The Dose - In Rural America, a Weak Signal Can Mean Worse Health

Episode Date: May 23, 2025

What happens when your zip code threatens your health? Broadband access is often framed as a tech issue, but in some rural communities it’s a matter of health equity. Broadband internet is so limited in some areas that patients can’t use remote monitoring devices, hospitals can’t support telehealth, and electronic health records slow down care instead of streamlining it. On this week’s episode of The Dose, journalist Sarah Jane Tribble joins host Joel Bervell to explain how internet dead zones are deepening chronic illness in rural communities. Drawing from her reporting for KFF Health News, Tribble shares the stories of people managing diabetes and kidney failure without reliable digital tools, and hospitals lacking the internet speeds needed to monitor high-risk patients.

The Dose is a production of the Commonwealth Fund, a foundation dedicated to health care for everyone. Right now, the United States government is aiming to cut $40 billion in programs run by the Department of Health and Human Services. In rural areas, where there are many federally funded programs meant to even out health disparities in the United States, the impacts could be devastating.

The decades-long, well-documented health challenges in rural America include not just the lack of infrastructure in place, but even the ability to connect via Internet to help. Four years ago, Congress passed a law that included funds to ensure rural Americans had access to faster, sturdier broadband internet. The Infrastructure Investment and Jobs Act directed $42 billion to expand and strengthen the reach of the internet to rural areas with low population and high poverty rates. Because those internet connections can have literally life and death implications for 3 million rural Americans. But in many places the money earmarked to solve these problems is not yet

reaching many Americans. My guest on this episode of The Dose is Sarah Jane Tribble, a journalist with KFF Health News and she's here for a conversation about her reporting that shows the link between health outcomes for people living with chronic disease like diabetes and kidney failure and how much access they have to the internet. Sarah Jane, welcome to The Dose. Thank you for having me, Joel. Thank you so much for being here. So you've been covering rural health issues for years, and this reporting focuses on so-called

dead zones, low infrastructure and internet access areas with high poverty rates. Essentially, places in the United States where inadequate access to health care continues to mean that people are living sicker and unfortunately living shorter lives. So I'm wondering, what prompted this series and was it mostly a follow the money type of investigation to see how or even if the money from the infrastructure investment and jobs act was getting to the places it was intended to go? Or was there something else that drove you towards it? Yeah. So first, what inspired the series? I grew up in rural Kansas, a place called Parsons, Kansas. I grew up on a dirt road outside of that. And I love rural America and I'm passionate

about it. And I was spending a lot of time going back to visit my parents who still live there and also doing reporting as a chief rural health correspondent for KFF Health News, traveling the country. And what I began to realize is that nobody had internet access. I'd go to a community and the leaders would say, go down to the library, they've got 5G, it'll work outside the library in your car, or, you know, I'd have to go other places or go to McDonald's to get my work done when I was out traveling. And my parents, who are, you know, aging, they also didn't have internet access.

So I began asking this question, you know, where's the broadband? Where's the high-speed internet? Because if you're like me, you wake up in the morning, I can access the internet immediately. I have, you know, very fast fiber access to my home now, and I can look at my watch and see the internet. My parents and many people I

was interviewing couldn't. And I began to wonder as my parents were aging, frankly, how it affected their healthcare. They couldn't do telehealth visits. So that was the first thing that inspired it. And then I work out of Washington, D.C. I was here during the pandemic. I saw that President Trump during his first term did an executive order on rural health that included telehealth access. There was a lot of talk about telehealth during the pandemic. So those two things together really sort of solidified the idea that why don't many of the people I go out and interview have telehealth access and how is that hurting them?

