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Craig Settles and Sean Gonsalves: Telehealth For All is a ‘Stroke of Genius’

Without access to a secure broadband connection, the co-author of this Expert Opinion would have died.

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Craig Settles (left) and Sean Gonsalves are the authors of this Expert Opinion.

My colleague Craig Settles likes to say he had a “stroke of genius” when writing his last book about building the gigabit city. “I literally had an ischemic stroke at 10:30 p.m. on a Saturday night,” he recalls. “If I had been in a low-income urban community with poor communication infrastructure, or in a rural area with bad broadband, I’d probably be dead.”

The “genius” part was realizing broadband is magic that directly or indirectly enables us to perform minor and major miracles that we could not do before, but faster and easier.

When Craig moved to Alameda, California, situated less than five miles from the heart of Silicon Valley, he could not get cell service without a signal booster, and even then it was sketchy. Several years later the service was better, which allowed him to speed-dial his best friend who called 9-1-1.

The neurologist who set up the stroke center in Alameda Hospital had mirrored much of its technology and servers in her home so she could see everything the ER staff was seeing as they administered life-saving procedures within 25 minutes of Craig’s gurney hitting the ER door.

While Craig counts his blessings, over 14 million urban households do not have broadband in their home – 75 percent of whom are African American and other people of color. Millions more technically have home Internet service but don’t have the connection speeds and capacity to use the applications needed for remote work and school, or telehealth.

And don’t forget the 4 million rural homes that do not have broadband subscriptions.

Broadband as Social Determinant of Health

The essential nature of broadband came to the fore with the onset of the pandemic. And it compelled states and local communities across the nation to take the connectivity crisis far more seriously, especially with the influx of federal funds from the American Rescue Plan Act and the Infrastructure Investment and Jobs Act.

Although advocates commonly, and understandably, tout the importance of broadband access in the context of remote work and schooling, what often gets overlooked are the transformative powers of telehealth and its potential to drive broadband adoption.

It’s no exaggeration to say that broadband is a major social determinant of individual health as it enables access to virtual healthcare and facilitates a host of other things critical to health, such as education, employment, housing, and social services, all of which require broadband, most especially for telehealth applications.

More than video chats with your doctor, telehealth uses high-speed Internet connectivity to observe, diagnose, initiate or otherwise medically intervene, administer, monitor, record, and/or report on the continuum of care. Public health, in particular, can leverage telehealth to a great advantage.

Yes, healthcare providers are increasingly integrating telehealth into the delivery of care. But, if the patients most in need of better access to healthcare do not have access to broadband, as well as computing devices and digital skills, tremendous healthcare benefits and cost-savings will be needlessly missed.

This suggests that “fiscally conservative” elected officials, many of whom claim to support universal access to broadband while lamenting the high cost of healthcare, have been thinking about this whole thing backwards. Instead of wailing about the cost of building universal robust broadband infrastructure that could be used for telehealth, why not flip the script?

Achieving universal broadband infrastructure that would last a lifetime would cost on the order of $100 billion, which is just two and a half percent of what we spend on healthcare in this country every single year. Hundreds of academic and industry studies say that even the most conservative telehealth initiatives save more than two and a half percent of system costs.

Talk about a return-on-investment! A hint of this can be seen in a study done by the National Center for Biotechnology Information which found there were as many as 3.5 million potential preventable adult inpatient hospital stays in 2017 alone. That amounted to $33.7 billion in health care costs just for that year.

Telehealth can eliminate many of those stays. And in terms of improving health outcomes, the study further found that the elderly, men, Black communities, and those insured with Medicaid would reap the biggest benefits.

So why not exploit the math, and pay for broadband using healthcare savings? Let’s connect every home, hospital, and community anchor institution in the country to robust broadband, and transform healthcare while bringing it into the 21st century. The municipal broadband model in which local communities build and own the infrastructure is ideal.

