    Senator Lujan. Thank you, Senator Rosen. Senator Klobuchar.

               STATEMENT OF HON. AMY KLOBUCHAR, 
                  U.S. SENATOR FROM MINNESOTA

    Senator Klobuchar. Well, very good. Thank you so much, 
Senator Lujan, for your leadership on this, as well as other 
issues related to getting information out to your constituents, 
the people in this country, and certainly telehealth. Our 
states may be a little different for temperature, Chairman, but 
we both have significant rural areas and know how important it 
is to get health care in innovative ways. And I also want to 
thank Senator Thune. He and I actually led a bill on telehealth 
before it was cool, like years ago when no one was talking.
    And part of that was we have major health care systems 
based in our states and one in South Dakota, obviously, Mayo in 
Sanford, Mayo in Minnesota, and they have wanted to reach rural 
areas and trying to figure out how best they do that. So, I 
think I will start out with you, Commissioner Carr. You 
testified highlighted in your testimony some of the challenges 
that rural communities face.
    What kind of investments, and you all know we just did, in 
the bipartisan infrastructure bill that we are very proud of 
that passed the Senate $65 billion when it came to broadband? 
And that is getting to these very areas that may not have an 
expert in a certain medical field next door, so it goes hand in 
hand. But do you want to talk about how important it is to get 
the broadband to make all the telehealth work?
    Mr. Carr. Yes. Thank you, Senator, for the question. You 
know, we do need billions and billions of dollars to finish the 
job of bridging the digital divide. And I think the most 
important challenge at the moment is implementation because we 
have a lot of dollars, for instance, already spread out across 
Department of Ag, Commerce, Education, Treasury.
    We have got to make sure we move in a coordinated way, so 
we are not putting money on top of other dollars, or wasting 
because this issue is just too important to quickly bridge the 
divide to not fully coordinate on this. I think that is going 
to be the biggest challenge is less so than the dollar amount 
right now, given the desire to invest in it, but is the 
implementation of those dollars.
    Senator Klobuchar. Good point. And I think part of this is 
mapping, as you know. And Senator Wicker, and we have talked 
about that. We actually had, in Minnesota, witness where we 
were commended for some of our mapping, but it is also about 
the accountability.
    You know, this issue where it goes out to a big telephone 
company, they don't actually build out. And one of the things I 
like about the bipartisan infrastructure bill is a lot of that 
is going to be focused out of Commerce with Secretary Raimondo. 
I had her in my--we had a long discussion about the claw backs 
and like if they are not actually doing it, that the money can 
be clawed back. And I think that accountability piece of it, it 
is going to be really important.
    And as you point out, Commissioner, there is also other 
funds and other things, but just getting it out there. Ms. 
Larson, the Universal Service Fund Rural Health Care Program 
funds modern telecom broadband services. In your view, how can 
the FCC work with Government partners and the private sector to 
coordinate the integration of telehealth?
    Ms. Larson. The USAC funds, as we have mentioned earlier, 
are very important to our rural geographies. And you are right, 
the local telecoms often don't have the circuit to build out. 
So how do we make sure that that circuitry is built and 
available to our rural communities. And ease of a collaborative 
application for USAC funding would be really well embraced by 
our rural communities.
    Senator Klobuchar. Very good. And the other question of you 
and then maybe Dr. Arora. The pandemic has shown about how we 
need to connect with family and friends. You know, we lost my 
dad this year, but during the pandemic, he was in assisted 
living, and that was one of the only ways of course, I could 
talk to him was through the internet. And we had some very 
interesting things with iPhones that they are trying to hold up 
with him. He had Alzheimer, so you can imagine suddenly this 
voice is coming on the thing.
    And it did make me think about how having a, you know, some 
of these facilities, getting them or making sure they have the 
screens in the way you can do this for people to be seeing 
their loved ones in a bigger way. And that is why Senator 
Capito, and I introduced the Access Act to expand telehealth 
support for seniors for virtual visits. Of course, it was 
pandemic based.
    But really, the same thing applies for out-of-town 
relatives and all kinds of things you would like to use it for. 
Ms. Larson, in your view, how will sustained telehealth, 
sustained, coupled with in-person care, bolster health services 
for elderly communities?
    Ms. Larson. You know, it is very important to understand 
that our telehealth can be the end of the clinical service 
requirement, and intervention can be ordered, and implemented 
via the phone or video, and, or it can be noted--you can note 
that this individual needs to come into a clinic visit face to 
face, maybe for an advanced tele--or non-telehealth, an 
advanced in-person visit. What is really important about that 
is that you need both to really get early access to the 
individual.
    And our seniors, again, with mobility issues and just not--
you know, we have understood that being home and sequestered a 
bit, not being exposed to viruses or other situations, and they 
really are more comfortable in their home. Can we retain the 
telehealth visit in the home where they are comfortable, they 
are accessible and then only bring them out of their 
comfortable environments into clinic environments as needed?
    Senator Klobuchar. Very good. Dr. Arora, you want to 
quickly add anything?
    Dr. Arora. Sure. Mr. Chairman, Senator Klobuchar, your 
state has been a leader in the telementoring Echo platform out 
of the University of Minnesota----
    Senator Klobuchar. I know there was a reason I ended with 
you, Dr. Arora. Now, continue on. Yes.
    [Laughter.]
    Dr. Arora. Thank you. Mayo Clinic, Hennepin Healthcare, 
Catholic Health Initiative St. Gabriel, they have used Echo for 
opioid addiction, viral hepatitis. And the Nursing Home Echo 
Project was amazing in that they, Hennepin Health System, 
mentored nursing homes in the entire State of Minnesota so that 
patients could get the best possible care there. But the 
challenge again, Senator Klobuchar, is the same.
    All these institutions are working either in philanthropy 
or, in this case, the Nursing Home Project, a Federal contract 
that we got from AHRQ, which we passed on to Minnesota. But 
there is no long term, sustainable way to support these 
institutions, to democratize their expertise so that every 
citizen of Minnesota can get the care they need, because every 
provider, nurse, doctor, community health worker is mentored 
with the best care, best knowledge. Thank you.
    Senator Klobuchar. Yes. Thank you. And I would note we have 
one of the lower death rates for seniors from COVID, and I 
think a lot of this was a coordination. And Dr. Ransone, I will 
put a question on the record. Thank you for your good work. 
Thank you.
    Senator Lujan. Thank you so much, Senator Klobuchar. 
Commissioner Carr, I wanted to follow up on a line of 
questioning from Senator Wicker. Is the Connected Care Pilot 
Program established by law or regulation?
    Mr. Carr. Connected Care looks to our general Universal 
Service Authority and then we stood up a rulemaking procedure 
to stand it up, and then applications come in. And so, at that 
point, it is a blend of adjudication, rulemaking, but it is a 
regulatory program we stood up pursuant to the Telecom Act.
    Senator Lujan. And did the FCC under Chairman Pai increase 
the Universal Service Fund contribution factor to collect the 
additional $100 million to support the Connected Care Pilot 
Program?
    Mr. Carr. The $100 million comes out of the General 
Universal Service Fund, yes.
    Senator Lujan. And do you believe that the Rural Health 
Care Program established by law has adequate funding?
    Mr. Carr. Yes and no. No, we have hit the cap in years 
before. We added some additional funding to it. We also allowed 
the rollover of funds to address it, but without getting into 
the weeds of it, the answer is we need to devote more resources 
to this to make sure we have the sufficient, predictable level 
of support needed. And if that is more money than it is more 
money, because that is what the statute requires.
    Senator Lujan. And while you have spoken out publicly with 
the next question and responded to Senator Wicker here as well, 
I still think it is important to hear from you on this in the 
hearing. How should the contribution factor be reformed to 
ensure that all programs under the Universal Service Fund have 
adequate resources?
    Mr. Carr. I think there is a couple of ways to do it. What 
we do now is we assess a 30 percent charge roughly on the 
telephone portion of consumers' bills, not the Internet 
portion. Some people have said we should just shift that charge 
over to the Internet bill, which would effectively increase the 
price of Internet at a point in time when we are all very 
focused on the affordability challenges. The idea that I have 
thrown out that is also reflected in that legislation is we 
should look to some set of large technology companies to begin 
to contribute into that fund to help stabilize it.
    One way you could do it in a sort of targeted way is 
looking at digital advertising services revenues, which is an 
over $100 billion a year in revenues. So, you could eliminate 
that 30 percent charge from customers' bill and replace it with 
a single digit percent charge on the digital advertising 
revenues, and it is much more difficult charge when placed 
there for it to actually find its way back into hitting a 
consumer directly.
    Senator Lujan. I just wanted to thank you for raising this. 
I want to recognize the Chair and Ranking Member Wicker for the 
work he has done in this space, and it is something I certainly 
agree with. What we have heard today are many ideas that have 
strong bipartisan support. The affordability piece here is one 
that is going to be critically important. Chair Cantwell 
reminded us 90 million people across America today don't have a 
connection because they can't afford it. That is why the 
emergency broadband benefit mattered. It is why the inclusion 
of affordability in the bipartisan infrastructure bill matters. 
But we have got to fix this other one.
    And I don't believe people should be paying that surcharge 
for long distance calls. I don't think people should be paying 
for long distance calls. I am often at my mother's home and I 
have shared this with several, and I was going to call a family 
member that lives out of state, and she picks up her landline. 
So, you know, mom, use your mobile and she, oh yes, you know. 
It turns out it doesn't cost you anything extra to use your 
mobile device if you have a connection. It is an old revenue 
stream.
    And when we can modernize in a bipartisan way to make 
affordability real and support the other programs in a way that 
does not directly hit the consumer but goes after the 
advertising funding that it turns out those companies benefit 
from, then more people are connected. It is in their interest. 
So, I am hopeful that we can find a strong bipartisan approach 
in that particular area.
    There are some other questions that I have today, but I 
will submit them into the record. And oh, very good. Well, 
before we closed the hearing, I want to recognize one of our 
colleagues who joined as well. And I will turn this over to 
Senator Young.