The second part of what you asked about, the fall of the money, of course, as a reporter, you want to say, you know, why don't they have the broadband? And I realized quickly that there's been billions of dollars through actually more than 15 different federal agencies over the years, 133 different programs that were paying for broadband access across the U.S. And they were run out of agencies like the USDA that does agriculture and the FCC, Federal Communications Commission. So what happened to that money? Why didn't it go to those rural areas? And so we explored that as well before then realizing that there was

this new $42 billion batch of money to write about as well. How did you map your destinations? Some of those pockets might seem obvious based on low population and high poverty, but were there other variables that you were looking at for the locations? Yeah. So what we did, and we have an amazing data reporter, Holly Hacker, who worked on this project with George Washington University's Mullen School, and they had primary care data as well as behavioral health care data that we worked with them on to sort of pull down from their website and analyze and place over the counties. They've done some of that work already on their website. I spent months interviewing experts about the FCC broadband maps, trying to figure out

how we could map broadband access. What I quickly learned was the maps of old have been widely considered inaccurate because they allowed companies to file these forms on where they covered, and the forms claim coverage on one house, and then the whole county would have coverage. So that meant the one house had coverage, but many other houses in the county didn't, but it still looked like on the FCC broadband map that it did. That they had coverage.

That they had coverage. So when you're giving out these federal grants for billions of dollars, they don't say, oh, this place doesn't have broadband because the maps didn't show they didn't have broadband. So learning about the maps was another sort of learning curve, if you will. And we ended up using FCC broadband maps, but the FCC actually re-upped their maps and they have a new way of doing it in the last year. And what metrics were you looking at or changes were you hoping to see made in these communities? Well, what we were really trying to figure out was where telehealth could work and couldn't work,

right? This big promise that we all heard about during the pandemic, this idea that kids were sitting outside of McDonald's or wherever to get their homework done. How does that play out for rural communities who don't have broadband access and also lack healthcare providers? So, the metrics we were really trying to measure in what we were calling our dead zone counties are places that lack high-speed internet as well as enough primary care and behavioral health care specialists. And what we found was there was more than 200 counties across the U.S., they're mostly rural counties, which was not a surprise to me. That's what my gut was telling me when we embarked on this project. And these are the places that, you know, have often been the last on the list to get resources,

whether at the state or local or even federal level. So it's really not surprising that these are the same places, you know, the deep south, Appalachia, the remote west, that also have places, people who live sicker and die younger than the rest of the country. They've just lacked resources on all levels for so long. Broadband's just another one of those. Absolutely, and in so many of these places, Americans are likely to die from chronic disease at earlier stages, whether it's things like diabetes. But I think what a lot of people don't realize

is access to high-speed internet isn't just about telemedicine, right? It's about whether you're even able to get a device to monitor your blood sugar levels that can be connected to the Internet. And these are all things that go into healthcare that need to be connected. Right, right. I mean, the first story that we have published, we talked with Barbara Williams. She's a resident of Greene County, Alabama. She grew up in that county, moved away and then moved back. And her and all her siblings have diabetes. And while her

sister told me that she would love to have a remote monitor and was getting one, Barbara says she doesn't want one, the challenge is even if you have a remote monitor, it works on Bluetooth on your phone, but you've got to have first of all the device, the phone that works to connect it. But then for it to be really useful, you want the data from that remote monitor to go to the doctor. And I interviewed a bunch of doctors about this who explained that if you can get that data to the doctor of what your blood sugar levels are, and Joelle, you'll know more about this than I will because you're a doctor,

but if you can get that data, then they can do the pre-work and assessment and monitor your diabetes more closely to make sure your medication levels are correct and make sure that how you're treating your diabetes and managing it on a daily basis is best for your body. But you can't do that in these places that don't have internet because you can't get the data to the doctor. Exactly. I'm glad you brought up Barbara Williams because I think she is a perfect example of people that you found in rural places in the United States like Greene County, Alabama that has just a population of 7,600 people. Birmingham, which is the largest nearby city, is an hour away. And I'm curious if you can also share what her health status is now and what are the long-term effects

where if she had had access to health care, things could have maybe gone differently for her. Yeah. When I last talked to her, her neuropathy and her legs, one of them was getting a bit worse. She can drive to the local Green County Hospital where she gets her care. And she believes that she's on the right medication. And, you know, what struck me the most about Barbara is she's a very strong person and she gets things done, right? She drives herself, she goes to the community center every morning with her sister to spend time with fellowshipping with others. She does all the things. But she doesn't have high-speed internet, so she doesn't have sort of that access to secondary care that one might have. When I met her, she had already had neuropathy in both of her legs, and she'd had diabetes for a while. And she manages her diabetes by feel mostly.