Telehealth Can Drive Broadband Adoption

Looking at it this way, universal access to telehealth has the potential to simultaneously solve the connectivity crisis and ensure that millions of families can lead healthier lives.

Here are six tactical ways of using telehealth to maximize public health in a community along with increasing broadband adoption.

  1. Re-inventing the doctor’s office visit for a variety of healthcare practices

Understanding telehealth, all you need are four walls, an Internet connection, a computer, a healthcare partner, and a healthy imagination to create a range of practical telehealth solutions.

Transform barbershops and hair salons into Covid vaccination and hypertension screening centers. The school nurse’s office can now become school telehealth centers. Libraries are starting to add telehealth kiosks.

Libraries Without Borders uses interactive Web health content, laptops, and wireless gear to outfit intercity laundromats on Saturdays. Tucson used ARPA funds to build out a wireless network on top of the city’s fiber infrastructure and gave 5,000 low-income homes the ability to have telehealth resources.

  1.  Telehealth can marry chronic healthcare, home care, and public health

Frederick Memorial now distributes hundreds of tablet computers for remote patient monitoring  in patients homes to check their vital signs, changing medical conditions and treatments, with data that goes to the hospital daily.

Urban hospitals should partner with ISPs to leverage the FCC’s Affordable Connectivity Program subsidy of up to $30 per month for Internet service and up to $75/month for households on Tribal lands. ACP also offers a $100 discount on computing devices.

  1. Enhance the emergency response and Emergency Department to save more lives and money.

African Americans and other populations of color have the highest rates of strokes, heart attacks, and other medical trauma. We could reverse the trend of hospitals that abandon poor urban communities and replace them with city telestroke or telehealth critical care “broadband subnetworks” that are hosted by major hospitals and linked to Federally Qualified Health Center, clinics, and other facilities.

  1. Expand efficiency of mental healthcare delivery

Mental health professionals getting to see patients in their homes and therefore providing an alternative to needing to go to a therapist’s office can not only eliminate no-show appointments but can provide those most in need of therapy with broader access to a variety of specialists.

Leveraging telehealth can be especially empowering for underserved communities in which approximately 30% of African American adults with mental illness receive treatment each year, compared to the U.S. average of 43%, according to the National Alliance on Mental Illness.

But as Carly McCord, Director of Clinical Services at the Texas A&M Telehealth Counseling Clinic, rightly points out: “Often we’re talking about intensive therapy, like treating PTSD, which you can’t do with crappy Internet connections. When your patient’s disclosing a trauma and your connection glitches, or you miss a word and have to say, ‘I’m sorry. Can you repeat that? ‘This is a huge problem.”

  1. Improving senior care and facilitating aging in place for our nearly 60 million seniors

Three-in-four older Americans want to stay in their homes and age in place, according to a AARP survey. And, if offered a choice, about 53 percent of respondents say they would prefer to have their health care needs managed by a mix of medical staff and healthcare technology.

A key broadband element in this telehealth equation is “smart home” technologies that include wirelessly-controlled sensors. Some sensors now can determine whether a person sat up in bed or actually fell on the floor, if patients are eating regularly, or if they are taking their medications on time.

  1. Re-imagining what hospital care can be

In areas prone to natural disasters, make prior arrangements with hotels, college dorms, warehouses, and other facilities where you can bring in generators, computers, telehealth equipment, and wireless intranets.

Use these buildings for seniors with health conditions who have been displaced: people with chronic illnesses and patients with non-serious injuries from the disaster should those people not have easy access to other residential or healthcare facilities.

Building and subsidizing access to robust community-owned broadband networks is a wise investment because it will improve health outcomes and return significant community savings for decades to come.

And with a flood of federal funds available to build broadband infrastructure and advance digital equity, we have a once-in-a-life opportunity to stitch this all together and deliver telehealth for all.

