The result for these Americans aged 65 and older due to this digital divide? Worsening health inequities and heightened health problems. Digital literacy and Internet connectivity have been dubbed super social determinants of health.

An August 2022 Frontiers in Public Health article noted: With the rapid development of digital health today, the lack of digital health literacy in older adults is an urgent problem.

Digital health literacy: A social determinant of health

I think digital literacy at its core is one of the most important social determinants of health that no one addresses because its so hard to solve, says Stefano Selorio, CEO of Carevocacy, a Miami-based tech tutoring business for older adults. 

In fact, studies have shown that a majority of Medicare recipients often lack digital literacy, says Brandon Aylward, director of digital health research and advisory services at RTI Health Advance, a health care consulting firm in Durham, N.C.

The digital health divide is especially large among Black, Hispanic and Afro-Caribbean adults aged 60 and older, according to a 2021 study done by Florida Atlantic University, the Dana-Farber Cancer Institute and the University of Massachusetts Medical School.

Study participants were up to five times less likely to have access to digital health information than those who were younger and more highly educated, had a higher income or were European Americans.

Two big barriers to digital health adoption

The Health Equity and Access Leadership Coalition says two barriers to widespread digital health adoption are: access to broadband, hardware and software; and health literacy.

Some 30 million Americans dont have broadband access and many of them are older adults living in rural areas.

Most Americans eligible for the U.S. governments small program to expand broadband access and lower costs arent using it due to a complicated application process. And the Federal Communication Commissions Lifeline program subsidizing the cost of smartphones and Internet service for low-income Americans has had rampant fraud.

Among people age 65 and older, just 44% use tablets and only 61% have smartphones, according to Pew Research Center.

One-quarter of Americans 65+ dont use the internet. By contrast, 98% of people in their 30s and 40s do.

And some Medicare beneficiaries who have smartphones, tablets or computers arent sure how to use them for their health.

Understanding how to use their technology

They need to know how to use their tech, says Liz Hamburg, founder and CEO of Candoo Tech, a New York City-based tech training company for older adults.

Hamburg cites a woman in California who contacted Candoo Tech after receiving a tablet from a local nonprofit.

Shed never used a tablet before, so we had a tech concierge show her how. Then she called back a couple of weeks later to say she needed an email address. We got her set up with Gmail. Then she needed to get onto her Medicare Advantage plan to message her doctor, Hamburg recalls. So, in two months, we went from never using the tablet to being able to message her doctor.

Falling numbers for telehealth and Medicare beneficiaries

Telehealth usage by Medicare beneficiaries offers one example of digital health problems for some older Americans.

One study highlighted that only a little over 35% of Medicare participants knew how to connect to their health care provider via telehealth, says Aylward.

But telehealth can be extremely useful for older adults with difficulty getting to a doctors office due to their health issues, says Selorio.

The percentage of Medicare beneficiaries using telehealth has dropped precipitously lately, however.

Just 15% of people with fee-for-service Medicare used telehealth in the second and third quarters of 2022, the latest statistics available, down from 47% when the pandemic hit in the second quarter of 2020, according to the Center for Medicare and Medicaid Services (CMS) Medicare Telehealth Trends Report. (Medicare will cover telehealth visits anywhere through 2024.)

Partly, Aylward says, the decline in telehealth usage reflects the trend of the overall U.S. population. Now that the COVID-19 risk going to a doctors office has lessened, patients are more apt to make their visits in-person, which they tend to prefer.

But doctors may be responsible for this shift, too.

A recent Harvard T.H. Chan School of Public Health survey published in Health Affairs found that four in five primary care doctors who had telehealth visits with patients during the pandemic would rather provide a small portion of care through telehealth in the future, or none at all.

Most doctors surveyed said telehealths quality of care was generally inferior to in-person care.

Digital-forward doctors

Some medical practices are far more digital-forward than others, encouraging the use of technology for scheduling and rescheduling appointments, answering patients questions and providing medical information. This can be very helpful for digitally health literate patients and unhelpful for others. (My primary care physicians and specialists are big on digital tech; my eye doctor is not.)

You have practices that have gone completely digital as far as their communications and scheduling. But then you have practices that havent adopted those kinds of approaches, says Aylward.

Darwin Hale, CEO and founder of Advocate Health Advisors, an Englewood, Fla. adviser to insurance agents who sell Medicare policies, believes improving digital health literacy for Medicare beneficiaries is a tremendous opportunity because digital health helps you have more accurate and more real-time information to make decisions on.