She has a monitor at home that she will use, but she doesn't use it every day. When I met her, she hadn't used it for weeks. And so that tells me that she's monitoring it by feeling, which may not be what the doctor would prefer, right? So it's different than what I heard from other patients, like Sam, who I met north of Washington, D.C., in Maryland, in one of the more higher-end counties. It's a leafy suburb.

And he is a former retired engineer, and he tracks his blood sugar levels with a watch that he calibrated himself. And he has internet in his home that can give continuous feedback to his doctor. He doesn't have neuropathy in both legs and he's had diabetes for a while too. Yeah that compliance piece that you're mentioning when it comes to being able to even monitor your own symptoms that's something that I've noticed as well when I was especially on my rural rotations in places where people are

often like you're saying, having to, like Barbara was doing, have to tell by feel, you know? And often when you're feeling things, that means it's too late. That's when neuropathy is already hit, or heart disease, or other conditions are starting to flare up.

And so compliance is so huge, and I think that's something that we don't often connect with the broadband piece of just moderating, allowing someone to have more say into their own care. Is there something that Greene County Hospital could have done to get access to funding that in theory is supposed to be allocated for exactly that kind of improved rural healthcare?

You know, my second story focuses on Greene County Hospital. So I spent quite a bit of time interviewing Marcia Pugh, who is the CEO administrator of that hospital. I don't know anybody I've met who's been so good at getting grants for equipment and things in that hospital. I did not ask her if there were grant programs for management of diabetes, but I do know this.

Of all the hospitals that I've been to and all the places that I've visited, whether it be health clinics or doctor's offices, if you know your population for the most part doesn't have internet access, expending the resources on something that you know your population can't actually use, it's not a wise move, right? So I don't know if Green County Hospital has applied for any grant funding for diabetes remote management, but I would guess that if their population can't use it, they probably wouldn't apply for it. Absolutely, and that makes a lot of sense.

I want to talk a little bit about the care stations that you saw as well. In your stories, you describe a public-private initiative that's installed what looks like literally a booth at the community center in Greene County. People can step into it without an appointment and get immediate, high-quality, free medical attention. Can you tell me more about these care stations and how you've heard that it's working? Yeah, first of all, I'll say it doesn't look just like a booth. It's kind of like a whole room put into a room. So this on med station, I think it's called technically on med care station is what they call it. It's a company out of Florida that's working with a lot of public private partnerships across the US from what I understand. They have

created these massive booths where you can drop down equipment and take your blood pressure and you pull up a monitor that's life-size in front of you of a person who's working remotely who can then give an assessment. And last I talked to the company it's working well in some areas, there's lots of people using them. In Greene County the booth is set up in the Bologee Community Center, which is probably 15, 20 minutes away by car from Greene County Hospital. The booth doesn't work with the hospital. The booth itself, when you get a caregiver on there, it's somebody who's remotely based

who can then make sure you get prescriptions that are sent with places OnMed has contracts with and does referrals to places where on med knows you can go. Needless to say they don't usually go to the rural hospital because rural hospitals across the country don't have specialists that you get referred to. So most likely if you go to this on med booth and biology you're going to be referred to Tallahassee or Birmingham. Gotcha and does that present more difficulties for when it comes to travel and having to get people to go farther out to other places like those states that you mentioned? I mean, certainly when you have in rural areas, the population is known to be older in general,

right? And so you combine older with maybe some of these chronic diseases and the need to go to the doctor becomes a trip, right? And how far do you want to travel? The OnMed booth, the thing that I heard from several people that I interviewed is they really liked being able to check their blood pressure, for example, in the booth, check their weight in the booth,

it's the dependable device, right? And I talked to folks who had, you know, lacerations that were checked out in the booth, who got prescriptions and just things that had been niggling them for a while that they could just check there to see if they had to drive someplace, right, or if they could get something taken care of right there. They found that convenience to be really good. But, you know, folks in rural areas are used to driving. It's just whether they're going to do it or not that's really the question.