Sean Gonsalves is a Senior Reporter, Editor and Communication Team Lead for the Institute for Local Self Reliance’s Community Broadband Networks Initiative. Saved from a stroke by telehealth, Craig Settles pays it forward by uniting community broadband teams and healthcare stakeholders through telehealth-broadband integration initiatives. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views reflected in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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Expert Opinion

Ted Hearn: A Supreme Court Case About Fish Could Harpoon The FCC

Opponents of the Chevron Doctrine aver that judicial deference has gone too far.

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The author of this Ted Hearn, Editor of Policyband

WASHINGTON, January 15, 2024 On Wednesday, the Supreme Court will hear a case about federal regulation of the fishing industry.

Anyone who thinks the case is about fish is going to need a bigger boat.

In reality, this whale of a case could harpoon the Federal Communications Commission, which is clearly at risk of seeing its newly approved, highly controversial digital discrimination rules aimed at broadband Internet Service Providers get fed to the sharks.

Since 1984, the Supreme Court’s Chevron Doctrine has required lower courts to defer to an agency like the FCC when reasonably interpreting vague legislative language passed by Congress. The doctrine was established in Chevron U.S.A. v. Natural Resources Defense Council.

Opponents of the Chevron Doctrine aver that judicial deference has gone too far, leading to outsized accretions of bureaucratic power that threaten the nation’s constitutional order sustained by the separation of powers.

“Chevron deference has become a central pillar of the modern administrative state,” said Stanford Law School Professor Michael W. McConnell. “Although Chevron appeared routine when it came out, it has become the most important doctrine in administrative law.”

The FCC under Democratic Chair Jessica Rosenworcel has a lot riding on the high court’s ruling in Loper Bright Enterprises v. Raimondo, which is ostensibly about the regulation of fisheries under the Magnuson-Stevens Act of 1976. A decision is not expected for several months after Wednesday’s oral arguments.

In November, the FCC adopted Internet digital discrimination rules as required by Congress in section 60506 of the Infrastructure Investment and Jobs Act of 2021.

The FCC rules included a “disparate impact” standard imported from civil rights law that can hold ISPs liable for unintentional acts of discrimination across a broad range of activities – from the price and quality of Internet service to late fees, equipment rentals, and the use of customer credit and account history.

Litigation on the basis that the FCC developed rules far broader than Congress intended is inevitable.

“The FCC’s regulatory overreach will prove impossible to administer and impossible to comply with,” said Michael Powell, President & CEO of the NCTA – The Internet & Television Association, in a Nov. 15, 2023 statement.

The Supreme Court likely has at least five justices who want to dismantle the Chevron Doctrine entirely. The Court majority that would do so is likely the same one that in 2022 barred an agency like the FCC from adopting rules of vast economic and political significance without explicit authority from Congress.

The Chevron Doctrine has its defenders, including the Environmental Defense Fund and other green groups that say opponents of judicial deference have been exaggerating the harms.

“This campaign is marked by the kind of sloganeering, argument by anecdote, and sacrifice of empirical rigor that are all too familiar in hardball politics but out of place in legal argumentation,” the EDF said in its amicus brief filed with the Supreme Court last September. “Like any shrewd campaigners, petitioners and their supporters seek to ‘drive up the negatives’ by misstating what Chevron instructs.”

Last June, an article on the Natural Resources Defense Council’s website disputed ideas that the Chevron Doctrine gave an agency like the FCC “a rubber stamp” to adopt onerous rule and regulations. Ironically, the NRDC supports the maintenance of the Chevron Doctrine, even though it was the losing party in the 1984 case.

“…As noted by the Brennan Center for Justice, a nonpartisan law and policy institute, federal agencies face legal challenges to their rules all the time – and only prevail in about 70% these challenges, even with the Chevron Doctrine on their side. In other words, their powers are far from unchecked,” the article said.