A proposal for Medicare Advantage members

One proposal to improve digital health literacy for people with Medicare Advantage plansthe private alternative to Original Medicare, known as Part C planscame recently from CMS.

The agency aims to require that Medicare Advantage plans offer digital health education to members with low digital health literacy, starting in 2024.

Low digital health literacy is one of the most significant obstacles in achieving telehealth equity, and many older adults with low digital health literacy experience gaps in access to the health care need, CMS wrote in its proposed rule.

Whether that proposal will take effect and, if so, exactly how the plans would decide which members need training and how to deliver it are all unknown as of now.

Hamburg says Candoo Tech is working with a Medicare Advantage plan that hadnt planned to help its members increase their digital health literacy. Then they went to a Town Hall meeting of their members and said it was one of the number one most requested topics, she recalls. So, they came back to us and said: Weve got to prioritize this.

Where to get digital health literacy help

The National Digital Inclusion Alliance, a nonprofit, has a list of organizations around the country providing digital literacy training and resources for reducing Internet and computer costs.

Companies like the software platform Icario offer programs to improve broadband access and education specifically for Medicare plan members. Icarios Digital Bridge tells those beneficiaries about the availability of free or low-cost devices, broadband internet service and tech support.

Other companies, like Candoo Tech, Carevocacy offer digital health tutoring and training, often through Medicare Advantage plans and senior housing developments.

One of the learners we worked with was trying to figure out what kind of cardiologist she wanted, says Selorio. She wouldnt have been able to do that if she didnt know who the cardiologists were in her hospitals system. We helped her figure that out and she was able to make a pick that was of her own choosing, rather than a recommendation from the hospital.

A Candoo survey found that 60% of its users have accessed telehealth or researched medical information since receiving the companys training.

Were working with a hospital system that uses a remote patient monitoring device so patients whove been released from the hospital record their weight and blood pressure and communicate with the doctor for seven or eight days. They found that if they can get them onto the system, theres a significant decrease in rehospitalization, says Hamburg. But theyre finding a lot of patients cant get onto the system, so were working with those patients.

Nonprofits such as AARPs Older Adult Technology Services (OATS) and public libraries offer digital health literacy instruction, too.

The 2020 Patients Accessing Technology at Home (PATH) Project from OATS and Maimonides Medical Center, for example, trained 19 chronically ill older adults living at home and their family caregivers how to use computers to enhance their health, using tech tools and encrypted email from geriatric medical providers.

Making digital health content user-friendly

Aylward says its important for digital health content to be tailored to users, especially for older patients.

Information thats presented in a clear and concise manner, thats easy to understand and doesnt include a lot of medical jargon, he suggests. Plus, visual aids or videos or interactive tools to really enhance engagement and comprehension.

Advocate Health Advisors, Hale says, is creating a series of digital health content thats tailored to veterans and for people on Medicaid.

Hamburg says digital health access and literacy can be so helpful for patients of all ages. I can go to a doctor and all of my blood tests and results are now accessible electronically. So instead of my bringing a huge file of stuff, everything is on there, she says. That really wouldnt have been possible even five years ago.

The Vancouver-based activewear company reported a strong first quarter and an upbeat forecast for the year ahead, driven in large part by a resurgence in demand from one of its key markets.  

Lululemons sales were up 24% to $2 billion, compared to analyst expectations of $1.93 billion. Of this, Chinas revenue alone grew 79% the last quarter versus the same period last year, pointing to the return in the demand for high-end products in the country. 

 Our Q1 results were strong as guests responded well to our product offering in all our markets across the globe, said Lululemon CFO Meghan Frank in a statement Thursday. A meaningful acceleration in our China sales trend, coupled with lower air freight, contributed to our better than planned financial performance.

Lululemon plans to open 30 to 35 stores internationally, with a majority of those being in China, Frank told analysts. The apparel-makers shares jumped almost 15% in after hours trading Thursday following the results. 

Lululemon is just the latest company to be boosted by Chinas appetite for retail spending, including the likes of luxury conglomerate LVMH, whose CFO Jean-Jacques Guiony noted in April that there was a pretty nice pick up in China which bodes well for the rest of the year, according to the Wall Street Journal. The company recorded a jump in quarterly sales for the start of this year, thanks to Chinas rebound.