                 STATEMENT OF HON. TODD YOUNG, 
                   U.S. SENATOR FROM INDIANA

    Senator Young. Well, thank you so much. I appreciate that, 
and I think----
    [Technical problems.]
    Senator Lujan. Senator Young, we may have a bad connection 
there. We are going to check with your office. One second, sir.
    Senator Young. OK. OK, thank you.
    Mr. Carr. I see that the FCC still has work to do.
    Senator Lujan. It appears that we have a better connection. 
Senator Young, you are recognize.
    [Technical problems.]
    Senator Lujan. It appears that we do have a bad connection 
with Senator Young right now. I don't know that we will be able 
to get him back on. I will ask one follow up here as we go, and 
we will see if we get Senator Young back. If not, we will close 
out the hearing.
    The other questions that I had, were along the lines of, 
because of the conversation we have had today and the data that 
we know from care that constituents patients are receiving 
across America, benefiting from telemedicine--now, whether it 
is a patient to their provider or it is provider to provider, 
telelementary services, there is data caps out there as well.
    And there needs to be a real conversation about data caps, 
so I think it is an old technology, it is an old revenue 
stream, but nonetheless, especially when it comes to 
telehealth, people should not be timed out when they are 
accessing care, especially what we have learned from veterans. 
The VA took this on and there were some benefits that we saw 
because of it.
    So rather than asking those questions in this hearing, I 
want to have a follow up conversation about this and see if 
there is a way that we can get some bipartisan support in 
looking at this as we are modernizing, especially with the 
investment across America. One last check for any of our other 
colleagues. We are trying. Well, very good Senator Young. You 
are recognized, sir.
    Senator Young. Alright. Thank you, Chairman. I really 
appreciate it and it is good to be with our panelists. And I 
would like to ask a question of Commissioner Carr. 
Incidentally, it is good to see you again, Commissioner. So, my 
question, I will lead into it by laying the groundwork about 
Indiana and our maternal mortality rate. So unfortunately, our 
State has one of the worst maternal mortality rates in the 
country, although it has improved somewhat in recent years. 
Hoosiers aren't alone in facing maternal health issues.
    According to the CDC, severe maternal morbidity impacted 
more than 50,000 women in the United States in 2014, and the 
rate of severe maternal morbidity increased nearly 200 percent 
from 1993 to 2014. Now this is a trend you would expect to hear 
about in a Third World country, and it is one that we have to 
reverse here in the U.S. So earlier this year, I have worked 
with some of my colleagues on both sides of the aisle, Senators 
Rosen and Fischer and Schatz and myself introduced the Data 
Mapping to Save Moms Lives Act. This was swiftly reported out 
of the Commerce committee.
    Our legislation would utilize data mapping to show where 
high rates of poor maternal health outcomes overlap with lack 
of access to broadband services. And the objective here is to 
help identify where improved access to telehealth services can 
be most effective. The 2020 annual report from the Indiana 
Maternal Mortality Review Committee specifically identifies 
increased access to pre- and post-partum medical and social 
work telehealth services as a recommendation to prevent 
maternal mortality.
    So Commissioner Carr, with that lead in, what steps do you 
believe we must take to increase access to telehealth services 
to address maternal health and other important health care 
issues?
    Mr. Carr. Well, thank you, Senator, for your leadership on 
this. I think your legislation would go a long way toward that. 
And I think as contemplated by the bill, we could include that 
in these maps that the FCC is working on right now. And to your 
point, that would help us to direct resources in the right 
direction to make sure we provide connectivity.
    I have visited a health care clinic in Virginia that 
addressed some of these issues and would send expectant mothers 
home with a connected blood pressure monitors and other 
devices, and they saw significant benefit. So, if we get 
connectivity and allow these telehealth services to be funded 
to provide it to these moms to be, we can literally save lives 
as your legislation lays out.
    Senator Young. Well, that is what myself and some of my 
colleagues who have helped champion this effort believe, and I 
am encouraged to hear you say that. Commissioner, how close, 
and you may have covered this earlier, but how close is the FCC 
to producing these new, more granular maps as directed by the 
Broadband Data Act?
    Mr. Carr. I don't know, Senator. I think that is a problem. 
It is--as indicated earlier, it is a bit of a black box. We 
have got the funding from Congress, I believe at the end of 
last year. In March of this year, I said the FCC should set the 
goal of finishing those maps at least targeted versions this 
fall. I don't expect it is going to happen this year.
    Obviously, there are a lot of people the FCC that are 
working very hard on this, but we have to get those maps done. 
If it means paring back what is included in the first version, 
then we should do that, but we have to get targeted maps out. 
It is the key to unlocking that additional funding from RDOF 
II, which is key to getting the 5G fund going, and is key to 
making sure as we have these billions of dollars across 
agencies that that funding can go through these completed maps 
so that we don't have overbuilding.
    But unless those maps are done, we are going have to hold 
back some of those billions of dollars that other agencies 
have, or it is going to go out there and uncoordinated manner.
    Senator Young. Well, I hope you will let myself and other 
members of the Committee know if there is anything we can do to 
expedite the process. Commissioner Carr, once again last time 
we dialoged within the committee, the FCC had just recently set 
up your $100 million Connected Care Pilot Telehealth Program. 
Can you provide us just a brief update on the program and 
lessons learned or notable takeaways thus far?
    Mr. Carr. I think the most surprising thing has been the 
uptake in telehealth generally, particularly with COVID-19. It 
has been less of a user issue, less of a technical issue, and I 
think what have been holding things back were regulatory and 
legal barriers and to some extent funding. And so, I think 
these programs are making a big difference.
    So far, Indiana has received about $6.7 million in 
telehealth funding, not from the Connected Care Pilot yet, but 
from the emergency COVID-19 programs. And so, I am very excited 
to see the data come in that I am confident is going to show 
improved health outcomes.
    Senator Young. I believe that will be the case as well. So, 
thank you so much. Back to you, Chairman.
    Senator Lujan. Senator Young, thank you so very much for 
being a part of this important hearing today. Dr. Ransone, Ms. 
Larson, Commissioner Carr, and Dr. Arora, thank you for being 
here today. And your testimony helped illustrate how the 
digital divide is standing in the way of connecting all 
Americans to essential telemedicine, remote health monitoring, 
and telementoring. Now we have a lot of work to do.
    Rural, Native American, Hispanic communities, whether you 
are living in big cities or in the most rural parts of our 
country, so many people are effectively cutoff from many of the 
benefits of telehealth. And we all understand the urgency and 
the importance of connecting every American to high quality, 
affordable, resilient, fast broadband. Without it, the current 
patterns of inequality will continue to grow, and we urgently 
need to deliver this relief to communities across the country.
    Families must be able to talk to their doctors without 
worrying about hitting a data gap or getting cutoff, so there 
are many other challenges we have to solve. In the end, 
critical remote monitoring systems must remain online during 
network outages, bad weather, and natural disasters. And under 
the leadership of Acting Chairwoman Rosenworcel, the Federal 
Communications Commission has been able to make progress here, 
even with a two, two Commission.
    Now, imagine the progress that the FCC can make if there 
were five members. It is simply unacceptable and inexcusable 
that there is no urgency from this Administration to nominate a 
fifth Commissioner. And I would say nominate Acting Chairwoman 
Rosenworcel, not just for another term, but to be the full 
chair of the Commission. I don't understand why this has not 
happened. I just want to close with this.
    I want to urge President Biden to renominate Acting 
Chairwoman Rosenworcel to nominate a fifth FCC Commissioner and 
a permanent head of NTIA. We have heard from many Senators 
today about the importance and the urgency to get these dollars 
into communities, expand capacity with telemedicine. The 
funding that was made available through spectrum auctions to 
get this back into communities, $1 billion that was 
appropriated to NTIA in the previous Congress for Native 
American connectivity, CARES Act, American Rescue Fund, the 
bipartisan infrastructure.
    If we are going to get this right, we need all of these 
positions filled and we are running out of time. If there is 
not urgency in appointing a fifth FCC Commissioner, 
renominating Commissioner Rosenworcel, there is going to be 
three FCC Commissioners instead of five in January. It is 
unacceptable. We all have to work to expand these programs, but 
we need these positions filled. These are priorities I have 
long advocated for, and I am going to continue to raise my 
voice in that fight.
    Now, the hearing record will remain open for two weeks 
until Thursday, October 21, 2021. Any Senators that would like 
to submit questions for the record for the witnesses should do 
so by that date. We ask that your responses be returned to the 
Committee by November 4, 2021. That concludes today's hearing.
    [Whereupon, at 12:23 p.m., the hearing was adjourned.]

                            A P P E N D I X

          Prepared Statement from Alliance for Connected Care
    The Alliance for Connected Care appreciates the opportunity to 
submit testimony for this hearing examining the importance of access to 
telehealth services, and the role that broadband plays in the public 
health response.
    The Alliance for Connected Care (the Alliance) is an advocacy 
organization dedicated to facilitating the delivery of high-quality 
care using connected care technology. Our members are leading health 
care and technology companies from across the health care spectrum, 
representing insurers, health systems, and technology innovators. Our 
Advisory Board includes more than 30 patient and provider groups, 
including many types of clinician specialty and patient advocacy groups 
who wish to better utilize the opportunities created by telehealth.
    We believe telehealth has the potential to broaden access to care 
and improve patient engagement, and we agree it demands thoughtful 
consideration to ensure all Americans are provided equal and equitable 
access. As highlighted by the COVID-19 pandemic, access and 
affordability of broadband is an important aspect to accessing health 
care services, including telehealth services.
    Broadband is essential to expanding access to telehealth. Without 
it, we will never reach populations who need access to behavioral 
health, primary care, specialty consults and more. We must invest in 
broadband alongside changing coverage policy for telehealth.
    The inequities in broadband access across geography, race, and 
income are clear. According to a 2021 Pew Research Center survey, home 
broadband use varies significantly across demographic groups, including 
race and income levels. Nearly all Americans with annual household 
incomes above $75,000 reported having a broadband connection at home, 
compared to just half of households making less than $30,000 a year. 
Similar stark contrasts can be seen between races and geography, with 
80 percent of Whites having access, compared to just 70 percent and 65 
percent of Blacks and Hispanics, respectively. Additionally, more than 
35 million rural Americans lack access to broadband.
    In January, the Federal Communications Commission (FCC) released 
their fourteenth annual Broadband Deployment Report finding progress in 
closing the digital divide. For example, the gap between urban and 
rural Americans with access to high-speed broadband service has been 
nearly halved, falling from 30 percentage points at the end of 2016 to 
just 16 points at the end of 2019. Despite significant progress being 
made, tens of millions of Americans do not have access to broadband. 
Estimates range from roughly 14.5 million to 42 million Americans in 
total, with the lowest coverage levels experienced in Tribal and rural 
areas.
    Below we summarize recommendations designed to support and maintain 
both patient and provider availability and affordability of broadband:

   Congress should invest in efforts that support broadband 
        affordability for patients and providers.

   Congress must continue to coordinate with other Federal 
        agencies to ensure improvements are being made to our taxpayer-
        funded programs, and that all patients deserving of these 
        benefits are being afforded access.

   Congress must make permanent the Emergency Broadband Benefit 
        program.

   Congress must continue to address anticompetitive behaviors 
        in all industries, and explore solutions that support patients.

   Congress should invest in efforts that support the 
        deployment of broadband for all Americans, including those 
        living in rural areas, on Tribal lands and to our Nation's 
        health care providers and centers.

   Congress must maintain access to audio-only services for 
        patients who, in the interim, continue to lack broadband access 
        and/or affordability.

   Congress should pass the Data Mapping to Save Moms' Live Act 
        (S. 198/H.R. 1218) in the 2022 Consolidated Appropriations 
        package.

   Congress should consider addressing antiquated licensure 
        requirements that impeded access to care to address gaps in the 
        delivery system and provide high-value care directly to 
        consumers in rural or underserved areas.

1. Congress should invest in efforts that support broadband 
        affordability and use for patients and providers.
    For digital health technologies to truly transform the way 
Americans obtain and receive access to health care services, we must 
address affordability and usability of the technology supporting that 
access.
    Telehealth has been a critical lifeline during the pandemic and 
public health emergency flexibilities have resulted in drastic 
increases in telemedicine utilization, introducing millions of 
Americans to a new way to access health care. Data from the Centers for 
Disease Control and Prevention (CDC) finds that during the period of 
June 26--November 6, 2020, 30.2 percent of weekly health center visits 
occurred via telehealth. In addition, preliminary data from the Centers 
for Medicare & Medicaid Services (CMS) show that between mid-March and 
mid-October 2020, over 24.5 million out of 63 million beneficiaries and 
enrollees received a Medicare telemedicine service. Finally, an HHS 
Office of the Assistant Secretary for Planning and Evaluation (ASPE) 
Medicare fee-for-service (FFS) telehealth report found that from mid-
March through early July, more than 10.1 million traditional Medicare 
beneficiaries used telehealth, including nearly 50 percent of primary 
care visits conducted via telehealth in April versus less than 1 
percent before the COVID-19 pandemic.
    Despite all of these advancements in telehealth usage, many 
households lack the ability to benefit from these digital services. 
This is partly due to the United States having one of the highest 
broadband prices among OECD countries.
Congress must continue to coordinate with other Federal agencies to 
        ensure improvements are being made to our taxpayer-funded 
        programs, and that all patients deserving of these benefits are 
        being afforded access.
   FCC's Lifeline program helps low-income consumers afford the 
        high cost of telecommunications services, including phone and 
        broadband. The program has helped millions of Americans connect 
        with the internet. However, as the COVID-19 pandemic took full 
        force and much of our in-person services were shutdown, 
        challenges and shortcomings of the program came to light.

   In April of 2020, Senators Klobuchar (D-MN) and Durbin (D-
        IL) and Representatives Fudge (D-OH) and Eshoo (D-CA), along 
        with 140 colleagues in both the House and Senate, urged the FCC 
        Chair at the time to ensure that the millions of Americans 
        eligible for the Lifeline Program are informed of their 
        eligibility status. ``The Lifeline program provides critical 
        connectivity for those who need it most. Informing consumers 
        about their Lifeline eligibility is a necessary step to help 
        close the digital divide and is clearly something we should 
        continue doing even after the pandemic ends,'' the members 
        wrote.

   Congress must continue to coordinate with other Federal 
        agencies to ensure improvements are being made to our taxpayer-
        funded programs, and that all patients deserving of these 
        benefits are being afforded access.
Congress must make permanent the Emergency Broadband Benefit program.
   The Alliance for Connected Care supported efforts to 
        establish the Emergency Broadband Benefit, a program that 
        bolsters access to broadband Internet services for low-income 
        and minority individuals. Passed in the Consolidated 
        Appropriations Act of 2021, Congress appropriated $3.2 billion 
        to the FCC to help low-income households pay for broadband 
        service and connected Internet devices.

   The Emergency Broadband Benefit program has proven to be a 
        successful entry point for tackling some of the inequities that 
        exist in access to broadband and Internet services. In 
        September, FCC Acting Chair Rosenworcel announced that the FCC 
        has enrolled over six million low-income households into the 
        country's largest broadband affordability program. 
        Additionally, nearly 1,200 broadband providers have agreed to 
        take part in the program.

   Congress must make permanent the Emergency Broadband Benefit 
        program. Without a permanent, government-funded structure for 
        this program, funds will expire and Americans will lose access 
        to this vital program. Similar programs like the Supplemental 
        Nutrition Assistance Program (SNAP) and other Federal programs 
        have proven to be effective models to deliver assistance. The 
        Emergency Broadband Benefit program should be treated the same.
Congress must continue to address anticompetitive behaviors in all 
        industries, and explore solutions that support patients.
   A provision later omitted from President Biden's 
        infrastructure plan would have promoted price transparency and 
        competition among Internet providers, including by lifting 
        barriers that prevent competition, and requiring Internet 
        providers to clearly disclose the prices they charge.

