One patient has to take two bus rides and walk a mile just to get herself and two young children to the doctor. Another patient relies on a van service to help herself and her daughter reach care, but she has missed three visits in the past five months. “They have us wait hours to get picked up, and then hours to get back home,” she said. “And I don’t always have money for the bus.”
These are just two of many patients we have met at a primary care clinic in New Jersey in recent months. Many of them are covered by Medicaid or have no insurance at all. The clinic’s no-show rate ranges from 15 to 30 percent on a given day, and that does not count all the late arrivals and cancellations that scramble the schedule. Some patients rely on sparse bus lines. Others depend on family or friends. Many resort to walking several miles, even in the winter.
Hurdles to accessing health care make life difficult both for patients and the clinicians who take care of them. There is growing recognition that the social circumstances surrounding patients’ lives — food insecurity, housing instability and lower educational attainment — have a significant impact on health and wellbeing. Even the best caregivers cannot always overcome the obstacles of chaotic social circumstances.
The link between transportation access and health has been recognized for at least half a century. Medicaid, established in 1965, required each state to include in its plan a provision for assuring transportation of recipients to and from providers of services. This transportation guarantee for disadvantaged population has been affirmed time and again in federal court, starting with Smith v. Vowell in 1974. Wrote the judge: “The deprivation of medically necessary transportation is disadvantageous even to the state for it only results in the end in higher medical costs.” Since that time, nonemergency medical transportation (NEMT) has evolved into an enormous system that spends more than $3 billion each year nationwide to help millions of low-income, elderly and disabled patients reach care.
Transportation assistance is both cost-effective and cost-saving. In 2005, the Transportation Research Board of the National Academy of Sciences found that providing transportation for disadvantaged patients with pre-natal care needs, as well as a range of chronic diseases such as diabetes and asthma, lowered health costs by more — in some cases 10 times more — than the upfront cost of the rides. Transportation for patients who need a variety of preventive services, such as breast cancer screening, was also determined to be cost-effective, meaning the cost was justified by quality of life gains. In 2008, Florida commissioned an independent evaluation of its NEMT program, which found that each dollar invested saved $11.08 in avoidable hospitalization costs: an ROI of more than 1,100 percent.
In recent years, however, policymakers in some states appear to be questioning the value of providing transportation to Medicaid beneficiaries. In 2015, Iowa and Indiana eliminated NEMT benefits for Medicaid beneficiaries, except for some categories such as pregnant women or “medically frail” individuals. Other states have shown interest in similar reforms. An architect of the Medicaid programs in Iowa and Indiana, Seema Verma, will soon take over leadership at the Centers for Medicare and Medicaid Services, which oversees Medicaid nationwide.
The erosion of NEMT benefits in these states, and attempts to erode them in others, has been fueled by an independent evaluation which concluded that the cutbacks did not decrease access to care: In Indiana, the evaluation found the “only” 11 percent of beneficiaries cited a lack of transportation as the reason for missed appointments. That might sound like evidence that there is not a real problem, until you consider that 11 percent of 1.5 million Medicaid beneficiaries in Indiana amounts to 165,000 people who need help. Furthermore, the study found that the most common reason for missed appointments was indeed transportation. Even then, the missed appointment measure does not account for people who do not even try to schedule an appointment because they know transportation would be a barrier.
Efforts to cut back on transportation assistance benefits, in light of their nominal cost and the powerful evidence of their cost-saving potential, is a short-sighted budgetary move that ignores the real needs of vulnerable patients and misses out on long-term savings. If we are to bend the cost curve in health care, it makes no sense to remove one our most simple and potent tools: a ride.
Instead, we should strengthen our medical transportation programs and improve their efficiency, reliability, convenience and transparency for patients, health care providers, insurers, regulators and transportation providers. The $3 billion we currently spend makes a difference, and is cost-effective, but it could reach even more people: almost 4 million Americans still miss appointments due to transportation each year, according to the Transportation Research Board.
We are finally moving in the right direction. Across the nation, new companies and cross-sector partnerships are emerging to introduce the technology and processes needed to build modernized NEMT systems. For example, hospitals and primary care clinics are experimenting with using Uber and Lyft. Existing NEMT providers are being connected to patients through mobile apps. Public transportation systems are making it easier for patients to access first-mile and last-mile trips to and from bus and subway stops. At Ride Health, we are building technology that allows health care providers to coordinate trips for patients and communicate with them before, during and after each journey.
These innovative efforts require that Medicaid and other payers maintain, and even expand, support for transportation programs. “Unless needy individuals can actually get to and from providers of services, the entire goal of a State Medicaid program is inhibited at the start,” reads a Medicaid administration manual from 1978. It is time for our policymakers to remember that simple idea, and to realize its full potential to improve the health of millions.
Imran Cronk is co-founder and CEO of Ride Health, an organization that seeks to help patients access transportation to medical appointments.