A problem with the NRDC article’s analysis is that it gave equal weight to each case in the sample. Broadband ISPs have much more at stake in their likely legal challenge to the FCC’s digital discrimination rules than in their potential case taking on new FCC rules requiring Internet providers to display ‘Broadband Nutrition Labels’ at the point of sale.

In the end, by scuttling the Chevron Doctrine, the Supreme Court will not only reel in a big fish like the administrative state, it will also send Congress a message about the need to craft clear laws.

“Congress will face more pressure to clearly articulate agency authority and delegate fewer details to administrative agencies,” the Brownstein Hyatt law firm said in a client alert last May.

Ted Hearn is the Editor of Policyband, a new website dedicated to comprehensive coverage of the broadband communications market. This piece is was published on Policyband on January 15, 2024, and is reprinted with permission.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views expressed in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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Bruce Kushnick: Look Overseas, America’s Prices for Broadband are Out of Control

America’s prices are 5–10 times higher than comparable data from other countries.

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The author of this Expert Opinion is Bruce Kushnick, New Networks Institute Executive Director.

This chart, taken from the European Union Report on Broadband, shows that a triple play — phone, cable TV, broadband-Internet, can cost about 36 Euros for a service with 30–100 Mbps speeds, and 21 Euros for a stand alone service.

The average U.S. triple play is about $220.00 a month, and with an exchange rate of 1 Euro=$1.09 Dollars, the overcharging, which we documented, is $150+ a month — or more.

The Digital Divide was created, in large part, because prices are unaffordable, and America is now paying for over 20 million low-income families to have broadband — up to $30. a month allowance.

America’s prices are out of control, yet where are the investigations and audits to explain how overseas prices are a fraction of what we are paying in the U.S.? And why are we giving billions to the companies that helped to create the Digital Divide in the first place?

We assembled our previous research with new findings in this new series, using both 3rd party expert analysis as well as actual examples from December 2023, comparing and detailing the out of control US prices vs the services of free Telecom in France and Spectrum-Charter in New York City.

America’s broken promises and the state 5-year broken broadband plans

America’s prices for broadband have made high speed internet unaffordable for many households, Moreover, the pandemic revealed a major Digital Divide where whole areas of the U.S. were never upgraded to fiber optic networks, much less high speed services even over the copper wires. Thus, no competition to lower rates.

And every state now has plans to ‘bridge the Digital Divide’, but in all of the state broadband plans, none have addressed how the Divide started in their state or about the massive financial price divide between America and the EU or Asian countries that charge a fraction of the prices charged in the US.

Over $150 billion is being given out in state and federal government subsidies over the next few years, and much of It going to the companies that helped to create the Digital Divide.

The states must investigate the core issues as they impact almost every FCC, NTIA, FTC, Congressional and state current and future actions.

The opening chart tells the tale of how the European countries did not allow for massive multiple additional made up fees, such as the Broadcast-Sports fee ($27.90 on a Spectrum Triple Play). Moreover, the services do not charge ridiculous prices for equipment, such as set top box, that is required to use the service. Also, because there is competition, customers have choices and prices have not skyrocketed, but are actually going down.

America’s prices are 5–10 times higher than comparable data from other countries

How can America’s prices for the stand-alone, double and triple play — (phone, cable TV and ISP-broadband) be 5–10 times more when comparing data from other countries, as highlighted in the European Union Commission’s report, published July 2022 for the year 2021. And, as the report details, even basic stand-alone high speed broadband prices overseas are a fraction of what we’re paying in the U.S.

  • America’s “Double play” — high speed broadband and phone service — is being overcharged, on average, almost $75 a month — a whopping $900 a year.
  • The “Triple play” is being overcharged by $180 a month on average; this comes to overcharged, over $2,200 for the triple play.

The current triple play in America, after the promotional prices end, is now around $220.00 a month, yet overseas, the average was around $40 a month, but the prices overseas are in decline. However, in some countries, it can be as low as $23.00 for 200 Mbps or more; only $15 for the double play.