Absolutely. Do you think this is something that's a good scalable solution that could be applied to other rural communities? And is there a point to other solutions that you saw surfacing as well? Onmed believes it's a scalable solution and they are working to deploy it to other communities I've been covering healthcare a long time and there have been a lot of times when I've covered telehealth booths and they have not lasted So I'll be watching as a reporter to see what happens in the future one of the concerns I have is somebody who is passionate about rural America and has been covering it for a long time is sort of this juxtaposition of bricks and mortar versus telehealth care,

right? So it's great to have access to telehealth, but at the same time the question also is, well, do you want some bricks and mortar person sitting there, a real life person? What's the best quality of care you can provide to a community in need? Sometimes it's better to have something rather than nothing, but at the same time, having something rather than nothing maybe is not, is that a policy default that America would be satisfied with for rural America? So it sounds like you're a little skeptical of it or?

I am always skeptical of everything. So it's not on-med that makes me it or I am always skeptical of everything so it's not on that that makes me skeptical I'm just skeptical of business ventures that go into rural America and try to provide solutions and That's a very challenging environment to be in because you've got low income. You've got these Engrained challenges in rural America, so I'm just always skeptical of that kind of any investment actually. Yeah, absolutely. I can understand that the skepticism overall of like wanting to make sure that a business is actually finding the needs of the community. And then you also think about the fact that funding is being cut as well. And so money isn't necessarily going to those areas anymore.

I want to talk a little bit also about a profile that you did on Leroy Walker. more. I want to talk a little bit also about a profile that you did on Leroy Walker. He was a 65 year old black man who lives in Utah. I hope I pronounced that right. You did. You did. Perfect. In Utah. It's the biggest city in Green County with a population of just under 3000. And so I'm going to set this scene here for listeners. Leroy has chronic high blood pressure, kidney failure. He needs dialysis treatment three times a week. But even in the Greene County Hospital, where he goes for treatment, he's at risk there because of the lack of high-speed internet.

I'm hoping you can kind of shed a light on what is going on there for listeners. Yeah. You know, rural hospitals across the U.S. lack resources. And what I found out in my reporting for this story, and this wasn't something that I had expected to find, to be honest, was that they also, in some cases, lack high-speed Internet for many reasons. Green County Hospital does not have high-speed Internet. They have high-speed Internet, but not fast enough Internet. What I mean by that is they pay for a plan that is above the national standard of 100

megabits per second over 20 megabits per second. So 100 is download speed, 20 is upload speed. Download lets you watch things on Netflix. Upload lets you do things like telehealth, pay your bills and taxes. So you want that upload speed too. That's sort of the minimum standard for high speed internet across the US. And they pay for a plan that's more than that. But when I tested their computers using kind of industry standard tests,

it was slower than what I just named off. Because they don't, you know, when you pay for an internet plan or a connection to your house, you get a minimum speed, you get a span. But you don't always get that consistent speed, right? Nobody does. It's like an up to speed that you're supposed to get. And that's what they have. Regardless, they need gigabit speed because in today's healthcare world, there are things

like central monitoring systems, you have scans for the imaging that you've got to send out to Tallahassee or Birmingham if you're in Greene County. I can't even name off all the devices that operate off of high-speed internet and interact with each other. But one nurse told me at Greene County Hospital, you know, at some hospitals, you go and the nurses have little packs on their side that help them alert them to what's going on in their patient rooms. Not here, I have to go check in person to make sure everything's okay at that hospital. And I interviewed a doctor after Leroy Walker was released from the hospital that said, yeah, you would want a monitoring system on a patient like Mr. Walker because he's got

