Health Policy$ense

Transportation and Medicaid: Breaking Through the Gridlock

Too early to cut benefits

Lack of transportation has been an enduring barrier to care, especially for low-income and rural patients. Many of these patients are covered by Medicaid, which, since 1966, has provided non-emergency transportation (NEMT) to medical appointments for free or at a heavily subsidized rate. Although NEMT is built into the foundation of Medicaid, some state governments are seeking leeway to drop that benefit. The movement stems from persistent budget constraints and a view that NEMT is ineffective. In a recent article, LDI Senior Fellow Krisda Chaiyachati and colleagues argue such restrictions are premature and potentially harmful. Instead, they call for a focus on evidence first.

Krisda Chaiyachati, MD, MPH, MSHP, is an Assistant Professor of Medicine at the University of Pennsylvania.

Under the Obama administration, Iowa and Indiana received Medicaid waivers to remove NEMT benefits, and the Trump administration has signaled a willingness to further shrink NEMT through section 1115 waivers. More recently, the Centers for Medicare & Medicaid Services announced they are formulating a rule to skip the waiver process entirely, and facilitate states’ desires to cut NEMT benefits.

Chaiyachati and colleagues call for data transparency, research, and support for NEMT before states consider dropping the benefit. They note that the demand for NEMT is strong; there were more than 59 million NEMT trips in 2015 alone. Large surveys of low-income patients show that between 24% and 51% report missing or rescheduling appointments because of unreliable transportation. Further, the potential upside for NEMT is substantial. For example, independent analysis of Medicaid claims finds that NEMT costs are small compared to savings associated with keeping dialysis and diabetes patients adherent to clinical guidelines.

Finally, and crucially, the debate over NEMT is occurring in an evidence vacuum. Before reforming or curtailing NEMT, policymakers still need answers to several basic questions: Who currently benefits from NEMT? Who needs NEMT the most? When do they need it, and why? These answers can reveal whether demand for NEMT is driven by those who benefit the most (that is, have the greatest need and have no alternatives) or if the benefits accrue to those who have other ways to travel to their medical appointments. The lack of clarity on the beneficiaries and outcomes of NEMT isn’t due lack of trying on the part of researchers. Reporting requirements for NEMT vary widely across states, and travel data cannot be linked to Medicaid claims or patient outcomes. These barriers have been stifling to answer fundamental questions about NEMT.

Rather than cut NEMT, Chaiyachati and colleagues argue that CMS and state Medicaid programs should focus on creating systems to gather and publish transparent, consistent data for public review, link those data to medical claims data, leverage Medicaid managed care organizations to track cost and outcomes, and test different NEMT approaches and programs.

The limited research to date on alternatives to NEMT suggest that the problem of transportation is not easily innovated away. Despite hype in the media over how ride-sharing may disrupt non-urgent medical transportation, a recent study led by Chaiyachati offered Lyft rides to Medicaid recipients and found no change in rates of missed appointments. The findings reinforce the need to carefully target patients who have unmet transportation needs when designing programs, and to situate NEMT within the larger context of how Medicaid can address social determinants of health. If states can feasibly provide transportation services that improve outcomes for vulnerable citizens, those programs would prove to be a wise use of scarce public resources.