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 # Audio-only telehealth is the equity-relevant modality because it over-indexes on populations that video-based telehealth systematically underserves
 
 Among telehealth modalities, audio-only demonstrates a distinct equity profile. Medicare beneficiaries who are older, racial/ethnic minorities, dual-enrolled, rural, or have low broadband access are significantly more likely to use audio-only than video-based telehealth. This pattern inverts the typical digital health disparity where higher-income, higher-education, urban populations dominate adoption. Audio-only reaches the populations that cannot manage video—whether due to broadband limitations, device access, digital literacy barriers, or privacy constraints (video requires private space that many low-income households lack). The modality functions as the most equitable telehealth option precisely because it removes the technical and environmental barriers that video imposes. Maryland is cited as the only state that has legislatively expanded Medicaid telehealth definition to include text messaging, suggesting policy recognition of modality-specific equity implications. The Crisis Text Line similarly over-indexes on young, rural, low-income users. This creates a policy implication: audio-only coverage and reimbursement parity is the equity-relevant lever for telehealth access, while video-based telehealth (the dominant modality) reinforces existing disparities. Video-based telehealth is 1.62-1.67x more common in low-deprivation areas (PNAS Nexus 2025), confirming the modality-specific disparity pattern.
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+## Challenging Evidence
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+**Source:** Journal of Telemedicine and Telecare, Medicare claims 2019-2020
+
+2019-2020 Medicare claims show telehealth disparities EXPANDED during COVID, not contracted. Non-Hispanic Black/African-American and Hispanic beneficiaries were less likely to utilize telehealth than White beneficiaries, with disparities growing in 2020. Rural patients went from MORE likely (2019) to LESS likely (2020) to use telehealth. This challenges the assumption that telehealth modality alone solves equity—the data shows structural displacement when demand surges overwhelm capacity.