Update (August 16, 2017): The authors have submitted a comment to the FCC  on Proceeding 17-108  Restoring Internet Freedom. This comment is based the blog post below as well as one dated August 18, 2014, both related to network neutrality.  The FCC Confirmation Number for the comment is 20170814865229268.

Original Post: In our August 18, 2014 Health Affairs Blog post “It’s Hard to Be Neutral About Network Neutrality for Health,” we discussed network neutrality and its potential impact on health care. With the new Trump administration, we are seeing changes to the Federal Communications Commission’s (FCC) stance about network neutrality (NN) and other important telecommunications policies that may significantly impact the delivery and pace of innovation in health care. The FCC, under the guise of “restoring internet freedom,” believes that big telecom giants should be allowed to treat their business partners more favorably than other companies.

The FCC is planning to overturn the landmark 2015 NN rules put in place by former Chairman Tom Wheeler requiring that all online content be treated equally. In the last week of April 2017, the new chairman of the FCC, Ajit Pai, announced plans to make network neutrality voluntary. Then, on May 18 the FCC voted 2-1 to move forward with this roll back of network neutrality protections. In our previous post, we discuss how the Internet has basically become a public good and should be treated as such with regards to regulation and laws. History suggests that the ideas of treating Internet access as a public good are not new. For example, there are laws preventing owners of essential public goods, such as shipping companies, bridges, and ports from abusing their position. These same principles should also apply to the Internet because through its evolution, it has become essential. There is growing evidence that this is true for health.

Reverting back to a voluntary approach to NN potentially threatens the well-being of many people, particularly those at risk for health disparities due to low income or rural residency. Not only does this voluntary approach shift winners and losers to favor large telecommunication giants, we are specifically concerned with several areas of health care being negatively impacted, including innovative solutions for telemedicine, health enhancement, and cost effective scalable sharing of health care data.

Rural Health Innovations Need Dependable Internet

Increasingly, telemedicine is being used to bring higher-end health care services to remote and rural areas to reduce health disparities. For telemedicine to be scalable and positively impact cost and outcomes, there must be a predictable infrastructure connecting patients, care providers, and technology. A prerequisite for telemedicine is broadband connectivity between telehealth sites. Reliable low cost service for telehealth is potentially threatened by the loss of NN. What happens to telehealth if Netflix traffic is preferred above medical applications? Could Internet Service Providers (ISPs) offer better services for one hospital system than another, helping them take over telehealth in a region? The undoing of NN weakens the infrastructure of reliable low cost connectivity that telehealth systems depend upon.

In addition, Internet service may be increasingly necessary to help patients stay healthy by connecting them to their providers for monitoring their chronic illnesses. If the cost of Internet service is prohibitive, it becomes another factor that worsens health disparities in low income individuals. The Lifeline Program has helped expand the availability of Internet and phone services that support care in lower income areas. The new FCC Chairman announced on March 29 that he was halting implementation of last year’s expansion of the Lifeline program to support broadband in addition to phone service. This change will not prevent Lifeline subsidies, but it will make it harder for ISPs to gain approval. More than 36 pending applications demonstrate the widespread need for subsidized service programs, but it’s unlikely the applications will be approved.

In addition to the requirements of broadband access for telemedicine, the health care industry needs high-speed Internet infrastructure to connect the personal medical devices and personal sensors for patient-led remote care. While it’s not certain how this infrastructure will evolve, the household router or the set-top box (the box you likely rent from your cable provider if you subscribe to cable TV) has become an important part of this infrastructure as a platform for innovation.

The set-top box, connected to a high definition TV and cable network and Internet, provides a constantly connected backhaul for smart, connected medical devices. But, development of an ecosystem of devices connected to the set-top box requires an open architecture, not the proprietary model favored by most cable vendors. It is simply not economically feasible to develop medical devices for each cable system. The open set-top box could provide that one point of access for health data and communications in the home, but this potential is threatened. The FCC is not moving forward with proposals to create open standards for set top boxes. It is leaving the docket open for changes in the future that are not related to these open standards.

Sharing Medical Data Requires High-Speed Connectivity

Last, we need to promote high-speed connectivity for all medical providers to enable cost effective use of electronic health record (EHR) technology and sharing of medical data. EHR systems are increasingly moving to cloud based platforms that require high speed connectivity. High-speed backhaul connections also are important for users with large amounts of data, such as rural hospitals for remote radiology and pathology applications in addition to other telehealth services. Smaller practices in more rural areas may have few options for Internet connectivity. The ability of health care providers to access reasonably priced high-speed connectivity in low-volume monopoly markets is threatened because the FCC is no longer supporting the regulation of fees to connect to backhaul broadband service. This could lead to internet service providers raising “connection fees charged to hospitals, small businesses, and wireless carriers in many markets where there is little or no competition for so-called backhaul broadband service.”

In summary, the new FCC may be proceeding in directions that may make it harder to use telehealth, cloud-based EHRs, and remote sensing technologies that improve access to care and potentially lower costs for all. A thoughtless move toward free enterprise on the Internet could have a negative impact on the health of the most medically underserved Americans. We urge the FCC to investigate the unintended consequences of policy changes to insure that they do not amplify issues of health disparities in lower income and rural populations.