Fifty billion dollars, and patients who can’t log in

by Connected Nation and the National Digital Inclusion Alliance

(May 21, 2026) - Fifty billion dollars is now flowing to states to transform rural healthcare. For communities that have endured decades of hospital closures, provider shortages, and dwindling options, that money is welcome and long overdue. But every dollar of it is assuming patients and their caregivers can navigate digital systems — and a lot of them can’t.

The Rural Health Transformation Program (RHTP), authorized under P.L. 119-21, is designed to modernize care delivery through telehealth expansion, remote monitoring, digital patient portals, and data-sharing infrastructure. These are good investments. But they are supply-side investments. They build the bridge without asking if residents know how to drive.

Rural adults were 42% less likely to use telemedicine than their urban counterparts, according to a 2023 analysis of National Health Interview Survey data — a gap that held even after controlling for income, insurance, education, and health status.^[1]

That gap isn’t primarily about broadband coverage. It’s about what happens after the signal arrives. Getting online doesn’t automatically mean someone can log into a patient portal, troubleshoot a video visit, or manage a remote monitoring device. Consider a 72-year-old with diabetes whose daughter handles her online accounts but works two jobs and isn’t always available. Or a veteran who knows of too many people who have been scammed online and is hesitant to trust “click here” to schedule an appointment. For a lot of rural patients and the people helping them — older adults, lower-income households, families stretched thin — the digital health system being built around them is one they’re not yet prepared to use.

Part of why this gap has persisted is that digital literacy has never been treated as a social contract, the way traditional literacy was — as a shared obligation. We have no agreed definition of what digital competence looks like, no system for teaching it, and no way to measure whether we’re making progress. RHTP won’t create this on its own. But how states and subgrantees design and run this program can either widen the gap or begin building a digital literacy social contract.

The chain breaks in more places than you think

Self-scheduling a telehealth appointment sounds simple. In practice it requires a working device, reliable internet, an active email address, a password the patient actually remembers, the ability to navigate an unfamiliar portal interface, and enough confidence to try again when something goes wrong. Any one of those links can fail. For older and lower-income rural patients, several often fail at once.

Health literacy makes it harder still. Research by Levy et al. found that among Americans 65 and older, only 10% of those with low health literacy used the internet for health information, compared to 32% of those with adequate health literacy. That disparity held after controlling for income, education, cognitive ability, and health status.^[2]

Device access is its own problem. Mobile phone ownership is near saturation — over 90% — but smartphones are poorly suited for clinical telehealth visits. Computers work better, and roughly 1 in 7 American households either lacks one or relies solely on a smartphone for internet access.^[3] Sieck et al. document how gaps in connectivity, devices, and skills cluster among the same populations already dealing with poverty, poor health, and limited opportunity — disadvantages that healthcare systems have largely failed to measure, let alone address.^[4]

There’s a dollar figure attached to this. The Brattle Group found that the $14.2 billion Affordable Connectivity Program, which subsidized broadband for lower-income households, more than paid for itself through $28.9–$29.5 billion in annual healthcare cost savings alone.^[5] Connectivity and digital skills aren’t soft social goods. They show up in the claims data.

RHTP state plans and sub-grant designs are being finalized now. What gets scored, what gets required, what gets measured — those decisions will determine whether this program reaches the patients who need it most, or ends up concentrated among the ones who were already comfortable online. That choice is being made, whether intentionally or not.

What states running these programs need to do

Some states are already moving. Louisiana is proposing smartphones and shared IT help desks. North Carolina has incorporated digital literacy programs. New Hampshire is expanding community access sites. These efforts are real, but their overall footprint in the national RHTP effort is much too small. Without clearer prioritization signals and thought leadership from the state level, digital readiness will fall short, with a few motivated subgrantees trying things out, while most never get around to it. Opportunities for synergy will be missed.

State administrators have levers that subgrantees don’t. They write the rules. They can cultivate strong relationships with other state agencies. Those rules can make patient digital readiness a program requirement or leave it as a nice-to-have. The choice is that direct. Here are a few concrete steps to take:

• Make digital navigator capacity an eligible and scored use of funds. If it’s not in the scoring criteria, most applicants won’t include it. If it’s a required component of telehealth expansion projects, it's built in from the start rather than bolted on later.

• Allow device distribution as a use of funds. Distribution of reliable, high-quality devices that meet the patient’s needs can be integrated with digital navigation services to ensure the patient has the digital skills needed to access remote health services, or stand alone. We recommend not limiting use to health only, as that restricts the patient’s ability to become more comfortable with the device and allows them to access additional health resources, such as researching health issues and care providers on their own.