   Similarly, the Alliance for Connected Care supported the 
        Community Broadband Act, which would prohibit banning or 
        limiting the ability of any state, regional, or local 
        governments to build broadband networks and provide Internet 
        services.

   According to a 2020 Institute for Local Self-Reliance report 
        which analyzed data from the FCC, more than 20 million 
        Americans live in broadband monopolies, whereby they have 
        access to only one broadband provider. Another roughly 100 
        million Americans live in areas with access to only two 
        broadband service providers.

   A lack of affordable broadband is a significant barrier to 
        not only virtual health care access, but also other important 
        social determinants of health such as education and employment 
        opportunities. Congress must ensure that Americans are not at 
        the detriment of corporate business, and that access to these 
        services takes precedent over corporate interests.
2. Congress should invest in efforts that support the deployment of 
        broadband for all Americans, including those living in rural 
        areas, on Tribal lands and to our Nation's schools and health 
        care providers.
Congress should expand and extend the FCC's COVID-19 Telehealth Program 
        and Connected Care Pilot Program
   The Alliance for Connected Care has been supportive of 
        calling for additional FCC funding to help health care 
        providers and others provide telemedicine. In June, 
        Representatives Spanberger (D-VA), co-leads Johnson (R-SD), 
        Matsui (D-CA) and Curtis (R-UT)--plus 31 bipartisan members of 
        Congress--sent a letter to House and Senate leaders emphasizing 
        the demand in their districts for reliable telehealth services 
        during the COVID-19 pandemic and the need to strengthen the 
        FCC's COVID-19 Telehealth Program.

   We applaud Congress' and the FTC's continued efforts to 
        close the digital divide and ensure health care providers have 
        the appropriate tools to take care of their patients in an 
        ever-evolving virtual world. The COVID-19 Telehealth Program 
        and Connected Care Pilot Program have remarkably increased 
        telehealth adoption among health care providers and health 
        centers serving those in need. Health care providers in each 
        state, territory, and the District of Columbia have received 
        funding.

   The Alliance for Connected Care urges FCC to extend these 
        programs, and for Congress to appropriate additional funding to 
        support such efforts.
Congress must continue coverage for audio-only services beyond the 
        COVID-19 public health emergency.
   Our nation has only just begun to make strides recognizing 
        and addressing broadband inequities. As we continue to reach 
        for 100 percent broadband coverage for all, Congress must 
        recognize and support policies that maintain coverage and 
        access where broadband is lacking.

   The Alliance believes that audio-only telehealth has been a 
        critical tool for many clinicians and patients during COVID-19, 
        especially when considering providing equitable access to care 
        for patients facing broadband, affordability and other 
        barriers. While we believe that audio-video communication is 
        the preferred modality for most telehealth, we strongly support 
        continued flexibility for audio-only--when clinically 
        appropriate and when meeting the need or request of the 
        patient.

   Congress must maintain access to audio-only services for 
        patients who in the interim continue to lack broadband access 
        and/or affordability.
Congress should pass the Data Mapping to Save Moms' Lives Act
   The Data Mapping to Save Moms' Lives Act (S. 198/H.R. 1218) 
        would use data mapping to identify areas of the country where 
        poor maternal health rates overlap with a lack of broadband 
        access, to better deploy telehealth services there.

   The United States is one of the only countries in the 
        developed world with a rising maternal mortality rate. The 
        problem is especially prevalent in rural communities and 
        amongst women of color who continue to experience 
        disproportionately high rates of maternal and infant mortality.

   This bill will give our Nation one more tool to combat the 
        devastating rising maternal mortality rate in this country. We 
        urge Congress to pass the Data Mapping to Save Moms' Lives Act 
        in future legislation, including considering inclusion of the 
        bill in the year-end appropriations package.
Congress should consider policies that drive greater flexibility for 
        clinicians to provide care across state lines.
   State lines create artificial barriers to the delivery of 
        care--complicating access for patients and creating additional 
        burden on clinicians. These lines sometimes split major urban 
        areas and hamper the ability of telemedicine providers to fill 
        in gaps in the delivery system and provide high-value care 
        directly to consumers in rural or underserved areas.

   Current efforts to expand interstate licensure have been 
        insufficient to meet the needs of patients and the clinicians 
        seeking to better serve them. One of the most effective 
        utilizers of telehealth networks to support the delivery of 
        care across state lines, the U.S. Department of Veterans 
        Affairs, supported 900,000 veterans though telemedicine visits 
        in Fiscal Year 2019--a majority of which were for mental health 
        care. The program demonstrated growth of 17 percent over the 
        prior Fiscal Year.

   As our entire ecosystem works to address inequities, we urge 
        Congress to consider addressing antiquated licensure laws that 
        impeded access to care, and the value of cross-state care in 
        providing greater access to health care and specialty medicine, 
        addressing provider shortages in rural and medically 
        underserved communities, improving follow-up and continuity of 
        care, and providing patients with more choice in the providers 
        they wish to see.

    Thank you for your consideration. We look forward to working with 
you on this important effort. Please contact Crystal Wallace at 301-
742-5240 or crystal
[email protected] with any questions.
            Sincerely,
                                             Krista Drobac,
                                                Executive Director,
                                           Alliance for Connected Care.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Ben Ray Lujan to 
                          Dr. Sterling Ransone
    As you stated, there is a clear link between digital equity and 
health equity. It's critical we support all providers providing the 
best care for their patients.

    Question 1. What can the FCC do to ensure better telehealth 
access--particularly among independent physician practices?
    Answer. FCC programs such as the COVID-19 Telehealth Program and 
Connected Care Pilot Program have increased telehealth adoption among 
community health centers and hospitals serving communities most in 
need. The COVID-19 Telehealth Program has also helped ensure patients 
have the connected devices they need to benefit from comprehensive 
telehealth and remote monitoring services. Unfortunately, these have 
largely excluded primary care practices, for which the startup and 
ongoing costs of telehealth impede adoption.
    For many small physician practices, especially those that serve a 
disproportionate number of Medicaid and uninsured patients, the costs 
of telehealth technology can be prohibitive. Many telemedicine vendor 
solutions charge setup fees ranging from $400 to $3,000 dollars, in 
addition to recurring subscription or transaction fees. Congress should 
ensure that small practices are adequately supported, either by making 
them eligible for funding through existing telehealth programs or by 
creating a new program. Supporting telehealth adoption within these 
practices will improve equitable and timely access health care and 
promote health care competition by enabling smaller practices to remain 
independent.
    The AAFP also supports the Connected Care Pilot Program's focus on 
improving equitable access to quality telehealth services for low-
income patients by addressing the high cost of broadband connectivity, 
including equipment and information services, and urges the FCC to 
extend and expand this program.
    Lastly, the FCC's Lifeline Program has been critical in helping 
low-income Americans access broadband; however, it is used almost 
exclusively for mobile, rather than in-home, broadband services. Mobile 
services have significant value, but broadband at home creates 
additional public benefits--including the ability to connect with your 
physician via telehealth. Additionally, mobile or wireless broadband 
connections may not have sufficient bandwidth depending on the 
telehealth platform. We urge Congress to expand and reform the Lifeline 
Program so it can also provide broadband access in homes and in turn 
expand access to all telehealth services.

    Question 2. How can digital health navigators break down barriers 
to ensure telehealth is reaching everyone who needs it?
    Answer. AAFP members have shared the challenges that their patients 
have faced during the COVID-19 pandemic in accessing telehealth 
services and their patient portals, including not having access to 
technology such as a smartphone, tablet or computer and not 
understanding how to navigate the technology or specific digital health 
platform. In my practice, many seniors have struggled to access these 
tools unless they have younger family members to help them log on or 
troubleshoot technology issues.
    To achieve the full promise of telehealth, Congress must act to 
address these structural barriers to virtual care. The AAFP has called 
for the creation of a pilot program to fund digital health navigators; 
develop digital health literacy programs; and deploy digital health 
tools that provide interpretive services at the point of care. These 
should be available in non-English languages, easily and securely 
integrate with third-party applications, and include assistive 
technology. Such a pilot should include robust evaluation and metrics 
to demonstrate how the interventions have addressed gaps in care or 
increased the access for underserved populations.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Amy Klobuchar to 
                          Dr. Sterling Ransone
    Supporting Small Physician Practices. Broadband connectivity is 
essential for telehealth. But in rural areas of my state, about 16 
percent of households lack access to broadband at baseline speeds. That 
means 144,000 Minnesota households don't have adequate access to the 
internet.

    Question 1. In your testimony, you note that we should be 
implementing Federal telehealth programs to support small physician 
practices. In your view, what can Congress do to better support local, 
rural providers?
    Answer. For many small physician practices, especially those that 
serve a disproportionate number of Medicaid, uninsured, and 
disadvantaged patients, the costs of telehealth technology can be 
prohibitive. Many telemedicine vendor solutions charge setup fees 
ranging from $400 to $3,000 dollars, in addition to recurring 
subscription or transaction fees. Congress should ensure that small 
practices are adequately supported, either by making them eligible for 
funding through existing telehealth programs or by creating a new 
program. Supporting telehealth adoption within these practices will 
improve equitable and timely access health care and promote health care 
competition by enabling smaller practices to remain independent.
    While many of these practices have adopted telehealth due to the 
pandemic, the AAFP saw adoption rise from 13 percent before the 
pandemic to 94 percent during the pandemic, they have done so in ways 
which are hard to sustain and to support a robust digital experience 
for their patients. Additionally, the scope of services that are and 
can be delivered with sustained payment reforms has grown 
significantly. These practices need training and support to transition 
from telehealth during a pandemic to sustained long-term telehealth 
delivery. Funded by the Health Resources and Services Administration 
(HRSA), Telehealth Resource Centers across the Nation provide practices 
with information and support around telehealth. Such Federal programs 
should be continued and expanded to help rural areas sustain and grow 
telehealth in their communities.
    As this Committee is acutely aware, our Nation has a long way to go 
before all Americans have high-speed broadband along with the tools and 
knowledge to leverage it for virtual video health care visits. Further, 
there may be times that an old-fashioned phone call is the best way for 
a clinician to treat a patient. From my own experience in a rural 
community, and talking with other family physicians, I can tell you 
that the reasons for this are lack of reliable, high-speed Internet 
connection; patients' inability to navigate complex technology required 
for video visits; and the challenge for physicians of adopting or 
perfecting a video-visit platform. Therefore, it is critical to 
preserve access to audio-only telehealth services provided by a 
patient's usual source of care.

    Rural Telehealth Funding. During the pandemic, we have worked to 
bolster the telehealth system across the country. The Federal 
Communications Commission (FCC) has awarded local health care providers 
in Minnesota nearly $2 million to expand telehealth services to 
increase access to care and services during the COVID-19 pandemic.

    Question 2. In your testimony, you highlight that telehealth can 
improve the quality and comprehensiveness of patient care. What should 
we do to capitalize on investments the Federal government is making in 
telehealth to advance care in the post-pandemic environment?
    Answer. Broadband access must be recognized as a social determinant 
of health. The COVID-19 pandemic has underscored the strong link 
between digital equity and health equity. Having access to broadband, 
especially in times of pandemic and disaster, is vital for connecting 
people to the most basic necessities, such as health care, education, 
and employment. To realize the potential of telehealth and address 
health disparities, Congress must invest in efforts to ensure universal 
access to affordable broadband services for individuals and health care 
providers.
    Telehealth benefit expansions must promote high-quality, 
comprehensive, continuous care and increase access to those services. 
Telehealth, when implemented thoughtfully, can improve the quality and 
comprehensiveness of patient care and expand access to that care for 
under-resourced communities and vulnerable populations. As outlined in 
our Joint Principles for Telehealth Policy, in partnership with the 
American Academy of Pediatrics and the American College of Physicians, 
the AAFP strongly believes that the permanent expansion of telehealth 
services should be done in a way that advances care continuity and the 
patient-physician relationship. Telehealth should also enable higher-
quality, more personalized care by making services more convenient and 
accessible for patients.
    Coverage and payment policies should support both patients' and 
clinicians' ability to choose the most appropriate modality of care 
(i.e., audio-video, audio-only or in-person) and ensure appropriate 
payment for care provided. Some patients and some cases are better 
suited to virtual care, and others require in-person care; some issues 
can be effectively treated through a phone call, whereas others require 
a visual or tactile examination. No two patients or cases are alike, 
and family physicians should be able to choose how to best care for 
them based on clinical judgement, not based on arbitrary insurance 
rules.
    While telehealth can expand the reach of some primary care services 
by making it more convenient and accessible to patients in their homes 
or offices, it is clear that virtual-only providers cannot offer fully 
comprehensive primary care. This underscores the importance of Federal 
policymakers supporting physician practices in adopting and sustaining 
telehealth so that we can offer our patients both in-person and virtual 
care as part of the patient's medical home. As Congress seeks 
additional studies to inform the direction of permanent telehealth 
policies and additional broadband investments, you should encourage the 
collection and reporting of data stratified by race, ethnicity, gender 
identity, language, and other key factors to help ensure health equity.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Kyrsten Sinema to 
                          Dr. Sterling Ransone
    Infrastructure Investment and Jobs Act. The bipartisan 
Infrastructure Investment and Jobs Act includes $65 billion for 
broadband deployment, rural and tribal broadband, digital equity, and 
affordability in Arizona and throughout the country.