Chanel, the second largest luxury brand globally, said its retail growth in China was ticking up even as big markets like the U.S. were easing. And the company expects to continue seeing growth as Chinese shoppers slowly begin traveling again. 

The most affluent part of the Chinese clientele is the one that is currently travelling, Chanel CFO Philippe Blondiaux told the Financial Times last week. The most limiting factor today preventing a full return of Chinese consumers to Europe is flight capacity. 

Chinas economic recovery

The worlds top retail companies had become reliant on spending by consumers in China, which was the largest luxury market until the pandemic kicked in. When COVID-19 restrictions were introduced, stores were shut for a prolonged period and travel was curbed, ending Chinas bull run as a luxury capital, consulting group Bain & Company noted. In 2022, the personal luxury market shrunk by 10% and foot traffic at malls was down 30% to 35%, both of which hurt brand sales. 

When Beijing rolled back restrictions a few months ago, the reopening of the Chinese economy brought more business to companies offering upscale goods from bags and jewelry to athletic attire.

In the first two months of 2023, Chinas consumer spending was up 3.5% compared to 2022, returning to growth after months of decline. The luxury market in China is expected to account for 25% of global luxury spending by 2025, according to accounting firm PwC, creating opportunity for high-end retailers. Moreover, luxury spending may be recovering even faster than the Chinese economy itselfthe sales of jewelry, gold and silver was up over 37% in March, according to data from Chinas National Bureau of Statistics cited by the New York Times.

But getting there wont be as easy for China. The bulk of Chinas luxury spending is spurred by people under 40with youth unemployment soaring and economic recovery happening at a slower-than-expected pace, luxury retail spending may not boom the way companies hope. 

Consumers holding back

Even though luxury brands typically cater to consumers who remain relatively better off when theres macroeconomic pressure like inflation, a number of retailers have seen discretionary spendingincluding clothes and electronicssuffer in recent months. For instance, clothing brand and Lululemon rival Under Armour cut its annual profit and sales forecast for the year in May citing inflation that was impacting demand and eating into profit margins. It also said consumers were holding back on expenses in the interest of cutting costs.  

Similarly, Nordstrom, a retailer offering middle to higher end products, saw that even though its customers were shopping, they were still pulling back expenses.   

But Lululemon said it hasnt experienced any change in demand for the last quarter. The company, which was grappling with high inventory pile-up last year, says it is expecting robust sales for the rest of 2023. 

In terms of our guests metrics, theyve remained very strong. Weve seen no change in our cohort behavior, in terms of frequency of purchase or engagement, Lululemon CEO Calvin McDonald said.  

Lululemon did not immediately return Fortunes request for comment.

Much like other Nashville staples, the goal of the Big Drag Bus is to bring the party and spread joyand theyre often successful. Co-owner and operator Josh Cloud started the venture after he was furloughed during COVID, and while he was originally concerned about the reaction it would receive, he says the Drag Bus just made people happy. Nearby pedestrians often dance along, wave, or tip the queens through the windows.

But a select group of politicians arent so enthusiastic. In March, Tennessees Republican Gov. Bill Lee signed a bill into law labeling adult cabaret performances or male or female impersonators who provide entertainment that appeals to a prurient interest in front of kids or in public a criminal offense. Even though the word drag never appears in the bill itself, its vague enough for a public bystander to report a drag performance as cabaret.

Pushback to the legislation was swift; Friends of George, a Memphis-based sketch and theater group focused on drag queens and kings, challenged the bill in court, which was paused on March 31, on the basis that it violates the First Amendment. The fate of that challenge will be determined Friday, June 2.

Courtesy of Josh Cloud. Tyler Shields @ Tymeallo Studios

But the law is part of a larger war against drag shows raging across the country, and activists say its just the latest way Tennessee is zeroing in on LGBTQ+ people, following a state law blocking transgender children from access to gender-affirming care. Its blatantly targeting the LGBTQ+ community and so clearly unconstitutional, says Todd Roman, co-owner of Big Drag Bus and owner of Nashville gay bar and dance club Play, adding that it could take the state back 50 years in terms of LGBTQ+ acceptance. 

Drag is a multi-million dollar business nationwide, and its roots go back decades in Tennessee, whose bigger cities like Nashville and Memphis host vibrant drag scenesso its ironic that the conservative-backed bill comes from a party that has built a pro-business and small government platform. Fortune spoke with six drag queens, business owners, and LGBTQ+ leaders in the state who say that the anti-drag bill not only delegitimizes Tennessee drag performers lives and identities, but instills a fear it will hurt their ability to earn money and negatively impact the local and state economy. 