• Require digital literacy baseline data as part of reporting. CMS expects measurable impact, and many state plans invoke data-driven decision-making without specifying what data will drive which decisions. Requiring subgrantees to screen patients for digital readiness at intake — using validated tools that already exist — turns that into an actual accountability mechanism, not just a line in a plan.

• Engage your state broadband or digital equity office as a formal partner. These offices built State Digital Equity/Opportunity/Access Plans in 2023 and 2024, developed community relationships, and know the local digital landscape in ways health agencies typically don’t. Federal funding for those programs has been cut, but the expertise and networks remain. Use them.

• Set an expectation for hybrid care pathways. State plans that assume patients will get there digitally are setting subgrantees up to serve the easy cases and miss the hard ones. Telehealth expansion projects should be required to include in-person and phone alternatives, with a supported path toward digital adoption, not a gate that excludes people who aren’t there yet.

The U.S. has no agreed national standard for digital literacy — nothing like Europe’s DigComp framework, which defines digital competence across five domains, has been adopted by more than twenty countries, and underpins an EU target of 80% of citizens meeting basic digital standards by 2030. RHTP can’t create a digital literacy social contract on its own, but it can move things in that direction. States that build consistent digital literacy data collection into their programs will generate something that doesn’t currently exist: population-level evidence of what patients can actually do, tied to health outcomes. That’s worth something well past the five-year program window.

What subgrantees can do on the ground

For providers and community organizations receiving RHTP funds, the most practical starting point is the digital navigator — a term coined by the NDIA community for a dedicated role focused on helping community members, including patients and caregivers, adopt and actually use digital health tools. Not a general patient navigator. Not IT support. Someone who sits with a patient or their caregiver, helps them set up a portal account, figures out why the video won’t connect, explains what a remote monitoring device does and why it matters, and builds enough confidence that the patient tries again next time instead of giving up.

UPMC Central Pennsylvania put this to the test across two hospitals. Ninety-eight percent of patients reported the navigator support helpful, and the program measurably reduced technology-related anxiety, one of the most stubborn barriers to telehealth adoption among older and lower-income patients.^[6]

In rural Northwest Arkansas, community health workers trained as digital navigators by the South Central Telehealth Resource Center helped patients set up equipment, manage remote monitoring tools, and stay engaged with telehealth over time, not just for one visit.^[7]

The role fits the rural context. It doesn’t require a clinical degree. An existing community health worker, peer specialist, or entry-level hire can do it. A published training curriculum covers the role across five domains in about ten hours: core smartphone skills, basic troubleshooting, app evaluation, clinical data literacy, and patient engagement. That’s a realistic workforce investment for providers who are already stretched.

Beyond the navigator role, subgrantees should screen for digital readiness at clinical intake for patients and, where relevant, the caregivers managing their care. A 3-item validated instrument developed at Vanderbilt for diverse, lower-income populations takes minutes to administer and gives providers something they mostly don’t have right now: actual data on where their patients are. That’s the precondition for everything else, and it’s also what demonstrates to states and CMS that the program is reaching the people it’s supposed to reach.

Subgrantees should also look past their own walls. Local government digital inclusion programs, libraries, community-based organizations, community colleges, and workforce programs are often already supporting digital skills development and providing digital navigators in the same zip codes. Investments in these existing programs along with creation of a referral program are a low-cost solution.  Healthcare already knows who the digitally excluded patients are — the data trail is sitting right there in portal non-use, telehealth no-shows, and tech support calls. Most providers just haven’t acted on it.

The window is now

Sub-grant criteria, program designs, and provider partnerships are being set right now. What goes in at this stage shapes the next five years. Digital readiness is far cheaper to build in from the beginning than to chase after the systems are live and the patients aren’t utilizing them.

States that set clear expectations of patient engagement in digital tools get subgrantees who build digital readiness into their programs. Subgrantees that screen patients, partner with local digital navigator programs, and track outcomes give states something to show CMS. Each level makes the other more effective, but someone has to go first, and in this structure, that’s the states.

The tools being built through RHTP can genuinely improve rural healthcare. Whether they do depends on whether the patients and caregivers in front of the screen can actually use them. That’s a solvable problem — but only if it gets treated as one.

Connected Nation and the National Digital Inclusion Alliance (NDIA) work every day to ensure that all people — regardless of where they live, how much they earn, or how old they are — can fully participate in a digital world.