    Question 1. How will this historic investment in broadband enable 
more Arizonans to access telehealth services, including Arizonans in 
rural and tribal areas?
    Answer. Full success of telehealth cannot be achieved without 
significantly improving our Nation's broadband infrastructure. The 
ongoing pandemic has highlighted the utility and importance of 
broadband for access to primary care, mental and behavioral health 
care, education, remote work, applications for support programs, and 
public health information. The $65 billion investment for broadband in 
the bipartisan infrastructure bill, which the AAFP supports, is a 
significant step to enable equitable telehealth access and 
utilization--particularly for rural and underserved communities.

    Medicare Coverage of Telehealth Services. Congress expanded the 
ability of Medicare of cover telehealth services in the midst of the 
COVID-19 pandemic. I have joined my colleagues from both parties to 
support legislation, the Creating Opportunities Now for Necessary and 
Effective Care Technologies (CONNECT) for Health Act of 2021, that 
would make Medicare coverage of many telehealth services permanent.

    Question 2. How would the CONNECT for Health Act enable more 
Arizonans to access health care services?
    Answer. The AAFP has not taken a position on the CONNECT for Health 
Act but it includes several provisions we support such as expanding the 
definition of originating site to include the home, permanently 
removing all geographic restrictions on telehealth services within the 
medical home, and permanently adding federally qualified health centers 
and rural health clinics as eligible distant site providers. These 
changes would help ensure physicians and patients can continue to use 
telehealth services beyond the pandemic and help to standardize 
coverage and payment of telehealth services across payers.

    Question 3. What would happen if telehealth services currently 
eligible for Medicare coverage were no longer covered by Medicare?
    Answer. In response to the pandemic, family physicians across the 
Nation have dramatically transformed and made significant investments 
in new technologies and care delivery models, not only to meet COVID 
driven patient demand, but to prepare for America's future health care 
needs. Many of the telehealth flexibilities are temporary and limited 
to the duration of the COVID-19 public health emergency. Without action 
from Congress, Medicare beneficiaries will abruptly lose access to 
nearly all recently expanded coverage of telehealth when the COVID-19 
PHE ends. This would have a chilling effect on access to and continuity 
of care across the health care system.
    We also have a long way to go before all Americans have high-speed 
broadband along with the tools and knowledge to leverage it for virtual 
video health care visits. There may be times that an old-fashioned 
phone call is the best way for a clinician to treat a patient. Many 
physicians routinely use telephone translation services to provide 
linguistically appropriate care, and these services can be more 
seamlessly integrated into telephone visits. Preserving access to 
audio-only telehealth services beyond the PHE is important for ensuring 
equitable access to care.
    With so many patients accessing care virtually, expectations for 
the future of our health care system have shifted significantly. 
Virtual care has provided unprecedented access for patients, but 
uncertainty as to the future of many telehealth policies will halt or 
reverse further adoption--to the detriment of both patients and 
physicians. The AAFP urges Congress to act before the PHE ends to 
ensure that patients continue to have access to their family physicians 
via telehealth services.

    Mental Health. The pandemic illustrated the importance for people 
of all ages to have access to mental health services, especially during 
periods of limited social interaction. Arizona's Teen Lifeline saw the 
volume of text messages received by its suicide prevention hotline 
increase over 450 percent during the pandemic.

    Question 4. How does telehealth provide more opportunities for 
patients to receive mental health services? Does the virtual nature of 
a telehealth appointment encourage some patients to reach out for help 
who may not otherwise?
    Answer. Telemedicine for mental health care is a growing interest 
in primary care and telehealth initiatives for these services are 
expanding rapidly. While the research is limited on this topic, there 
are a growing number of studies assessing the benefits, comparative 
effectiveness with face-to-face visits, and cost comparisons. At the 
beginning of the COVID-19 pandemic, telehealth visits increased by 135 
percent compared to that time period in 2019, and 93 percent of those 
visits were for non-COVID concerns. In addition, mental health concerns 
increased rapidly during the pandemic. Other trends show a 
disproportionate effect on the mental health concerns of communities of 
color, mothers, and essential workers.
    The AAFP is supportive of efforts to expand access to mental health 
services via telehealth and encourages Congress to address the 
legislative barriers outlined in previous testimony to the Senate 
Finance Committee and Joint Principles for Telehealth Policy. In 
particular, the AAFP strongly believes that the permanent expansion of 
telehealth services should be done in a way that advances care 
continuity and the patient-physician relationship. Telehealth for 
mental health services can help address the shortage of over 6,000 
mental health professionals in the U.S., particularly for rural and 
underserved areas that face a disproportionate impact of the shortage.

    Mental Health for Veterans. Nearly half a million veterans live in 
Arizona. The COVID-19 pandemic and recent events in Afghanistan have 
led to an increase in the number of veterans seeking mental health 
treatment.

    Question 5. How can telehealth services help veterans receive the 
mental health care they need before a veteran faces a mental health 
crisis?
    Answer. The Department of Veterans Affairs is responsible for 
providing health care to the Nation's 18.2 million veterans, serving 
more than 9 million veterans every year. However, many veterans often 
face challenges when seeking care. A recent study shows veterans often 
have to wait longer to receive care compared to non-VA facilities. 
Additionally, many veterans live in rural areas where the nearest VA 
health care facility may be hours away.
    Veterans often deal with both mental and physical health issues, 
and unfortunately, long wait times and limited VA resources can often 
impede veterans' access to care. Continued investments in VA telehealth 
programs, such as the telehealth tablet program, can increase health 
care access and strengthen the patient-physician relationship.
                                 ______
                                 
 Response to Written Questions Submitted by Minority Committee Members 
                        to Dr. Sterling Ransone
    Question 1. As we evaluate what telehealth flexibilities to make 
permanent, do you agree the removal of the originating site restriction 
on telehealth is valuable, especially for frontier and tribal 
communities given the high prevalence of chronic conditions?
    Answer. Congress should permanently remove the section 1834(m) 
geographic originating site restrictions to ensure that all Medicare 
beneficiaries can access care at home. The COVID-19 pandemic has 
demonstrated that enabling physicians to virtually care for their 
patients at home can not only reduce patients' and clinicians' risk of 
exposure to pathogens and infection but also increase accessibility for 
patients who may be homebound or lack transportation. It can also offer 
opportunities to engage distant family members and caregivers. 
Telehealth visits allow physicians to get to know their patients in the 
comfort of their home and observe things they normally cannot see 
during an in-office visit. This helps us to identify social and 
environmental factors that may be affecting their health, and to 
develop more personalized treatment plans.

    Question 2. Dr. Ransone, could you discuss how remote monitoring is 
used today, in addition to telehealth, to help in the care of those 
living with chronic conditions like diabetes or hypertension? What 
steps should we consider to support Americans ability manage their 
chronic conditions more effectively when they are outside of a health 
care facility?
    Answer. The lack of broadband access is limiting the potential of 
many digital health tools, such as remote patient monitoring and 
patient portals. Remote monitoring devices can feed real-time patient 
data, such as vital signs, to clinicians and allow them to adjust 
medications and treatment regimens as needed without bringing the 
patient back into the office; however, these devices work only with a 
strong, reliable Internet connection. I have a patient with congestive 
heart failure issues who drives more than an hour each way to see me, 
and who would benefit tremendously from this technology, but we can't 
use it because of poor bandwidth.
    The COVID-19 pandemic has reinforced how lack of access to 
broadband and end-user devices perpetuates digital health inequity, and 
limited access to virtual health information worsens the digital 
divide. It is not enough to simply expand access to broadband. Congress 
must ensure that patients in need can access end-user devices, such as 
tablets, to connect to digital health tools and invest in training and 
assistance so these patients can confidently use those tools to ensure 
we don't further marginalize and disenfranchise them.

    Question 3. Can you speak to the value of audio-only services in 
ultra-rural communities without access to broadband? Is there a better 
way that we can target these services to communities that need them?
    Answer. Our nation has a long way to go before all Americans have 
high-speed broadband and the tools and knowledge to leverage it for 
virtual video health care visits. Further, there may be times that an 
old-fashioned phone call is the best way for a clinician to treat a 
patient. Therefore, it is critical to preserve access to audio-only 
telehealth services provided by a patient's usual source of care.
    From my own experience, and talking with other family physicians, I 
can tell you that the reasons for this are lack of reliable, high-speed 
Internet connection; patients' inability to navigate complex technology 
required for video visits; and the challenge for physicians of adopting 
or perfecting a video-visit platform.
    Face-to-face interactions between a physician and a patient are 
important components of a patient's care that allow a physician to 
gather a comprehensive understanding of the patient and their needs and 
build trust and communication. Unlike video visits, telephone visits do 
not allow physicians the benefit of being able to visually examine a 
patient or read body language and facial expressions. To protect 
patient safety and reduce potential for fraud, it may be prudent to 
limit coverage of telephone visits to established patients within their 
medical home.
    Many physicians routinely use telephone translation services to 
provide linguistically appropriate care, and these services can be more 
seamlessly integrated into telephone visits, whereas integrating 
translation services into audio-video platforms can be costly and 
complex. Preserving access to audio-only telehealth services is 
important for ensuring equitable access to care.
    Coverage and payment policies should support both patients' and 
clinicians' ability to choose the most appropriate modality of care 
(i.e., audio-video, audio-only or in-person) and ensure appropriate 
payment for the care provided. Some patients and some cases are better 
suited to virtual care, and others require in-person care; some issues 
can be effectively treated through a phone call, whereas others require 
a visual or tactile examination. As a family physician, I am highly 
trained and adhere to standards of care. I also know my patients and 
have formed trusted relationships with them over years. No two patients 
or cases are alike, and I should be able to choose how to care for them 
based on my clinical judgement, not based on arbitrary insurance rules.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Ben Ray Lujan to 
                           Hon. Brendan Carr
    Question 1. During questioning, you stated that Universal Service 
Fund reform was necessary to ensure sufficient and predictable support. 
You also stated that the current contribution rate could spike to 
seventy-five percent under the current system based on a recent study.
    What are the benefits for including contributions from online 
advertising and other sources of revenue generation that rely on high-
speed broadband in the Universal Service Fund? What are potential 
consequences for failing to reform the contribution mechanism?
    Answer. There are two key sources of funding today for the FCC's 
Connected Care and COVID-19 telehealth programs--the FCC's Universal 
Service Fund (USF) and congressional appropriations. At the outset, we 
need to rethink the mechanism by which USF is currently funded. A study 
prepared earlier this year showed that the 30 percent charge paid by 
consumers today on the assessable portion of their telephone bills 
could exceed 75 percent in the next few years. This is an unstable 
contribution mechanism that needs to be revisited. Failing to do so 
will result in higher costs for customers of traditional telephone 
service.
    I have put forth a proposal to assess contributions on large 
technology companies, such as Google and Facebook. To your question, 
this approach have several benefits. For one, it would sharply reduce 
consumers' monthly costs by eliminating or largely eliminating the 
existing 30 percent charge from their monthly bill. For another, this 
approach would provide a stable, long-term funding solution for the 
FCC's USF initiatives. For yet another, this approach would align 
incentives given both the bandwidth consumed by these companies and the 
benefits large technology companies realize from greater connectivity. 
Finally, a fee based on digital advertising revenue, in particular, 
would be difficult to pass on to consumers due to the nature of the 
digital advertising business model.

    Question 2. You stressed the important lesson of applications and 
uptake regarding the COVID-19 Telehealth Program during the hearing.
    Should the COVID-19 Telehealth Program or a similar initiative to 
help health care providers provide telehealth and connected care 
services to patients at their homes or mobile locations (including 
remote patient monitoring) be made into a permanent program at the FCC?
    Answer. Yes. The COVID-19 pandemic has helped demonstrate firsthand 
the value of care at a distance. Long term, we should make sure these 
types of programs are available to support telehealth services. In my 
view, there are still questions about how to fund such programs and how 
to maximize their effectiveness. I welcome the opportunity to work with 
you and members of the committee on these important questions.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Kyrsten Sinema to 
                           Hon. Brendan Carr
    Infrastructure Investment and Jobs Act. The bipartisan 
Infrastructure Investment and Jobs Act includes $65 billion for 
broadband deployment, rural and tribal broadband, digital equity, and 
affordability in Arizona and throughout the country.

