14 Jan AiroAV Said: Cutting Medicaid Non-Emergency Medical Transportation Will
As has been discussed previously on the Health Affairs Blog (here, here, and here), Medicaid’s non-emergency medical transportation (NEMT) benefit is stuck in the crosscurrents of competing trends: On the one hand, the value of the benefit is increasingly apparent due to recent research and the increasing interest in NEMT as a tool to address social determinants of health. On the other, the Trump administration is persistently taken actions (including a Request for Information scheduled for this year and a regulation projected for 2021 that will have the effect of curtailing Medicaid NEMT, even as the administration advances policies to promote NEMT in other health care markets (including as a transportation supplemental benefit in Medicare Advantage).
The purpose of this post is not to re-hash arguments previously made on the blog but to advance a new argument for the importance of NEMT. That is: Because Medicaid NEMT and local transportation services are commonly provided by the same local transportation agencies, the two services are interdependent. Cuts to Medicaid NEMT would therefore undermine entire communities’—not just Medicaid beneficiaries’—access to transportation. This is particularly true in rural states where local transportation agencies have fewer funding streams and serve less affluent communities. While states rely on different models to deliver NEMT (including contracting with statewide NEMT brokers, embedding NEMT within managed care organization contracts, and directly reimbursing transportation providers), transportation agencies remain important providers of NEMT—particularly in rural communities. To create efficiencies, transportation agencies commingle Medicaid NEMT with other essential services, including para-transit for people with developmental and physical disabilities, senior rides for older adults, and services for other vulnerable citizens who rely on public transportation to get to work, grocery stores, vocational training, and other destinations necessary to maintaining community engagement.
The co-dependency between Medicaid NEMT and broader community transportation services is not well understood in health policy circles. For this reason, the Medical Transportation Access Coalition (MTAC) partnered with the Community Transportation Association of America to document the interconnectedness of Medicaid NEMT and community transportation. We interviewed local transportation agency heads from four states (Iowa, Idaho, Vermont, and West Virginia) and reviewed their program statistics. Given the limited scope of our research, our findings are more suggestive than conclusive. However, given the dearth of research on this subject, we still think this blog post makes an important contribution to the policy debate about NEMT. The information presented below is further documented in a longer report posted on the MTAC website concurrent with this post.
Synergies Between Medicaid NEMT And Community Transportation Services
Community transportation services are commonly provided via vans that operate on fixed routes. These routes are only viable when publicly subsidized riders—such as those on Medicaid—fill the vehicles. If NEMT was curtailed, Medicaid riders and funds would leave these routes. Inevitably, this would constrict funds and force a reduction in community transportation services for non-Medicaid purposes. Of the five local transportation agencies we interviewed, the percentage of their budget supplied by Medicaid NEMT ranged from 5 percent to 59 percent. Large swaths of rural America are not served by taxi or transportation network companies such as Uber or Lyft; in hundreds of rural communities, there simply is no public transportation alternative to those offered by these local transportation services.
Medicaid NEMT And State Transportation Funds
In one of the four states we sampled, Iowa, NEMT rides figure prominently in the state’s Department of Transportation funding formula for local transportation agencies. In Iowa, transportation agencies draw state transportation funds based upon the number of rides they provide. Thirty-four percent of the rides offered by one of the interviewed transportation agencies are from Medicaid NEMT. If these rides disappeared, that agency would face a 34 percent reduction in state transportation funds. We interviewed two Iowa local transportation agency heads who speculated that if these funds were lost they would need to cut services well beyond just their Medicaid rides. One suggested he would defer purchases to update his vehicle fleet. This would compound an existing problem—60 percent of his fleet is already beyond the recommended age for public transportation vehicles.
In West Virginia and Idaho, local transportation agencies do not have the benefit of state Department of Transportation funds; this increases their dependency on NEMT. The local transportation head we interviewed in West Virginia noted that NEMT contracts generate 24 percent of agency funding; in contrast, only 2 percent of its funding comes from local governments.
State Medicaid NEMT Rule Changes
In two of the four states we examined (Vermont and Iowa), state Medicaid offices—as part of broader Medicaid cost-saving moves—recently revised Medicaid NEMT reimbursement to the detriment of local transportation agencies. The Department of Health Access in Vermont now reimburses local transportation providers based on a per-member-per-week capitated payment built on the number of Medicaid beneficiaries who have taken a trip within the past 13 months. This rate is not adjusted for long-distance trips or riders who require several trips per week (such as riders with substance use disorders [SUDs] who require frequent trips for treatment). Thus, local transportation agencies are disadvantaged for being responsive to their most rural residents…