According to the EU report, we’ve even been beaten out by Bulgaria, Romania and let’s not forget Slovakia:

  • “Overall, Lithuania and Romania have the most attractive prices for broadband internet in the EU. All the offers in these countries belong to the cluster of the least expensive countries in their respective baskets. Bulgaria, Latvia and Slovakia follow. Poland, Hungary, France and Spain have low prices especially for Triple Play.”

But when the EU report says prices are “attractive”, we are talking $10–12 bucks a month for stand-alone broadband and $20–23 for the triple play, with speed of 200 Mbps or more.

By the way, Bulgaria does get Netflix and their Top 10 shows are close to America’s viewing.

How is it possible that America’s Triple Play is $150-$200 a month over what is being charged overseas? That’s over $2,200.00 a year ‘extra’ being charged to families — including low-income families and fixed income seniors. This is on top of the fact that there could be only one or no providers of high-speed services in the rural regions or in low-income neighborhoods of cities.

It would be one thing if it was a small differential between the overseas EU group and others price of service, but this is a difference that is too large to be ignored.

What are the underlying issues?

No Serious Competition to keep market forces and rate increases at bay. First, AT&T et al. failed to show up with high-speed competition to keep the cable companies, the other group of providers that use a wired connection, in check. For example, in CA, AT&T-Pac Bell had obligations to bring fiber optic broadband throughout the state and our maps showed that much of AT&T’s entire Los Angeles county region had been left to deteriorate and not upgraded as promised with fiber optic infrastructure.

Made-up Fees and surcharges are out of control. One of the sleaziest practices in the US has become the addition of made-up taxes, fees and surcharges that are not mandated or government sanctioned. This is being done so that the companies can quote a price that is missing 20–40% of the total costs,

Made-Up Taxes include:

  • Broadcast and Sports surcharge: $15–24.00 a month
  • Cost Recovery Fee: $1.99–2.99
  • Admin Fees: $1.49-$2.99 per month
  • Pass-through taxes, Gross receipts tax, telecom taxes

The largest and most egregious added fee is now the Sports and Broadcast surcharge, which is really 2 separate charges that have been merged in many cases:

Made-up, Broadcast-Sports Fees Up 820%; Overcharging $250+ a Year — then Quintuple-Taxed, Fee’d and Surcharged.” This article was written in December 2021, and along the way there have been increases bringing the total charge on the Spectrum NY June 2022 bill to $23.70 a month. This one fee on the Spectrum NY Triple play bill is more than the entire charges for a triple play in many overseas EU countries.

This charge went up to $27.90 a month extra in 2023. That is an overall increase of 1,140%.

  • Quadruple Taxed, Fee’d and Surcharged. — If the increases to this one fee is not enough, there are made-up taxes, fees and surcharges being applied to this fee as it is considered ‘revenue’ to the company and is taxed as such. And some of these surcharges are actually tax pass-throughs where the company gets to have the customer pay the company’s taxes.
  • It is impossible to calculate the exact tax assessment as there is no ‘Rosetta Stone’ to be able to unravel how each tax, fee and surcharge is applied.

But, considering that basic telecom taxes can be 12–20% depending on the city and state, if a 15% tax is applied, that would add an additional $3.55 more per month.

  • Not included in the advertised price: To add irony to obfuscation, this fee is never included in the advertised rates, nor is it added completely in the promotional price, making the increases after the promotion even more egregious.
  • Not included in the EU statistics for the U.S. Triple Play: Ironically, the EU informed us that they do not include the extra charges and fees in the US because — well, the other countries only have a VAT (Value Added Tax), and not the made-up fees.
  • No Oversight, No Audits; Regulators Failed U.S.: The idea that a state-franchised cable service or the Holding Companies that control the state telecommunications public utility can just make up fees and add them to bills with no one asking for a cost analysis or some other justification to raise this make-believe charge, should have the peanut gallery screaming.
  • Public has Amnesia: No one knows who these local telecom companies are or what they’ve been able to get away with. And virtually no one could answer basic questions about who the companies are or the services they offer.
  • Let’s give government subsidies to keep America in a perpetual state of “Please Sir May I have another?” Currently there are subsidies being given to low-income families to go online, which are then handed over to the same companies that have caused this Divide in the first place; i.e.; a new flavor of Corporate Welfare. We will address these issues in an upcoming story.