    Question 1. How will this historic investment in broadband enable 
more Arizonans to access telehealth services, including Arizonans in 
rural and tribal areas?
    Answer. Supporting telehealth technology is one of my top 
priorities at the FCC. Since joining the Commission, I have had the 
opportunity to visit 44 different health care facilities across 22 
states to learn more about the work we can do at the Federal level to 
support telehealth. Through these visits I have seen firsthand the 
transformational impact of this technology on patients' lives and the 
importance of investment in broadband and the devices that power these 
services.
    And while the FCC has made significant progress over the last few 
years in closing the digital divide, too many Americans, particularly 
in rural and tribal areas, remain unconnected. The goal of the $65 
billion is to ensure that every American has access to affordable, 
high-speed service. That will be key to ensure that the benefits of 
broadband-powered telehealth are available to everyone in every 
community.
    The good news is that we now have more Federal dollars available 
for bridging the digital divide than ever before. Indeed, by some 
estimates we have more dollars available than necessary for 
accomplishing that goal. So the challenge going forward will be to 
ensure that these dollars serve the important purposes identified by 
Congress and do not get sidetracked by significant amounts of waste, 
fraud, and abuse. Ensuring that those dollars connect communities has 
to be the goal, and it is one that will require significant oversight 
in the months and years to come.
    Over the past year, for instance, Congress has provided a range of 
Federal agencies--including the FCC, Department of the Treasury, 
Department of Education, Department of Agriculture, and NTIA--and 
states with over $800 billion of additional funding that could be used 
to bring broadband to all Americans. Distributing these significant 
resources (as well as the additional $65 billion) on behalf of the 
American people is an incredible responsibility, and if Federal 
agencies and states work in a coordinated manner, we have the 
opportunity to ensure that every American gets connected.
    While the importance of coordination cannot be overstated, I have 
significant concerns. Indeed, based on my own inquires and analysis of 
the various funding programs and interagency agreements, I do not 
believe that the appropriate coordination framework is in place. 
Ultimately, congressional intervention may be necessary to ensure that 
taxpayer money is not wasted and that broadband is finally deployed 
throughout Arizona.

    Funding for Telehealth Services. Congress created the COVID-19 
Telehealth Program as part of the Coronavirus Aid, Relief, and Economic 
Security (CARES) Act, to enable health care providers to provide 
services to their patients at their homes or other mobile locations in 
response to the COVID-19 pandemic. The program dispersed $200 million 
in appropriated funds as grants to health care providers, including to 
seven providers across Arizona in Colorado City, Flagstaff, Page, 
Sahuarita, Tucson, and Window Rock. Congress later appropriated nearly 
$250 million in the Consolidated Appropriations Act, 2021 to continue 
the COVID-19 Telehealth Program in December 2020. In August, the FCC 
awarded Tuba City Regional Health Care in Tuba City, Arizona, on the 
Navajo Nation, a grant worth $266,946 to develop its telehealth 
capabilities with funds from the Consolidated Appropriations Act under 
phase 2 of the COVID-19 Telehealth Program.

    Question 2. How can Congress build on funding to support telehealth 
authorized during the pandemic to improve telehealth services in rural 
areas, including tribal lands?
    Answer. The funding that has been made available to-date has 
created significant benefits--both in terms of health outcomes and a 
reduction in costs. However, legal and regulatory barriers remain. I 
believe that Congress can best support telehealth in rural areas, 
including tribal lands, by looking for ways to eliminate these 
barriers. As noted in my testimony, there are licensing and 
reimbursement issues that have held back telehealth. While HHS has 
helped facilitate greater access to telehealth services during the 
COVID-19 pandemic through the issuance of waivers of some of their 
regulations and requirements, these waivers are set to expire at the 
end of the public health emergency declaration. We must not return to 
the status quo and should move to make some of these waivers permanent.

    Question 3. Does the FCC require additional resources to facilitate 
telehealth capabilities in Arizona and throughout the country?
    Answer. There are two key sources of funding today for the FCC's 
Connected Care and COVID-19 telehealth programs--the FCC's Universal 
Service Fund (USF) and congressional appropriations. At the outset, we 
need to rethink the mechanism by which USF is currently funded. A study 
prepared earlier this year showed that the 30 percent charge paid by 
consumers today on the assessable portion of their telephone bills 
could exceed 75 percent in the next few years. This is an unstable 
contribution mechanism that needs to be revisited. I have put forth a 
proposal to assess contributions on large technology companies, such as 
Google and Facebook. Doing so would sharply reduce consumers' monthly 
costs, provide a stable long-term funding solution for the FCC's USF 
initiatives, and align incentives given both the bandwidth consumed by 
these companies and the benefits large technology companies realize 
from greater connectivity.
    Further, I think we need to begin discussing a long-term solution 
to funding these types of telehealth initiatives. The Connected Care 
Pilot Program for instance is a three-year initiative. One goal for the 
program is to provide additional evidence regarding the value that 
flows from connected care technologies. In my view, the portions of the 
health care industry that benefit from these technologies and their 
associated reductions in health care costs should be the ones that 
support them in the long run.

    Mental Health for Veterans. Nearly half a million veterans live in 
Arizona. The COVID-19 pandemic and recent events in Afghanistan have 
led to an increase in the number of veterans seeking mental health 
treatment.

    Question 4. How is the FCC coordinating with the Department of 
Veterans' Affairs to enable more veterans to receive telehealth 
services, especially veterans living in rural areas or on tribal lands?
    Answer. In terms of current coordination between the FCC and the 
VA, I would have to defer to Chairwoman Jessica Rosenworcel. However, 
in my view the VA has been an important leader in implementing 
telehealth services aggressively for our veterans. And I highly value 
the relationship and previous collaboration between the VA and the FCC.
    The VA's remote patient monitoring program has resulted in a 25 
percent reduction in days of inpatient care and a 19 percent reduction 
in hospital admission for more than 43,000 veterans. It also cost 
$1,600 per patient compared to more than $13,000 per patient for VA's 
home-based primary services. While at the FCC, I have visited several 
VA facilities and seen these benefits firsthand. During a trip to Ohio, 
I met a veteran receiving care in West Virginia from specialists 
located in Cincinnati that monitor his vitals, use video calls, and 
employ AI to improve his care. In Texas, I had the opportunity to talk 
to a veteran who credits her great progress from wheelchair to walking 
again to the VA care she received virtually on her smartphone, 
including video visits. Back in Washington, D.C., I also had the 
opportunity to participate in a video discussion with a service-
disabled veteran of the U.S. Navy that has been using telehealth and 
remote patient monitoring to improve his care.
    These visits have informed my work on the FCC's Connected Care 
Pilot Program, which is focused on low-income Americans and veterans 
and was developed following engagement with other agencies, including 
the VA. In the adoption of the Connected Care Pilot Program rules, the 
FCC recognized that veteran patients are more likely to have complex, 
high-cost health care needs, reside in areas with physician shortages, 
and may not have Internet access. In the FCC's most recent announcement 
selecting its third set of Connected Care projects, several of the 
selected entities will focus almost exclusively on veterans, including 
across Alaska, Hawaii, Indiana, New Jersey, New York, Mississippi, 
Ohio, and Pennsylvania.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Ron Johnson to 
                           Hon. Brendan Carr
    Question 1. The CARES Act provided $200 million to the FCC to 
support health care providers' use of telehealth services. The funding 
was depleted by July 2020. The Consolidated Appropriations Act of 2021 
provided $249.95 million, but only $123.6 million has been approved to 
date, including $40 million awarded on October 21, 2021.
    What is the status of the remaining $126.35 million funds?
    Can you explain why it has taken longer to distribute funds in the 
second round? Has the need for the funds changed?
    Do you believe that any remaining funds should be repurposed?
    Answer. As part of the FCC majority last year, I was pleased that 
the agency acted expeditiously in awarding the $200 million in CARES 
Act telehealth funding appropriated by Congress. I have seen firsthand 
the benefits that these funds brought to communities by allowing health 
care providers to expand their telehealth services during the pandemic. 
Available studies also indicate that the type of telehealth services 
supported by this initiative result in significant savings in terms of 
health care costs.
    While the agency committed all $200 million of those CARES Act 
dollars within four months of the law passing, the FCC has not moved as 
quickly with awarding the $249 million that Congress appropriated in 
December 2020. Just this week, the FCC concluded the initial phase of 
the awards--totaling approximately $166 million--and facilities that 
did not receive funding will have until November 19, 2021, to 
supplement their applications before the remaining funds are committed. 
So while Congress added some additional procedural requirements with 
that December 2020 appropriation, I believe the FCC can and should move 
with great dispatch to distribute the remaining funding. Despite the 
longer timeline this year, it is my understanding that there is still 
far more demand for these funds than dollars available. For instance, 
in this second round of the COVID-19 program, we received 1,953 
applications requesting almost $895 million.

    Question 2. As you know, the new Connected Care Pilot Program will 
utilize up to $100 million from the Universal Service Fund programs to 
help defray health care providers' costs of providing connected care 
services.
    How does this program differ from the COVID-19 Telehealth Program? 
Is there any duplication in services and funding?
    To date, the FCC has awarded $57.8 million to 50 providers. Does 
the FCC plan to award any additional funding?
    Answer. While I am disappointed that the FCC has not moved more 
expeditiously this year in committing the full $100 million from the 
Connected Care Pilot Program, the agency is planning on awarding the 
full amount of that funding. The studies I have seen show that the type 
of telehealth programs supported here not only greatly improve patient 
outcomes but save significant costs when compared to more traditional 
methods of care.
    The two different programs--Connected Care Pilot Program and the 
COVID-19 Telehealth Program--are separate initiatives with several 
distinguishing features. The Pilot Program--which the FCC began work on 
in 2018--is a three-year program that receives funding from the USF and 
is therefore subject to the funding restrictions in section 254 of the 
Communications Act. Accordingly, the Pilot Program only provides 
partial reimbursement for certain types of services and equipment. The 
COVID-19 Telehealth Program, in contrast, received funding through the 
CARES Act and congressional appropriations, so it provides full funding 
for a broader range of technology and services. For example, tablets, 
smartphones and other connected devices are funded by the COVID-19 
Telehealth Program but not by the Pilot Program.
    Under FCC rules for each program, participants are prohibited from 
receiving duplicative funding for equipment or services that are 
already funded by other FCC initiatives. Our rules also prohibit 
awardees from receiving duplicative funding from other Federal and 
state programs.
    As of last month, the FCC has awarded over $69.3 million of the 
$100 million total in funding through the Pilot Program. I have called 
for the FCC to move quickly to issue the remaining funding to expand 
more access to telehealth services across the country.

    Question 3. The Biden Administration has signaled it will restore 
heavy-handed net neutrality rules.
    How would restoring net neutrality harm the buildout of broadband 
in rural areas and negatively impact telehealth services?
    How does a light touch regulation and spectrum allocation help 
expand broadband networks and advance next-generation technologies?
    Answer. Since the adoption of the FCC's Restoring Internet Freedom 
order and the repeal of the Obama-era utility-style regulation of the 
Internet in 2017, there has been an unprecedented acceleration in the 
pace of Internet builds, including in rural America. In 2016, for 
instance, U.S. providers built just 708 new cell sites. In 2019, with 
the utility-style regulations gone and new streamlined infrastructure 
rules in place, providers built over 46,000 new cells sites--a 65-fold 
increase. Telecom crews also set records for new high-speed fiber 
builds--adding over 450,000 route miles in 2019 alone, which represents 
a nearly 70 percent increase over 2016.
    As a direct result of these Internet builds, Internet speeds have 
more than tripled over the last four years. Competition has increased 
too, with the percentage of Americans with more than two options for 
high-speed service jumping by 52 percent between 2016 and 2018 alone. 
Prices continue to decrease for fixed and wireless services. The 
digital divide has been cut nearly in half since 2016.
    Indeed, COVID-19 was the ultimate stress test of global telecom 
policy. As stay-at-home recommendations spread across the world, many 
people recreated their daily routines online. Virtually overnight, 
network usage spiked here and abroad. Our networks showed speed and 
resiliency despite this surge in usage because of the common-sense 
regulatory framework that governs America's broadband networks. In 
contrast, in Europe--where regulators have long imposed heavy-handed 
and utility-style regulations to their Internet providers--officials 
worried that the continent's networks would collapse under the strain 
in demand. So regulators there asked streamers like Netflix and others 
to degrade the quality of their signals to take up less bandwidth. We 
did not face those issues in the U.S. because our regulatory framework 
has encouraged providers to invest substantially more in their networks 
that than their counterparts in Europe.
    As we've seen before, a return to the heavy-handed, utility-style 
regulations would likely lead to a decline in network investment and a 
decline in innovative service offerings. New broadband deployments 
could be delayed or abandoned, ultimately precluding some parts of 
rural America from receiving the services they want and need.
    By contrast, the FCC and Congress should maintain a forward-looking 
approach that builds on the successes of recent years. We must continue 
make spectrum commercially available as quickly as possible. We must 
also ensure that the FCC's infrastructure reforms are not rolled back 
so that industry can continue its record-breaking investment in 
America's broadband networks.

