The Bad Politics and Bad Policy of Ted Cruz’s Latest Plan

It feels rather old and tired to go back to the line “the cruelty is the point” except, well, it’s true. The latest example of this doesn’t single out health care, but the far-reaching implications will undoubtedly affect it.

On November 21, 2024, the recently reelected Sen. Ted Cruz expressed his desire to wage war on internet access. More specifically, he called on the Biden Administration to halt a $1.25 billion “Digital Equity” program, which is administered through the National Telecommunications and Information Association and authorized as part of the Infrastructure Reinvestment and Jobs Act of 2021. The goal of this program is simple: help to ensure that covered populations (defined as racial or ethnic minority groups, low-income people, seniors, veterans, people with disabilities, and rural Americans) have access to affordable broadband internet.

For Sen. Cruz, this program was a bridge too far, engaging in unconstitutional racial discrimination by including race as one of a handful of covered categories. And Sen. Cruz asserts that the government has not produced evidence that racial or ethnic minorities face discrimination in accessing the internet, despite the Department of Health and Human Services finding in 2021 that White and Asian individuals are more likely than other racial groups to have internet and Pew Research finding in 2024 notable racial disparities in home broadband use.

This is not the first or the last time that we have seen allegations that racial considerations (even as one of many factors, along with income, age, disability status, and geography) equate to “reverse discrimination,” and in 2023 in Students for Fair Admissions, Inc. v. President and Fellows of Harvard College, the Supreme Court undid decades of precedent in this space within the context of higher education. It is safe to say that any such existing diversity-related initiatives will get the ax under the incoming Administration.

But let’s talk about why this undoing would be bad for health care specifically. Why is internet access such an important aspect of health policy? Let’s dig in.

According to the 2020 U.S. Census, about 1 in 5 Americans (or about 66 million) live in rural areas (though there aren’t standardized definitions of what precisely constitutes rural). And I know this will shock you, dear readers, but health care providers tend not to flock to these areas when establishing their practices. In fact, while 20% of Americans live in rural areas, only about 10% of physicians practice there and two thirds of primary care health professional shortage areas were located in rural areas.

So, what are the implications of this? To begin with, having fewer health care providers (for both physical and behavioral health) means that people seeking care in rural areas tend to need to wait longer for an available appointment. For routine care, this may not be a significant problem. For less routine care, it might be. And this public health problem is only exacerbated by the problem of rural hospital closures, which are driven by a number of different economic, demographic, and policy factors (among them, problems of uncompensated care in the context of non-expansion of Medicaid).

What’s more, even when able to get an appointment, people in rural areas tend to have to travel much longer distances in order to see a health care provider, with rural residents typically traveling twice as long to get to the nearest hospital. This can be a real challenge for some people given the time, cost, and hassle factors associated with this, especially if lacking a source of reliable transportation. For example, public transportation tends be considerably worse in rural than urban areas.

What these factors collectively point to is the importance of social determinants of health, or the constellation of non-medical factors that have significant impacts on our health (whether education, neighborhood or built environment, or economic stability). In fact, social determinants of health are considered to be substantially MORE important than medical care in determining our health outcomes.

So, what does all this have to do with Sen. Cruz’s proposal regarding internet access?

Telemedicine has been a key tool in helping rural communities to better access health care. As we all experienced amid the COVID-19 pandemic, while telemedicine is not a solution for all medical care – there are some things that must be done in person – it is an invaluable tool through which to access primary care, specialists, and behavioral health providers from the comfort of one’s home, without having to secure transportation and spend extra time away from work or family simply getting to/from medical appointments. But while millions of Americans rely on libraries for internet (with digital disparities particularly pronounced in rural areas), health-related appointments are obviously more private and best conducted with privacy.

The National Association of Insurance Commissioners observed in 2022 that while telehealth has a great deal of promise in reducing health disparities in the U.S., in addition to promoting access to otherwise inaccessible culturally competent care, this effect is limited by inequitable access to home broadband internet. Thus, they write, “those who would likely benefit the most from telehealth are also the ones with the greatest obstacles in using it.”

This fundamentally highlights the good policy of promoting affordable access to home internet, and working to level the playing field in this access, which helps to facilitate access to health care and so much more. This is to say, cutting funding from this program is bad policy, producing not only worse inequities, but worse overall health outcomes (which are, not surprisingly, costly to treat).

Now, the politics (writes the political scientist). Sure, Sen. Cruz just won re-election and doesn’t need to operate as a “single-minded seeker of reelection” (to quote David Mayhew) for quite some time. But roughly 3.8 million Texans live in rural areas (the largest rural population among all states). What’s more, in 2021 the United States Census Bureau reported that over 8% of Texas households lacked home internet, with another 14% only having internet access through a smartphone. This is significant in the context of the high demand for telemedicine in Texas: According to a 2023 Accenture survey, 4.8 million Texans used telemedicine amid the pandemic and most said that they would like to continue to use it in the aftermath of the pandemic. Thus, this is a large swath of Sen. Cruz’s constituents who would benefit from the sustaining of this program. Setting aside the partisan politics of “owning the libs” (and yes, I recognize that this is a big caveat, especially now), preserving this program is good politics, improving overall quality of life and health care access specifically.

There are many programs that have clear ideological divides. Abortion. Health insurance. Environmental policy. Public education. Civil rights. But internet access is an infrastructure investment that combines good policy and good politics, with large majorities in both parties favoring expanding broadband internet access. This is a fight only being waged in Washington D.C. and the end result will only move us backward, not forward.