The telecom holding companies that control the critical infrastructure wires, towers and antennas created the Digital Divide. They also control the pricing of all services, wireline, wireless, broadband, internet and even cable, and as we will discuss, they also were able to manipulate the accounting formulas to have the state telecom utility act as a cash machine to fund, illegally, the other lines of business.

America must go after these cooked books and must clean up the mess. There is plenty of money to get America upgraded, and it must be seen as the first step in LA County to clean up the mess and decades of public policy and regulatory issues.

Government subsidies, both state and federal, to companies who have created the Digital Divide and can control the prices and profits over the public utility wires needs immediate investigations — not more gifts of largesse.

Bruce Kushnick is Executive Director of New Networks Institute and a founding member of the Irregulators. He has been a telecom analyst for 40 years, and playing the piano for 65 years. A version of this piece originally appeared on Medium on January 9, 2024, and is reprinted with permission.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views expressed in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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Expert Opinion

Chip Pickering: ‘Broadband Ready City Checklist’ a 5-Point Guide for Cities

The checklist covers fair and reasonable costs, timely permitting reviews, greater transparency and innovative deployment processes.

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The author of this Expert Opinion is Chip Pickering, CEO of INCOMPAS

With the historic broadband funding finally hitting the states this year, we are at an exciting juncture in the deployment process. As we begin this new phase, it is essential that states, cities, and towns have processes in place to ensure they are ready to hit the ground running when the money arrives in their bank accounts.

Many of our members plan to actively compete for the BEAD money, so we have submitted comments directly to the states on their Initial Proposals to NTIA. Through these comments, we have stressed the importance of ensuring state broadband offices address barriers to deployment including gaining access to the public rights-of-way and streamlining the permitting process.

To reinforce this, we put together the “Broadband Ready City” Checklist as a guide for state and local governments to coordinate and effectively implement the $42.5 billion Broadband Equity, Access, and Deployment Program.

The checklist covers five points on promoting fair and reasonable costs on applications and accessing the rights-of-way, to timely permitting reviews, greater transparency in the review process, and promoting more innovative deployment processes and construction techniques such as micro-trenching.

We were excited to see Kansas be one of the first states to lead on adopting specific local ordinances ahead of time and before any BEAD funding is awarded. I would like to personally commend Governor Laura Kelly and the Kansas Office of Broadband Development for their work in introducing a new statewide program called “Kansas Broadband Ready Communities.” This is an important step in the right direction.

By certifying communities and towns as a Broadband Ready Community, these state and local review guidelines will enable faster processing that will allow the deployment of broadband infrastructure more quickly, including small cells and other wireless equipment and fiber that is used by both fixed and mobile providers to connect their networks. An efficient and effective permitting process will help ensure that the taxpayer’s investment through the BEAD Program will deliver broadband service faster and more affordably.

We appreciate the Kansas Office of Broadband Development taking this important step, and we urge other states to build on this and implement the language of our “Broadband Ready City” Checklist.

As we continue to work hard to bridge the digital divide, we believe this process will serve as a catalyst for removing barriers to deployment at the state and local level and lead to more successful broadband projects in the future.

Chip Pickering is CEO of INCOMPAS, the internet and competitive networks association. For nearly three decades, he has been at the forefront of every major telecommunications milestone, from his time as a Senate staffer on the Commerce Committee shaping the Telecommunications Act of 1996, to his role as a Member of Congress leading on tech issues and overseeing the transition to the commercial internet. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views expressed in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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