    Question 4. In April 2021, members of the Congressional Hispanic 
Caucus called on the FCC to stop the sale of WSUA-AM to America CV, 
owner of the conservative America TeVe network.
    You issued a tweet stating, ``This crosses a clear line drawn by 
the First Amendment and would turn the FCC into an arm of the DNC.''
    Have there been any further attempts from Democrats or private 
businesses to call on the FCC to censor conservative media or 
viewpoints? If so, what has been the response from the FCC?
    What factors does the FCC consider when it reviews acquisitions?
    Answer. The repeated calls by elected officials for the FCC to deny 
a transaction based on the political viewpoints that those politicians 
ascribe to the purchaser crosses a line. The FCC has no business 
acceding to such demands or using our regulatory process to censor 
political opinions. As you note, the elected officials appear to be 
pressuring the agency to take action that they believe will increase 
their electoral odds in Florida in 2022. This is a deeply troubling 
assault on free speech and the FCC's status as an independent agency.
    Indeed, the perceived political views of an entity purchasing a 
broadcast radio station have no bearing in the FCC's transaction review 
process. Station acquisitions, such as the proposed sale of WSUA-AM, 
are governed by our broadcast ownership limits and related regulations. 
And while each transaction must be measured on its own merits, 
political viewpoints are not part of this consideration.
    Unfortunately, the WSUA-AM letter is not an isolated incident, and 
I have long and frequently spoken out against such efforts to stifle 
political speech.
    In February of this year, two senior Democrats on the House Energy 
and Commerce Committee selectively targeted a handful of news media 
outlets for their coverage of political events. Their decision to write 
letters to the cable providers and other regulated entities that carry 
these news media outlets sent a message that is as clear as it is 
troubling--these regulated entities will pay a price if the targeted 
newsrooms do not conform to the Members' preferred political 
narratives. This is a chilling transgression of the free speech rights 
that every media outlet in this country enjoys.
    And less than a month after the WSUA-AM letter, the Office of the 
State's Attorney for Baltimore City, led by Democrat Marilyn Mosby, 
filed a formal complaint with the FCC asking the Commission ``to enlist 
the full investigative and enforcement powers granted to you by the 
Federal government to take action against the
    [local broadcaster] WBFF as soon as possible'' for ``the tone'' and 
``the frequency of'' stories by WBFF journalists about State's Attorney 
Marilyn Mosby. This complaint was a direct attack on free speech and 
journalistic freedom. Indeed, invoking the power of the state to 
silence journalists for unfavorable coverage strikes at the very heart 
of the First Amendment.
    I have repeatedly called on my FCC colleagues to join me in 
denouncing each of these efforts to inject partisan politics into the 
FCC's processes. Moreover, I called for the FCC to immediately dismiss 
the Mosby complaint with prejudice, though to my knowledge the 
complaint is still pending. I find this inaction unconscionable, as no 
journalists should have a complaint like this from their city's top 
prosecutor hanging over their newsroom.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Roger Wicker to 
                           Hon. Brendan Carr
    Question. When Congress provided additional telehealth funding for 
the COVID-19 Telehealth program, we required the Commission to be more 
transparent in its selection criteria and process.
    How can the Commission improve the transparency of the selection 
process for both the COVID-19 Telehealth and Connected Care Pilot 
programs?
    Are the application scoring criteria publicly available to 
potential applicants?
    Should individual applications be made available for public 
comment?
    Do commissioners have a role in the process, or is it driven solely 
by the staff at the direction of the Acting Chairwoman's office?
    Answer. Yes, the application scoring criteria for both Round 2 of 
the COVID-19 Telehealth Program and the Connected Care Pilot Program 
are publicly available. For Round 2 of the COVID-19 Telehealth Program, 
for example, applications are evaluated by staff using objective 
factors about the health care provider and the area they serve, such as 
whether it is an area hit hard by COVID-19, is a rural county or low-
income area, or whether it is an area where there is a health care 
provider shortage.
    Individual applications are made available publicly on the FCC's 
website. Currently, however, they are not made available for public 
comment as part of the review process. When we stood up these programs, 
our goal was to be transparent by adopting the scoring criteria 
publicly at the Commission level in order to help ensure an even 
playing field and to provide FCC staff and USAC with appropriate 
guidance for the funding process. I believe my colleagues and I struck 
the right balance between ensuring a wide and equitable distribution of 
funding and promoting the widest possible participation of health care 
providers. But of course there is always room for improvement, and I am 
open to taking a different or modified approach. I agree that we should 
strive for transparency, and I am open to working with you on ideas 
that would further advance this interest.
    As you know, supporting telehealth technology is one of my top 
priorities at the FCC. From our visits to the North Sunflower Medical 
Clinic in Ruleville to the state-of-the-art Center for Telehealth at 
the University of Mississippi Medical Center, we have seen firsthand 
the transformational impact of this technology on patients' lives. That 
is why I am pleased that FCC staff under both former Chairman Pai and 
Chairwoman Rosenworcel have been open to working collaboratively with 
me and my staff on these important bipartisan initiatives.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Shelley Moore Capito to 

                           Hon. Brendan Carr
    Question 1. Commissioner Carr -many communities in my state have 
had to forego other Federal funding opportunities that would allow for 
more rapid broadband deployment to unserved areas because certain 
census blocks were included in an RDOF bid.
    What potential Federal remediation efforts are there for rural 
areas in my state that were included in an RDOF census block but are 
also eligible for other types of Federal support?
    Answer. I am deeply disappointed in the pace of funding for 
successful bidders in the first phase of the RDOF, including those 
looking to rapidly deploy broadband to unserved areas in West Virginia. 
Indeed, RDOF is the FCC's most significant step towards connecting the 
hardest-to-serve parts of the country. It will allow providers to bring 
millions of Americans across the digital divide. But none of that can 
happen if the money is not allocated quickly and comprehensively.
    The Phase I auction closed nearly a year ago, but the agency has 
been slow to release funds and has fallen behind the pace set by the 
previous administration in the Connect America Fund II auction. The 
time I spent with you in West Virginia highlighted the urgency required 
when it comes to deploying broadband in unserved communities. Broadband 
connectivity is a key economic driver for small communities and is 
vitally important for the adoption and proliferation of telehealth 
initiatives, such as those we saw at Boone Memorial Hospital and the 
Charleston Area Medical Center.
    The most important thing the FCC can do to help promote broadband 
builds in rural West Virginia is to get the RDOF money into the hands 
of the broadband providers that have been forced to sit idly by as the 
FCC's process grinds along. That said, if the FCC does not accelerate 
the disbursement of funds to West Virginia providers that are now 
foregoing other Federal funding opportunities, I am open to working 
with stakeholders to identify ways for these providers to access 
Federal funding from other sources.

    Question 2. Commissioner Carr--in late June--the FCC, NTIA, and 
USDA all entered into an interagency agreement to coordinate broadband 
funding deployment.
    In your experience--can you speak to the effectiveness of these 
interagency agreements--and do you have thoughts on how to beef up 
coordination between agencies to ensure the efficient use of taxpayer 
money to deploy broadband in West Virginia?
    Answer. Over the past year, Congress has provided a range of 
Federal agencies--including the FCC, Department of the Treasury, 
Department of Education, Department of Agriculture, and NTIA--and 
states with over $800 billion of additional funding that could be used 
to bring broadband to all Americans. This is more than enough money to 
close the digital divide, and it is imperative that we not waste this 
opportunity. Distributing these significant resources on behalf of the 
American people is an incredible responsibility, and if Federal 
agencies and states work in a coordinated manner, we have the 
opportunity to ensure that every American gets connected.
    While the importance of coordination cannot be overstated, I have 
significant concerns. As you note, the FCC executed an interagency 
agreement with USDA and NTIA for the sharing of limited information, 
but that agreement does not apply to all of the ongoing and planned 
broadband spending programs nor does it cover all of the agencies that 
Congress recently provided funding for broadband projects. It also does 
not require the use of a common set of data or standards. We are 
already seeing divergent funding standards that will likely reduce 
investment in unserved areas in West Virginia and there are even 
reports that one agency wants to exclude certain funding programs from 
established administrative procedures and public disclosure 
requirements.
    It was apparent to me early in the process that coordination was 
lacking. That is why, in July of this year, I sent letters to the other 
agencies that have been entrusted with Federal broadband funding asking 
various questions to help ensure greater collaboration and 
coordination. The responses I received--from those agencies that 
provided a response--confirmed my concerns that we are not on the right 
track. Indeed, the picture that emerges is of opaque and disparate 
funding processes, incomplete information sharing, lack of performance 
metrics and measuring, and a high likelihood of waste, overbuilding, 
and missed opportunities to connect those most in need. And hanging 
over all of this is the FCC's failure to produce accurate broadband 
maps to help guide funding decisions and the necessary collaboration 
between agencies.
    This collaboration is key to avoiding the problems that plagued the 
government's last major broadband stimulus initiative. Following the 
2008 recession, Congress appropriated a then-unprecedented $7.2 billion 
for broadband in the American Recovery and Reinvestment Act of 2009. As 
GAO found in multiple reports examining that initiative, failures in 
program design, reporting, and coordination resulted in significant 
waste and an inability to verify the impact of Federal funds on 
broadband availability and subscribership. Given the magnitude of 
current funding and the pressing need to connect more Americans, it is 
even more important that we ensure that these funds are spent wisely 
and that their impact is carefully measured.
    At present, however, I do not believe that the appropriate 
coordination framework is in place. Ultimately, congressional 
intervention--either through legislation or a hearing--may be necessary 
to ensure that taxpayer money is not wasted and that broadband is 
finally deployed throughout West Virginia.
                                 ______
                                 
      Response to Written Question Submitted by Hon. Mike Lee to 
                           Hon. Brendan Carr
    Question. Telehealth is vital for patients to be able to have easy, 
remote access to their doctor. The COVID-19 pandemic has only 
reinforced the importance of telehealth offerings. In the early months 
of the COVID-19 pandemic, the Commission along with HHS acted swiftly 
and issued a number of waivers to more easily facilitate telehealth 
offerings.
    Have these waivers been effective? And if so, should they be 
codified?
    In addition to codifying the waivers, are there any other statutory 
changes that Congress should consider to help lower the regulatory 
barriers associated with the provision of telehealth services in the 
United States?
    Answer. COVID-19 accelerated the use and adoption of telehealth. 
And the HHS waivers played a key role in driving this trend.
    Moreover, the data I have seen shows that expanding the reach of 
telehealth services delivers significant benefits--both in terms of 
health outcomes and a reduction in health care costs. For instance, a 
pre-pandemic study of the Veterans Health Administration's remote 
patient monitoring program showed a 25 percent reduction in days of 
inpatient care and a 19 percent reduction in hospital admissions for 
more than 43,000 veterans. It also cost $1,600 per patient compared to 
more than $13,000 per patient for VHA's home-based primary services. 
Another remote patient monitoring initiative showed a 46 percent 
reduction in ER visits, a 53 percent reduction in hospital admissions, 
and a 25 percent shorter length of stay. Analysts estimate that the 
widespread use of remote patient technology and virtual doctor visits 
could save the American health care system $305 billion annually.
    I have been able to hear of these significant benefits firsthand in 
recent years. Since 2018, I have had the opportunity to visit 44 
different health care facilities across 22 states. One thing I heard 
from many of these visits is the critical importance of these HHS and 
FCC waivers to the expansion of telehealth services. And while these 
waivers are set to expire at the end of the COVID-19 public health 
emergency declaration, we cannot afford a return to the status quo once 
the pandemic ends. We have made too much progress to move backwards. 
For this reason, I fully support making these waivers permanent.
    In terms of other statutory changes, I believe we need to begin 
discussing a long-term solution to funding these types of initiatives. 
The Connected Care Pilot Program for instance is a three-year 
initiative. One goal for the program is to provide additional evidence 
regarding the value that flows from connected care technologies. In my 
view, the portions of the health care industry that benefit from these 
technologies and their associated reductions in health care costs 
should be the ones that support them in the long run.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Dan Sullivan to 
                           Hon. Brendan Carr
    Question 1. Thank you for helping us with the waiver of the Rural 
Health Care rules at the beginning of this year. As you mention in your 
testimony--the new rules would have resulted in irrational and insane 
results in Alaska. Obviously, there is more work to be done--As we work 
toward a permanent fix to the Rural Health Care Program rules, will you 
commit to work with me and Alaskan stakeholders to ensure that new 
rules avoid irrational and anomalous results BEFORE the rules are put 
into place--unlike last time?
    I also appreciate you mentioning in your testimony the need to 
impose firmer deadlines on RHC funding decisions--I hope you mean that 
and I look forward to seeing the results.
    Answer. In 2018, I traveled to Alaska to see firsthand some of the 
unique challenges that the residents in Alaskan communities face. I 
also witnessed the transformative impact that broadband connectivity 
and telehealth services can have when available to these communities. 
And I carry these experiences with me as my colleagues and I continue 
to improve the administration of the FCC's initiatives, including the 
RHC Program and the Alaska Plan. I agree with you that there are 
additional steps the FCC can take to make the FCC's initiatives more 
effective, and I commit to working with you and Alaskan stakeholders to 
ensure that any new rules applicable to Alaskan providers avoid the 
irrational and anomalous results hit Alaska recently.
    In particular, there are additional steps the FCC can take to 
ensure the RHC Program provides the sufficient and predictable level of 
support necessary to meet the needs of rural health care providers. 
While the issuance of the January 2021 waiver and the addition of 
additional rates into the RHC database were positive steps that I 
pushed for, there is certainly more we can do to improve the 
administration of the FCC's initiatives, including by imposing firmer 
deadlines on funding decisions. I believe that imposing firmer 
deadlines on funding decisions would provide greater certainty for 
Alaskan providers.
    I have also been working to make certain adjustments to 
administration of the 10-year Alaska Plan to aid providers by reducing 
burdens and ensuring the Alaska Plan meets its objectives. I am pleased 
that just this week, the FCC granted a 7-month extension of the 
deadline for the submission of drive test data. While the existing 
deadline was set for March 1, 2022, Alaskan providers asked for a 7-
month extension until September 30, 2022, in order to have adequate 
time to complete the testing after winter has ended in Alaska. The FCC 
has not yet adopted a final order on the drive test parameters or a 
drive test model, despite the deadline for submission by providers, and 
I believe the newly-granted extension is highly warranted in light of 
the adverse weather conditions in Alaska during the winter months. I 
also believe the FCC should make certain changes to the drive test data 
parameters as they were initially proposed by the FCC's Wireline 
Competition Bureau in July in order to alleviate providers' concerns 
about unnecessary burdens in data collection. Further, I believe it 
would be inappropriate for the FCC to make any decision regarding 
duplication of 4G LTE service in certain areas of Alaska, and therefore 
eliminating funding for those areas, using our potentially faulty Form 
477 data. Those decisions should be postponed until the FCC has more 
accurate data from its ongoing data collection.
    I look forward to continuing to work with my FCC colleagues and 
stakeholders on these efforts and a broader set of reforms that will 
ensure the FCC meets its statutory obligations to Alaska.