Within the gay community, there is a great sense of fear on a number of things, for the performers themselves, their livelihoods, says Roman.

No place like home

RuPauls Drag Race has helped drag become a major part of mainstream American culture, providing some stars with a creative outlet and catapulting others into fame and fortune. But many of Tennessees drag workers were exposed to the industry way before Drag Race came onto the scene.

The first time Tracey Ottomey ever saw drag was as a child watching the 1995 film To Wong Foo (Ottomey, like all other drag performers Fortune spoke with, asked to be referred to by her stage name). When she got older, Ottomey went to her first drag barPlay. I saw my first drag queen in real life, and I was like, Oh my gosh, that is the coolest thing, she says. Thats what I wanted to do.

A drag queen for more than 10 years now, Ottomey first took to the stage intending to channel Britney Spears, but has since realized shes more of a Tina Fey, given her knack for stand-up. She says she loves how drag lets her be a different person and tap into the strong women that she once idolized growing up. 

It was a similar experience for Obsinity. Twenty years ago, she watched awestruck as a drag performer dressed as Wonder Woman twirled fire batons and set a stage on fire. At the time, she thought it was the coolest art form. But as a self-proclaimed shy kid, she never thought that would one day be heruntil a friend dared her to enter a drag talent show two years later. After winning, her drag career just blew up from there, she says.

Drag ultimately helped bring Obsinity, who has been performing an impression of Reba in Nashville for the past 10 years, out of her shell. I walk out [on stage] and the first thing I hear is like five people scream Reba, she says. Its a very rewarding feeling.

Obsinity and Ottomey, along with other Tennessee drag workers, say that the artf orm elicits creativity, imagination, and joy. Its a great way to find bits of yourself that you didnt know existed; when you put on another persona, you really take on a new identity and you never quite know who thats going to be until they manifest themselves, says drag queen Veronika Elektronika.

Originally from New York City, Electronika has been performing since her theater kid days. She says drag appealed to her as a way to stretch out her theater wings so she could be the star of her own show and learn a new skill. Through it, she found freedom, expression, diversity, and connection, a common theme among many of the queens who said the close-knit community they discovered in Nashvilles drag scene helped them feel at homesomething important for LGBTQ+ members who can sometimes find themselves shunned by family.  

Courtesy of Veronika Elektronika

But they say that Tennessees burlesque law is threatening to take all of that away. Even though the law might be overturned, Ottomey says she feels shaken it even got this far. Taking away someones way to make a living is just another form of quieting trans and gay individuals, she adds: They want to silence us completely. A lot of trans people do drag to support themselves. Its just one way for them to silence us even more. 

In Nashville, once home to Drag Race stars Brook Lynn Hytes and Jorgeous, the typical drag queen makes $100 to $200 per shift (which is often five to six hours), depending on their experience, Roman says. A part-time drag queen working four days a week shared with Fortune that she typically takes home between $900 to $1,400 a week.

While the bill wouldnt impact adults-only drag clubs and bars, if implemented, it would affect restaurants and bars that welcome kids, along with public activities like the Big Drag Bus, and events such as Pride. A boon for local economies everywhere, Pride events can rake in as much as$30 million in bigger cities nationwide. But that kind of economic gain is on shaky ground in Tennessee, where a Pride festival in Knoxville, which draws up to 80,000 people a year, has already threatened to cancel an event if the law is pushed through. The festival in the town of Franklin agreed to not include a drag performance this year, but is still meeting resistance to city permit attempts. And in this months Midsouth Pride festival in Memphis, drag entertainers are planning to forgo costume changes so they dont run the risk of being reported as cabaret, as well as tips should the bill be enforced. 

Tennessee already has obscenity laws in place that monitor how people dress, those in the states drag industry say, but theyre not equally enforced. That extra law monitoring adult cabaret is therefore redundant, explains Friends of George board member Micah Winter Cole. Both Roman and Cloud, the Big Drag Bus owners, point out that there are restaurants that offer kids menus and have scantily-clad waitresses. Cloud calls it hypocritical that drag queens are expected to cover up. Our girls are way more covered up than the Tennessee Titans cheerleaders on Sunday morning, he says. 

