This past June, California’s Department of Healthcare Services went live with the implementation of its non-medical transportation (NMT) benefit. NMT is described by the National Health Law Program as “transportation provided to access medically necessary services, which is provided by ordinary forms of transportation (public transportation, taxi, or any other forms of public or private transportation).” While transportation as a benefit has long existed under California’s Medicaid program as “non-emergency medical transportation” (NEMT), it was limited to only providing transportation when there was a medical reason that a patient could not have taken public or private transportation. Instead, under the new NMT benefit these restrictions would disappear. The language of the bill suggests that transportation will be covered for all patients who cannot reasonably afford transportation to medically-related appointments, pick up medication or even visit a dependent in the hospital.
Improving the Medicaid transportation benefit nationwide is necessary to provide adequate care to medically underserved patients. In some states, patients who are defined as “medically-able” do not qualify for NEMT, but are still limited in their transportation options because of other social and financial reasons. In other states, transportation requirements are stringent, ride quantity is capped, and prior authorization and copayments limit access to transportation services. It is estimated that over 3.6 million Medicaid beneficiaries “miss or delay care” annually due to transportation related issues. A study in the Journal of Immigrant and Minority Health found that 25 percent of missed appointments were due to transportation problems and that bus users were twice as likely to miss their appointments compared to car users. More states should consider expanding the transportation benefit for their Medicaid program to cover this gap. Flexibly implemented NMT may lead to higher appointment attendance and greater continuity of care.
Though the benefits of NMT are clear, rolling it out to all patients who need it can seem like a daunting task for any state Medicaid agency. Transportation needs are highly specific to location and individuals; they would be difficult to offer effectively to patients who truly need them. State Medicaid agencies can start by aggressively expanding transportation during well-defined periods where missed appointments are common during a medically sensitive period in a person’s health. One medically sensitive period where many patients do not get access to necessary care is during the postpartum period. The postpartum period, as defined by Medicaid, is the six-week timeframe after a mother delivers in which she still maintains Medicaid coverage. Within this period, the American College of Gynecologists recommends at least one visit in the first three weeks after delivery with the potential for additional visits as needed for maternal/infant complications. Unfortunately, a California study found that only 49.4 percent of its Medicaid mothers attended a postpartum visit and African-American mothers are significantly less likely to attend their postpartum appointment than white mothers. This may be explained by the fact that many mothers may not have adequate access to transportation during the postpartum period under the current NEMT Medicaid benefit. According to Tara Tinnin, program coordinator of the Washington University’s Perinatal Behavioral Health Service, a St. Louis initiative called FLOURISH that works on addressing disparities in infant and maternal health has started a program to make transportation more accessible and reliable for mother’s in the area. Even with the improvements, “we still have issues [with transportation] every now and then … Sometimes, patients still get turned down [for transportation] for mental health appointments. We have a slush fund to provide cab vouchers for women to get appointments but it’s a major barrier in St. Louis.”
The story of American perinatal care cannot be understood without contextualizing it with the story of Medicaid. According to a Kaiser Family Foundation report, 24 states have 50 percent or more of their births delivered through Medicaid. Medicaid’s own limitations with the six-week postpartum period severely limits the health insurance program’s ability for providers to care for moms effectively after they deliver. Dr. Ebony Carter, an OB/GYN at Barnes-Jewish Hospital, outlined it best, “[patients] have their babies and six weeks later they lose their insurance … What good have I done them to let them know exactly what they need to do when they don’t have the tools or resources to do any of it?” Nonetheless, with the severe restrictions on the definition of the postpartum period that still exist due to Missouri’s decision to not expand Medicaid, it is especially important for mothers on Medicaid to attend their postpartum appointments. For this reason, reliable transportation is an essential benefit for pregnant mothers. The story of the American pregnancy is also defined by racial inequity. In the past year, ProPublica’s “Lost Mothers” series has told the stories of moms who died during childbirth and revealed the broad racial disparities which define American perinatal care. We must continue efforts to remove the implicit bias, lack of communication, systemic racism, and care fragmentation that black mothers experience. While improved access to transportation does not explicitly address racial disparities, it will improve overall maternal health and disproportionately serve African-American mothers.
Because of the limitations of NEMT and the high-volume of Medicaid pregnancies, state Medicaid agencies should strongly consider expanding Medicaid’s transportation benefit for postpartum moms. NEMT can only provide transportation to mothers under limited circumstances and often require prior authorization, an extensive treatment plan, or a well-defined disability. Outside of California’s NMT program, there is precedent for expanding Medicaid’s transportation benefit. In New York’s Medicaid program, patients on a Health and Recovery Plan (HARP) are allowed access to non-medical transportation to home and community-based services (job interview, wellness seminar, etc.). Similarly, in Colorado, patients who receive care under an HCBS waiver are permitted to access non-medical transportation for non-medical appointments. Many Medicaid managed care plans negotiate with their state Medicaid agencies to offer an expanded transportation benefit beyond what the Medicaid fee-for-service offers.
To establish a non-medical transportation benefit during the postpartum period, state Medicaid agencies should more directly negotiate with transportation network companies (TNC) like Uber and Lyft and public transportation to provide on-demand transportation services. Since non-medical transportation does not require special accommodations for medical need, the licensure requirements would be easier and there would be more eligible vehicles to provide transportation services. With this increased access to postpartum care, pregnancy-related complications could potentially be managed more effectively and ultimately lead to fewer instances of morbidity and mortality.
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