    Question 2. During the pandemic it became very clear that 
telehealth was going to be a big part of the solution. Therefore, 
Congress invested $200 million in the FCC COVID-19 Telehealth Program 
in the CARES Act. This program was unprecedented for the FCC because it 
allowed them to fund devices for patients and software, not just 
connectivity and broadband. This was important for Alaska, more than 80 
percent of Alaskan communities are off the road system. This means you 
need to use planes or boats to reach many of these communities. That 
makes traveling for health expensive and inconvenient, therefore we 
relay our telehealth infrastructure more than most states.
    The first round of the program received more than 5,000 
applications, but only 539 requests were funded. Congress then 
allocated an addition $249 million under the Consolidated 
Appropriations Act of 2021. Three programs received awards in Alaska: 
the North Slope funded kiosks and wireless networking equipment to 
high-risk, low-income, and geographically isolated residents.
    In Kotzebue, they used the award to replace Health IT 
infrastructure to meet the demands of COVID-19 testing, treatment, and 
vaccination in rural communities off the road system, and ANTHC used 
their award to supplement the existing telehealth program in residents 
living in remote communities.
    My question is this, the COVID-19 Telehealth Program expanded 
eligible technologies and services to include devices, tablets, smart 
phones and related technologies, have you seen a benefit to this shift? 
As we work to expand access to broadband, can you help explain how we 
should be thinking about ways to expand access to telehealth and 
digital health technologies through programs like the COVID-19 
Telehealth Program?
    Answer. In my view, Congress made the right decision by funding the 
COVID-19 Telehealth Program through its own appropriation rather than 
through USF dollars. By doing so, the Commission was able to design a 
program without the restrictions that are in place with our other USF 
programs, such as not funding devices. This is a good thing. The trend 
we are seeing in health care towards connected care is one that I have 
seen the benefits of firsthand at the Alaska Native Tribal Healthcare 
Consortium at the Alaska Native Medical Center. Indeed, you and I 
joined the Alaska Native Health Board for a discussion about the role 
that broadband can play in addressing health care challenges in remote 
areas. But for all its promise, patients and care providers can't take 
full advantage of these innovative services without broadband-powered 
devices. We should continue to build on efforts that promote a more 
holistic solution like the one you describe.

    Question 3. Obviously broadband is challenging for my state. This 
has resulted in a reliance on audio-only services in some Alaskan 
communities. I understand the national concern that the government 
needs to be funding quality services and that audio-only is not as 
beneficial as visual telehealth. However, Alaska has communities with 
no access to broadband. We cannot discuss advancing telehealth without 
discussing the value of audio-only for communities without access to 
broadband.
    Last year I cosponsored a letter to HHS defending the use of audio-
only services and asking for equity in reimbursements. HHS, thankfully, 
responded to this letter and did increase the reimbursement for audio-
only services.
    Can you speak to the value of audio-only services in ultra-rural 
communities without access to broadband? Is there a better way that we 
can target these services to communities that need them?
    Answer. Despite the great strides that have been made to close the 
digital divide and expand connectivity, there remain communities that 
lack access to broadband services. It is imperative that those 
communities have access to audio-only services, particularly where 
other forms of telehealth are not available. This is especially 
important in geographic areas like Alaska where there may be great 
distance between an individual and their health care providers or 
specialists.
    There are other times where audio-only services may also be 
helpful. As we heard from Mr. Ransone from the American Academy of 
Family Physicians during his testimony, there may be times where a 
phone call may be the better way for a clinician to treat a patient, 
particularly where there are technical challenges with using a platform 
or language barriers that require the use of telephone translation 
services.
    And while there are unique benefits to video visits, where patients 
can be visually examined, for example, Mr. Ransone also pointed to 
literature showing that patient outcomes were generally comparable 
between video conference and audio-only. In my view, this refutes any 
argument that these services should not be reimbursed where they are 
appropriate for use.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Maria Cantwell to 
                             Deanna Larson
    Question 1. In 2019, I visited Harborview Medical Center in Seattle 
and heard how doctors in rural areas can consult in real time with 
experts who are based elsewhere. We met a patient who lived on the 
smallest island in the San Juan chain and was able to receive a stroke 
diagnosis and transportation to Seattle for surgery within six hours 
thanks to his ``tele-stroke'' care. And, we heard from the panel during 
the hearing regarding how telehealth can improve patient care through 
increasing availability of both primary care and specialist care.
    In your experience, what areas of healthcare have seen the greatest 
increase of delivery through telehealth? How did the pandemic increase 
utilization of telehealth visits?
    Answer. From Avel's perspective, one area of healthcare that has 
seen the greatest increase of delivery through telehealth has been in 
behavioral health. The Public Health Emergency waiver allowed for the 
delivery of behavioral health care and services at the patient's home, 
reducing no-show rates and improving outcomes. For example, Avel 
partnered with the Indian Health Service to offer behavioral health to 
patients in the great plains, Billings, MT, and Albuquerque, NM areas. 
This flexibility and continued access to care was critical to those who 
needed to maintain their medication schedule and helped avoid any 
disruption of care for those struggling with mental health disorders.
    In addition, another area we saw increased demand was acute health 
care for rural and underserved communities. These small critical access 
hospitals and clinics needed help with the increased number of cases 
requiring acute care, and our hospitalist, ICU, and emergency 
clinicians stepped in to help meet this demand.
    Overall, telehealth visits increased during the pandemic because 
regulatory bodies understood the need to allow for more flexibility in 
care delivery. The PHE waivers opened telemedicine care to previously 
unqualified individuals which resulted a dramatic increase in 
utilization. For example, before the pandemic, telehealth visits 
accounted for less than 1 percent of all total visits. At its peak in 
April of 2020, nearly 52 percent of all health care visits nation-wide 
in April of 2020 were telehealth in nature.
    When considering these national trends in telehealth utilization 
during the pandemic, the CDC notes ``telehealth could have multiple 
benefits during the pandemic by expanding access to care, reducing 
disease exposure for staff and patients, preserving [PPE], and reducing 
patient demand on facilities. Telehealth policy changes might continue 
to support increased care access during and after the pandemic.''
    Ultimately, Avel appreciates the work that was done to improve 
patient's access to telemedicine care through the Public Health 
Emergency waivers, and strongly encourages to make the temporary 
changes permanent. Healthcare--like every sector--was fundamentally 
altered by COVID-19. We must utilize every resource and avenue to 
ensure patients, regardless of what they earn or where they live, have 
access to high quality care.

    Question 2. One persistent challenge with telemedicine, even with 
the payment flexibilities afforded by the public health emergency, is 
the ability for physicians to care for patients across state lines. 
This can be challenging when large metropolitan areas straddle state 
lines, such as the City of Vancouver, Washington that borders Oregon. 
In these instances, state licensing laws can act as a barrier for 
patients to receive telehealth services.
    In your experience, how would telehealth patients benefit from a 
healthcare system that cuts across state licensing barriers? What are 
the categories of care that would most benefit from a telehealth 
delivery system that cuts across state licensing barriers?
    Answer. The U.S. healthcare system would be greatly improved by 
enabling healthcare delivery across state lines. The true value of 
digital care cannot be harnessed, especially to reach hard-to-reach 
patients, if providers only have the ability to practice in their 
immediate geographic location. Avel recognizes and acknowledges the 
importance of maintaining a viable and thorough registration and 
licensing process to protects patients. Unfortunately, the current 
regulatory process has the effect of hindering access to telemedicine 
care, particularly when the multi-state licensing process is overly 
burdensome for the provider. It is for this reason Avel strongly 
supports the adoption of a universal approach that cuts down on time 
and eliminates redundancy.
    When considering the patient benefits of a telehealth delivery 
system that cuts across state licensing barriers, one must first 
consider the obstacles and challenges the existing system poses. The 
first obstacle being access. People who live in remote areas or 
underserved communities struggle with access to healthcare, and this 
can translate to lack of care options available to treat more acute or 
severe conditions. This makes telemedicine care an attractive option 
because it helps save patients drive time and the costs associated with 
making long trips to receive health care.
    Although telemedicine expands access to care, the next obstacle is 
whether physicians can meet the licensing and credentialing 
requirements of each state in which they practice. For example, when 
Avel partners with a new provider to deliver telemedicine care for 
particular service line (i.e., Emergency or Hospitalist), this 
individual must be licensed and credentialed in every state that Avel 
currently offers that service before they can start responding to 
calls. On average, this process can take months and varies based on 
each individual state.
    Reducing burdens on the multi-state licensing process would 
drastically cut down on the time it would take for new providers to 
start delivering telemedicine care to patients. Those who would benefit 
most include specialists practice across state borders and rural 
hospitals and critical access hospitals who require acute care. If 
clinicians are able to practice across state lines, telehealth can be 
used to address workforce shortages in primary care, specialty care, 
behavioral health and substance use disorder, and other types of 
clinical care in both rural and urban areas. Additionally, telehealth 
fills gaps in care coverage by connecting patients to the specialists 
they need, regardless of where the specialist is based.
    As for critical access and community hospitals in underserved 
communities, the quicker these facilities can implement telemedicine 
care, the more equipped they are to deliver the next level of care and 
keep patients in the local community, reducing costly transfers and 
boosting capacity.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Kyrsten Sinema to 
                             Deanna Larson
    Infrastructure Investment and Jobs Act. The bipartisan 
Infrastructure Investment and Jobs Act includes $65 billion for 
broadband deployment, rural and tribal broadband, digital equity, and 
affordability in Arizona and throughout the country.

    Question 1. How will this historic investment in broadband enable 
more Arizonans to access telehealth services, including Arizonans in 
rural and tribal areas?
    Answer. For millions of Arizonans, telehealth and digital health 
care tools are out of reach because they lack broadband access, the 
budget to purchase service, the tools to connect and the training to 
use digital devices--all critical to realizing the full potential of 
virtual medicine.
    Enhanced broadband connectivity and access remains a critical 
component of providing high quality telemedicine care for underserved 
and rural communities. These infrastructure investments will allow for 
high-speed Internet to reach remote and underserved areas that 
currently lack access. What does this mean for patients? It means that 
high-tech, two-way audio/visual telemedicine care will be delivered--
improving delivery options (including in acute and emergent care), 
reducing interruptions caused by low-bandwidth or high-latency, and 
ensuring all patients, regardless of where they live, receive high 
quality care when and where they need it.