long-term heart concerns. And so Leroy, he knows that he, the nurses and the staff were doing everything they could, right? He knows that they really cared about him. And they, you know, the nurse came into the room and made sure he was warm and tucked his feet under the covers and checked his vitals. But there was, you know, if she left the room,

there was nothing to watch him. There was no monitoring system because one, they can't afford it. And even if they could afford it, the tech guy at Greene County Hospital told me it probably wouldn't work on their internet. Yeah. I mean you're mentioning so many great illustrations right now about how basic monitoring equipment relies on unstable internet, the lack of what nurses and physicians can do. I'm curious, in your

reporting, did you hear about anyone talking about how it's led to missed alerts or delayed care or a situation for someone like Leroy or anyone else? Well, I mean that's it's a good question and it's challenging, right? Because if or delayed care, or a situation for someone like Leroy or anyone else? Well, I mean, that's a good question. And it's challenging, right? Because if you're a nurse or a doctor doing everything you can to take care of your patients, you don't want to talk about the missed alerts. Absolutely, yeah. Right? And maybe you don't know what you're missing because you don't have the monitoring system. You're doing everything you can for your patients.

So I did look at state reports and federal reports and so forth. The challenge is, if you say, did tell that the lack of internet connectivity cause a challenge for a staff member? Well, or could it be that staff member didn't respond in time or would have, you know, just speaking generally, not about one specific hospital. So yeah, I did look. But the internet is just so ingrained in health systems and in the way the modern hospital health care system works that it's hard to kind of tease it out when it comes to care.

I mean, for example, the federal government requires electronic health records, right? And the reasons for that are plentiful. You probably know them better than I. But they make it easier for nurses and doctors to do their jobs and to keep track of patients and the care they're giving to patients. If you don't have a good electronic health record system, then you're having to do double work in many different ways. And does that affect your patients? Well, one could see that, you know, if you're taking the time to transfer a paper chart to an electronic chart, yeah, you're not spending time doing other things. Yep.

Yep. I mean, I'm curious, we've talked a little bit about the provider side from the patient side. And you mentioned that Leroy knows that his doctors are doing everything that they can. But did you get the sense that Leroy understood the risks that he's facing because of inadequate broadband? Or is this just kind of the normal for patients that are like him in the rural areas? I'm always curious about this because in medicine, we always try and find that gap of what do

patients understand versus what we're telling them. And so I'm curious from your reporting if you're able to get a sense of that. Yeah. So one of the things that struck me immediately as I began to go out to communities, whether it be Idaho or Alabama or West Virginia, these places I visited that are on the map for lacking all three services, is people know what they don't have, right?

Like if I'm living in rural America, I still watch TV, I still watch YouTube, I still get on social media even if I can't stream all the stories. I know what's out there. I know what's possible. I know that I don't have that. And I heard that from a lot of people. I know I should be able to email my doctor. I've never used a patient portal, but I know they exist. They're aware of what they don't have, and they may not know how to operate those devices. They may not know exactly what that technology can give them, but they know it's out there and they know they don't have it.

And Leroy included, he talks about when he goes to Tallahassee and Birmingham, he sees what's at those hospitals. And he has said very distinctly his own hospital, the community hospital should have the same thing those hospitals have. Absolutely. What do you foresee in these two places, in other rural places, in light of the announced budget cuts to HHS and the rigorous review order that's been issued by the Trump administration?