Elektronika also worries the ban will also affect drag-related retail businesses, like her company that sells cosmetics and costumes. It has a direct effect on our business because a lot of our clientele are drag performers, she says. The less drag there is, the less income my small business has. It affects me in multiple arenas. 

The party is still going, but workers fear it wont last forever

Shortly after the cabaret law was signed in March, and before it was paused from going into effect later that month, Electronika recalls strutting onto a stage to ask the crowd of 600 people: Do I look like a felon to you? She was met with screams and cheers of support. 

Both she and Cloud noted that more people have been showing up to tours and shows in the past few months, and drag workers say the law has actually given the drag business a boost almost the best PR we could have asked for, because its highlighting what we do versus what we dont do, Elektronika says. 

To be sure, private drag venues, such as night clubs like Play, wont be directly affected by the ruling either waythey are out of the public eye, and children are not allowed. That leaves many business operators and owners operating as they once would. And many queens are already operating in a PG- or even G-rated manner already. Obsinity explains shes not changing the way she performs, and adds theres nothing provocative about her performance.

I mean, come on, Im doing Reba, she says.

Even so, the law is about an unevenly targeted policing of who can express themselves and what is considered provocative. While the drag scene is just one growing staple of Tennessees culture, Roman says that the law would negatively impact Nashvilles local economy since drag is such a major part of the citys booming nightlife and tourism industry. After all, it would still impact public performances like the Big Drag Bus and Pride events. And Ottomey is afraid that even if the law affects only part of the drag scene, it will eventually scare people away from even private drag shows. The far-right extremist Proud Boys have already been targeting drag shows across the country in recent months.

Its dangerous when the government tries to trample on the rights of marginalized communities, says Elektronika. And I think thats bad for any economy. 

Courtesy of Tracey Ottomey

Activists like Winter Cole warn that drag isnt where this bill stops, arguing it poses a larger danger to transgender people because it criminalizes what women and men look like when they get dressed. Roman worries it will have real world implications in the form of lost lives for struggling young adults, explaining that his cousin, who didnt grow up with an accepting family, ended up dying by suicide.

In the meantime, the business owners and drag workers Fortune spoke with are waiting to see how overreaching the legislature can be. We see the Republican Party time and time again tout the idea of small government, yet here they are trying to go into small business, says Elektronika. 

Tennessees LGBTQ+ community is hopeful that a judge will rule the bill partly or wholly unconstitutional, which would nullify it completely. Winter Cole remains cautiously optimistic, believing that while the road ahead will be long, but not so rough road ahead. 

Theres going to be a bigger fear, a louder voice in the back of our minds now about it, says Ottomey. But as long as we keep being ourselves, they cant take that from us.

The 2022 ordinance, which the city plans to begin enforcing next month, would require owners to register with the mayors office, disclose who else lives in the property, and promise to comply with zoning, construction and maintenance ordinances.

Airbnb called the restrictions extreme and oppressive and a de facto ban against short-term rentals that left the company no choice but to sue.

Taken together, these features of the registration scheme appear intended to drive the short-term rental trade out of New York City once and for all, Airbnb said. The company said the mayors Office of Special Enforcement failed to consider reasonable alternatives.

A spokesman for Mayor Eric Adams said city hall will review the lawsuit.

This administration is committed to protecting safety and community livability for residents, preserving permanent housing stock, and ensuring our hospitality sector can continue to recover and thrive, said the spokesman, Jonah Allon. The rules governing short-term rentals have been clear for years, and the 2022 registration law was properly adopted by the city council, he added.

San Francisco-based Airbnb filed the lawsuit in state court in Manhattan. Three Airbnb hosts filed a companion lawsuit against the city.

Airbnb sued New York state in 2016 over a ban on advertising short-term rentals. It dropped that lawsuit when the city promised not to enforce it. In 2020, Airbnb settled a lawsuit against the city over monthly reporting requirements for its listings. Airbnb said the 2022 ordinance violates both settlements.

The New York restrictions are among many efforts by local communities to regulate short-term rentals without banning them. New Orleans is among cities taking on the rental giant, after a court struck down a previous law.

In some places, opponents have raised concerns about noise and safety. Critics also say the growth of short-term rentals pioneered by Airbnb has contributed to a shortage of affordable housing for residents, particularly in vacation towns. Those complaints extend far beyond U.S. borders.

On Thursday in Italy, the popular tourist destination of Florence announced an immediate ban on new vacation rentals in the citys historic center.