Turn Libraries into Points of Care

The Problem

This play addresses three simultaneous access failures: telehealth, workforce training, and benefits enrollment. Importantly, broadband alone cannot solve these intersectional challenges without purpose-built private access infrastructure

Approximately 99 million Americans live in federally designated primary care Health Professional Shortage Areas (HRSA HPSA data, 2024). A 2023 GAO report found that rural hospital closures leave affected residents traveling 20–30 additional miles on average to reach comparable specialty care (GAO-23-105765). For these residents, the library is the nearest institution with reliable broadband — but the open floor plan, shared computers, and ambient noise make it unusable for a telehealth appointment, a benefits intake interview, or a workforce training session that requires sustained attention and privacy.

The stakes are documented. The first operational Medicaid work requirement program — Arkansas in 2018 — lost 18,164 beneficiaries in six months. A study published in the New England Journal of Medicine found that coverage losses were driven primarily by failure to navigate compliance documentation systems, not failure to actually perform qualifying work activities (Sommers et al., NEJM 381(11), 2019). 96.5% of affected beneficiaries were already working, already exempt, or faced documentation barriers they could not overcome. Compliance infrastructure is not an administrative convenience. Its absence is a documented public health failure that stripped coverage from people who were entitled to keep it.

The Context

Three simultaneous policy pressures converge on this play. First, states with active or pending Medicaid work requirements face compliance documentation mandates for which no purpose-built physical infrastructure exists, the Arkansas NEJM study documents precisely what happens when that infrastructure is absent. Second, state broadband offices that invested BEAD funds in library and CAI connectivity face growing pressure from governors and legislatures to demonstrate measurable utilization returns on that investment. Third, rural and low-income residents face persistent barriers to telehealth, workforce training, and benefits enrollment not because broadband is absent at their local library, but because the open floor plan makes it unusable for the services they need.

Service portals address all three pressures simultaneously: they convert existing connectivity investment into documented service delivery, generate the compliance and utilization data both state and federal agencies require, and provide the private access infrastructure that transforms broadband into usable healthcare, workforce, and benefits access. CPF balances with near-term expenditure deadlines and many state or federal funding at the intersection of technology and health which includes workforce development facilities and combination infrastructure projects… this is a play that states can design and fund now.

The Demand Signal

Three converging bodies of evidence document that the demand for private-access service delivery infrastructure at community anchor institutions is real, growing, and unmet by current CAI broadband investment.

First, the telehealth utilization gap. A 2023 peer-reviewed study published in the National Library of Medicine found that counties with the highest broadband availability had 47% higher telehealth utilization than those with the lowest but a separate JAMA Network Open study of 172,387 Wisconsin Medicaid beneficiaries found that telehealth disparities persisted even among patients with high-speed internet at home. Broadband connectivity alone does not produce telehealth utilization. The Kruse et al. systematic review of 45 studies identified private access space and not connection speed as the primary adoption barrier. Libraries upgraded by BEAD have the connection. They do not have the space.

Second, the HRSA shortage data quantifies the population with no alternative. HRSA identifies 99 million Americans in federally designated primary care Health Professional Shortage Areas. For these residents, the local library is frequently the only institution with reliable broadband within reasonable distance. Telehealth demand in shortage areas is documented and unmet. The infrastructure to use it at community access points is not.

Third, the Medicaid compliance deadline is now federal law. The One Big Beautiful Bill Act, signed July 4, 2025, mandates Medicaid work requirements for adults in the ACA expansion group beginning January 1, 2027; a requirement that applies to 43 states. Nebraska begins enforcement May 1, 2026. Montana on July 1, 2026. Iowa on December 1, 2026. Every state that expanded Medicaid must build compliance documentation infrastructure before the deadline or risk the outcome the Arkansas program documented: 18,164 people losing coverage in six months because the online reporting system failed them, not because they weren't working. The compliance infrastructure gap is no longer a policy experiment in a handful of states. It is a 43-state implementation problem with a hard deadline and no state has purpose-built the physical access points residents need to navigate it.

Each service portal is a freestanding, soundproofed booth approximately 4×4 feet in footprint, ADA-compliant in interior dimensions and approach path. States should plan for two unit configurations: a standard unit (ADA approach path and interior compliance) and a wheelchair-accessible variant (larger footprint, interior turning radius, height-adjustable interface); a minimum of 20% of any state fleet should be wheelchair-accessible units. For libraries or CAIs without available open floor space, an existing office or meeting room may substitute as the portal enclosure.

The exterior panel displays a QR code for walk-up booking and a status indicator (available / occupied / scheduled). The interior is equipped with a 27-inch medical-grade touchscreen display with adjustable height and tilt, a clinical-quality camera with 1080p resolution, noise-canceling directional microphone, a privacy screen film preventing external viewing, and a privacy lock controlled from inside. USB-C and standard AC power outlets support peripheral devices including blood pressure cuffs, pulse oximeters, and document scanners for sites that opt into peripheral health monitoring packages. All specifications are minimums; higher-performance equivalents are acceptable.

Minimum viable connection is 25/3 Mbps with latency under 150ms; optimal performance requires 100 Mbps symmetric with latency under 50ms. Booths do not require dedicated circuits and standard 20A outlets are sufficient. Electrical prep consists of verifying outlet availability within the booth's cable run, typically completed by a library maintenance staff member in under two hours.

The guided touchscreen interface presents three service modes: Telehealth (connecting to state-approved telemedicine platforms including Teladoc and state Medicaid telehealth networks), Workforce Training (linking to state workforce portal and approved training platforms), and Benefits Enrollment (linking to state and federal benefits systems including Medicaid, SNAP, and unemployment). The interface is designed for zero prior digital literacy: large buttons, plain language at a 6th-grade reading level, and step-by-step guided navigation. Language selection is available on the first screen.

A fleet management dashboard accessible to whomever is governing their use such as state broadband office and to CAI administrators provide real-time utilization data, session logs, compliance reporting outputs, and maintenance alerts for each unit. All session data is logged automatically, generating the audit trail for NTIA reporting, Medicaid work-requirement compliance documentation, and workforce program outcome reporting without requiring manual staff input.