Right. So you just mentioned two separate things, the HHS cuts, but also the rigorous review order is on the broadband program, right, the $42 billion infrastructure program that is under review. States were supposed to start getting money from the federal government and doling it out to companies to build broadband. What do I think is gonna happen? Well, in Greene County, I know that in my story, I've interviewed Alabama Fiber Network. They are building out. They do plan to meet a deadline for previous federal funding, not the latest $42 billion project, but another project is from the COVID pandemic money, right? They plan to get that high-speed internet built to the hospital by, you know, 2026,

right? So I know that's the plan. Now whether the hospital will be able to afford the high-speed internet that's built there is also another question. So I don't know if they're gonna get high-speed internet or not. But there are other places where, you know, I've been, and they may not get internet to those customers. And there is talk right now with the $42 billion program, one of the reasons the rigorous review

is happening is because Republicans, in particular, have been on Capitol Hill in Congress talking about being tech neutral. And the idea there, if I can say it kind of generally, is they want the program to include satellite, low Earth orbit satellites, which would be like Amazon's Kuiper, but also Starlink, of course, right? And here's the puzzlement to me as a reporter, since I've been learning about this program is the $42 billion infrastructure program was launched in 2021. It has had a ramp up and the Republicans will say it's been too slow. And there are plenty of Democrats who also would say that the program could have gone faster. But in reality, what happened was new mapping was

done, right? States went out and had residents and organizations challenge the federal mapping to say, this isn't covered, we need, you know, money to cover it. So it was trying to kind of correct mistakes of the past, right? That takes time. And in some cases, you know, broadband offices had, at the state level, had to staff up and put this mapping together, and then they went out to the communities. There were Digital Equity Act requirements where you meet with people in communities across the state. All the states across the U.S. have done this work over the last several years, and now they're ready to sort of implement the program. So you're seeing states sort

of push back on this idea of the rigorous review. The question now is what's going to happen, right? Like, is the money going to go out? And when I last talked to, I was emailing with somebody from Delaware who was waiting for the money to be released and it hasn't been yet and they're ready. They're ready for, they're ready to do construction. Absolutely. And you said that you not much were surprising in the original mapping of the dead zones. Was there anything that was surprising in what you found or potential for better care in those places? I think what surprised me was finding out that there were places that didn't have internet that previously had been told that they had high speed access to internet, right? Because with the new FCC mapping and the challenge process in these states, when

I went out to the ground and talked to people about the Internet they had and tried to use it, it wasn't really existent. I would go places and a company would have claimed that they provide to that area or territory and the residents would be like, no, I can't access the Internet. How often that happened actually surprised me. I didn't expect it to be, you know, in counties across the U.S. And if I may, you know, as we talk about this, the other thing that I learned in my reporting was this idea that, you know, there is a lack of Internet access in urban areas too, right? So the mapping project we've done, it highlights mostly rural

areas because we're focused on infrastructure, right? Where are the wires going? How do we build those fiber optic lines out to places so that people can have access to the internet? But in plenty of urban areas, people lack access too. And that $42 billion infrastructure plan was connected to something else called the Affordable Connectivity Program, which Congress didn't renew last year. They didn't renew funding for it last year. It ran out of money. But what that program did, because it was passed at the same time, it was supposed to

help, experts have said, provide customers to these companies that spend the money to build out to these places. And the program that was helping pay for that, activists are very upset that it's over with because 23 million households across the U.S. were using that program when it ended. Wow. Well, Sarah, I want to say thank you so much for joining me today and for the incredible work that you're doing to shine a light on the intersection of healthcare when it comes to chronic disease, digital inequities in rural America, and as you've mentioned as well in urban America. I think what your reporting makes clear is that your stories aren't

just about broadband, they're about survival and whether we're giving people that often are left behind access to what they need to better their health. So truly thank you once again for everything that you're doing, for sharing your insights and for helping us better understand the stakes. Thank you, Joel. I'm happy to share the stories. This episode of The Dose was produced by Jodie Becker, Micky Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design,

and Paul Frame for web support. Our theme music is Arizona Moon by Blue Dot Sessions. If you want to check us out online visit thedose.show. There you'll be able to learn more about today's episode and explore other resources. That's it for The Dose. I'm Joelle Brevel and thank you for listening.