    Medicare Coverage of Telehealth Services. Congress expanded the 
ability of Medicare of cover telehealth services in the midst of the 
COVID-19 pandemic. I have joined my colleagues from both parties to 
support legislation, the Creating Opportunities Now for Necessary and 
Effective Care Technologies (CONNECT) for Health Act of 2021, that 
would make Medicare coverage of many telehealth services permanent.

    Question 2. How would the CONNECT for Health Act enable more 
Arizonans to access health care services?
    Answer. Prior to the pandemic, Medicare coverage of telehealth was 
limited to only patients in specific rural geographic areas at specific 
facilities (``originating sites'') for a limited set of practitioners 
to provide a limited set of services. During the pandemic, Congress 
gave HHS the authority to waive these geographic and originating site 
restrictions so that Medicare beneficiaries could see providers 
remotely. This has largely been successful in its goal to continue 
access to necessary care without creating fraud or overutilization 
problems.
    If passed, this bill would expand care options and allow patients, 
including the some 350,000 Arizonans who live in rural areas, to access 
more care options. As we saw with our Behavioral health services when 
patients can schedule appointments in the privacy of their own home, 
there is a significant drop in no-show rates and a noticeable uptick in 
utilization.

    Question 3. What would happen if telehealth services currently 
eligible for Medicare coverage were no longer covered by Medicare?
    Answer. The telehealth cliff is approaching and, if Congress allows 
the waivers to lapse, we will return to the state of disparate care. 
Senior citizens who have come to rely on the flexibility and 
independence associated with telemedicine care will experience reduced 
access and limited care services. Ultimately, beneficiaries would lose 
access to clinically appropriate and necessary virtual care services if 
telehealth services currently eligible for Medicare coverage were no 
longer covered.

    Mental Health. The pandemic illustrated the importance for people 
of all ages to have access to mental health services, especially during 
periods of limited social interaction. Arizona's Teen Lifeline saw the 
volume of text messages received by its suicide prevention hotline 
increase over 450 percent during the pandemic.

    Question 4. How does telehealth provide more opportunities for 
patients to receive mental health services? Does the virtual nature of 
a telehealth appointment encourage some patients to reach out for help 
who may not otherwise?
    Answer. It is no longer difficult or uncomfortable to receive 
health care--particularly behavioral health--through a screen. As 
technology has become ubiquitous in our society, so too has our ability 
to deliver high quality healthcare through advanced, two-way audio and 
video technology. Telehealth has created opportunities for patients to 
receive mental health services in communities where behavioral health 
professionals are not always readily available in person. Also, since 
most individuals, including children, are comfortable with the 
technology, it removes barriers to care these patients to adapt to 
telehealth and reap its associated benefits--less drive time, reduced 
costs, and improved access to care when and where it is needed.
    Additionally, now that behavioral health services can be delivered 
right to a patient's location, we see more patients attending their 
appointments and feeling comfortable since they are usually in the 
privacy of their own home. For example, Avel data demonstrates the 
positive impact of Avel's in-home behavioral health services when 
delivered to Indian Health Services patients in the Billings, Great 
Plains, and Albuquerque areas, including a sharp reduction in no-show 
rates.

    Mental Health for Veterans. Nearly half a million veterans live in 
Arizona. The COVID-19 pandemic and recent events in Afghanistan have 
led to an increase in the number of veterans seeking mental health 
treatment.

    Question 5. How can telehealth services help veterans receive the 
mental health care they need before a veteran faces a mental health 
crisis?
    Answer. Telehealth can ensure timely access to critical behavioral 
health services. When veterans are close to experiencing a mental 
health crisis, every second counts, and telemedicine can help these 
individuals connect with high quality expert care. And, for some 
veterans, telemental health care allows them the flexibility to choose 
to receive mental health care where and when they need it without fear 
of stigma.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Ben Ray Lujan to 
                           Dr. Sanjeev Arora
    Question. In expanding telehealth access, telementoring services 
like Project ECHO must remain a core focus. Having a presence in every 
state, Project ECHO has shown that telementoring has a role to play in 
expanding access to critical health services nationwide.
    What are the most effective ways for Congress to provide sustained 
support for telementoring services?
    Answer. Telementoring models, such as Project ECHO, enhance 
workforce capacity in underserved areas by empowering community-based 
primary care providers with the knowledge to manage patients with 
complex conditions. There are now ECHO projects at more than 250 
organizations in all 50 states across the U.S., many of these at major 
academic health centers like the University of New Mexico, University 
of Washington, the University of Hawaii, MD Anderson, the University of 
Minnesota, and many more.
    Despite receiving some financial support from federal, state, and 
local government grants and national foundations, telementoring has not 
yet been integrated into reimbursement models or other financing models 
for federally-supported health care in the U.S. Efforts by Congress to 
provide sustained support for telementoring services will be critical 
for establishing a cohesive and responsive telehealth system that 
ensures access to high quality care for rural and underserved 
communities across the country while optimizing the effective use of 
health care workforce resources.
    I want to highlight three pathways in particular to encourage 
Congress to explore, but a more comprehensive slate of ideas is 
included in the Center for Health Care Strategies report Project ECHO: 
Policy Pathways to Sustainability at: https://www.chcs.org/media/
Project-ECHO-Policy-Paper_011819.pdf.

  1.  Direct the Center for Medicare and Medicaid Services (CMS) to 
        issue guidance to state Medicaid offices on financing 
        strategies currently available through Medicaid to support 
        telementoring--and request they explore existing authorities 
        through Medicare as well. In the previous Congress, more than 
        twenty Senators--including multiple members of this Committee--
        signed a letter to the then-HHS Secretary requesting that CMS 
        issue this guidance to states, but it was never acted on.

  2.  Fully fund the telementoring grant program established in the 
        Consolidated Appropriations Act of 2021 (P.L. 116-159) at the 
        $10 million level annually over five years as authorized in the 
        Act. This program, which is being administered by the Health 
        Resources and Services Administration (HRSA) awarded grants 
        this fall to evaluate, develop and expand the use of 
        technology-enabled collaborative learning and capacity building 
        models (telementoring) like Project ECHO.

  3.  Commit to exploring longer-term changes to healthcare financing 
        to embed sustainable and ongoing funding for effective 
        telementoring approaches. This effort by Congress could explore 
        multiple different options such as: adding an enhanced Medicaid 
        match rate; adding telementoring to the physician fee schedule; 
        building it into a CMMI demonstration; embedding funding in 
        HRSA health center grants; including it in the Merit-Based 
        Incentive Payment Incentive System (MIPS); and even exploring 
        new or tying existing GME slots to participation in 
        telementoring.

    We would be grateful to work directly with you and any other 
interested Senators or Representatives to discuss these ideas further.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Kyrsten Sinema to 
                           Dr. Sanjeev Arora
    Infrastructure Investment and Jobs Act. The bipartisan 
Infrastructure Investment and Jobs Act includes $65 billion for 
broadband deployment, rural and tribal broadband, digital equity, and 
affordability in Arizona and throughout the country.

    Question 1. How will this historic investment in broadband enable 
more Arizonans to access telehealth services, including Arizonans in 
rural and tribal areas?
    Answer. Improving broadband will support all domains of 
telehealth--remote monitoring; telemedicine; and telementoring. All 
three can advance health equity in rural and underserved communities. 
People across the country face a lack of specialists. There are simply 
not enough experts anywhere to serve all that need their help and 
patients everywhere have to wait weeks and months to see a specialist. 
And that's where telementoring to build workforce capacity comes in.
    Telementoring models like Project ECHO actively work with the 
Indian Health Service and other rural healthcare providers in Arizona, 
and across the country, to improve access to best-practice and 
specialized healthcare. By investing in the infrastructure of 
broadband, telementoring programs like the ECHO model help support 
recruitment and retention of providers, especially in rural areas, and 
increase access to best practice specialty care to patients in remote 
areas and within traditionally marginalized groups. More than 400 
publications demonstrate the effectiveness of ECHO programs to support 
expanded access to best practice care (https://hsc.unm.edu/echo/
partner-portal/data-marketplace/publications-reach/).

    Medicare Coverage of Telehealth Services. Congress expanded the 
ability of Medicare of cover telehealth services in the midst of the 
COVID-19 pandemic. I have joined my colleagues from both parties to 
support legislation, the Creating Opportunities Now for Necessary and 
Effective Care Technologies (CONNECT) for Health Act of 2021, that 
would make Medicare coverage of many telehealth services permanent.

    Question 2. How would the CONNECT for Health Act enable more 
Arizonans to access health care services?
    Answer. Creating systemic changes to our healthcare system which 
financially support telehealth services will help put telehealth 
solutions on a path to sustainability. I hope Congress will commit to 
exploring and supporting longer-term changes to healthcare financing 
for approaches like telementoring that can support our healthcare 
workforce.

    Question 3. What would happen if telehealth services currently 
eligible for Medicare coverage were no longer covered by Medicare?
    Answer. As we have seen the pandemic exposed what we all knew 
instinctively--we need to fundamentally reorient our healthcare system 
to enable patients to get the care they need, when they need it, where 
they live. We learned that ensuring financial sustainability for 
telehealth services is vital for the future of healthcare in the United 
States.

    Mental Health. The pandemic illustrated the importance for people 
of all ages to have access to mental health services, especially during 
periods of limited social interaction. Arizona's Teen Lifeline saw the 
volume of text messages received by its suicide prevention hotline 
increase over 450 percent during the pandemic.

    Question 4. How does telehealth provide more opportunities for 
patients to receive mental health services? Does the virtual nature of 
a telehealth appointment encourage some patients to reach out for help 
who may not otherwise?
    Answer. Ensuring access to mental health services to all Americans 
is vital. Across the country we are facing a shortage of experts in 
mental health modalities. Capacity building models, like Project ECHO, 
can help close that gap by creating more experts in both rural and 
urban settings.
    As an example of the role the ECHO model can play in expanding 
access to behavioral health, Arizona State University has developed a 
range of ECHO programs to expand access to behavioral health and 
addiction treatment services in the state. Every Wednesday a team hosts 
a behavioral health integration ECHO program. More than half of 
patients with behavioral health problems seek treatment by their 
primary care providers. By training care teams how to identify key 
issues and work with complex patients, this program is helping expand 
access to quality care throughout the state (Project ECHO | College of 
Health Solutions (asu.edu).

    Mental Health for Veterans. Nearly half a million veterans live in 
Arizona. The COVID-19 pandemic and recent events in Afghanistan have 
led to an increase in the number of veterans seeking mental health 
treatment.

    Question 5. How can telehealth services help veterans receive the 
mental health care they need before a veteran faces a mental health 
crisis?
    Answer. Ensuring access to mental health services for Veterans is 
critical, especially in light of the mental health crises many face as 
a result of their service. Building capacity by embedding telementoring 
models into the VA and into rural health practices, to ensure that 
veterans have access to the expertise they need, is a critical step in 
ensuring better care for our Nation's heroes. Historically, Project 
ECHO has worked collaboratively with the Department of Veterans 
Affairs. The ECHO model has been adopted in many parts of the VA system 
to support priority issues such as expanding Hepatitis C treatment. We 
would welcome recommendations of how we can help support the 
Department's priority of providing broad access for veterans for mental 
health services.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Dan Sullivan to 
                           Dr. Sanjeev Arora
    Question. Obviously broadband is challenging for my state. This has 
resulted in a reliance on audio-only services in some Alaskan 
communities. I understand the national concern that the government 
needs to be funding quality services and that audio-only is not as 
beneficial as visual telehealth. However, Alaska has communities with 
no access to broadband. We cannot discuss advancing telehealth without 
discussing the value of audio-only for communities without access to 
broadband.
    Last year I cosponsored a letter to HHS defending the use of audio-
only services and asking for equity in reimbursements. HHS, thankfully, 
responded to this letter and did increase the reimbursement for audio-
only services.
    Can you speak to the value of audio-only services in ultra-rural 
communities without access to broadband? Is there a better way that we 
can target these services to communities that need them?
    Answer. It is our belief that communities should use the best 
available technology to support access to quality medical care. If for 
very rural communities, where that is audio-only, our experience has 
been that this access is better than no access at all in expanding 
care.
    With respect for the echo model ECHO for telementoring, in rural 
Alaska and other very rural parts of the country, we know that some 
participants in ECHO virtual communities of practice participate via 
phone rather than video. Rural providers are often very isolated and 
many times the only providers in their community. Access to virtual 
communities of practice provides a much-needed trusted venue for 
providers to learn from peers working in similar situations and from 
leading specialists. As broadband becomes more accessible through 
innovations in technology, we are hopeful that a growing number of 
these communities will be connected to broadband over time and 
encourage officials to work toward universal broadband coverage across 
the entire country. This infrastructure provides the technology 
railroad tracks for access to healthcare.

                                  [all]