Rides can be hard to come by when you’re making poverty wages, which is why Medicaid subsidizes transportation for those who would otherwise have trouble keeping their medical appointments.
But most private insurance policies, purchased though commercial health carriers, don’t have transportation benefits built into them. That’s one of the reasons why advocates for the Medicaid population say the state-run health insurance program is often a better fit for low-income households than private insurance.
And it’s why those same advocates say states like Pennsylvania — which wants to take the federal money that has been earmarked for Medicaid expansion by the Affordable Care Act, and instead use it for an assistance program that will help low-income Pennsylvanians buy insurance on their own — are missing the big picture.
“The whole point of giving people this coverage is so they can access primary care to prevent [their] problems from getting worse,” said Joan Alker, executive director at the Center for Children and Families and a professor at the Georgetown University Health Policy Institute.
The absence of transportation funds for new Medicaid enrollees “potentially will cause people to miss appointments for things they need,” especially those with chronic conditions who need regular, frequent treatments.
As per federal law, every state offers some kind of transportation assistance as part of its existing Medicaid programs. But at least two states, Pennsylvania and Iowa, have asked the federal government to waive the requirement to provide transportation funding for the enrollees who would be made newly eligible for Medicaid-type benefits via the Affordable Care Act.
The ACA, which became law in 2010, sought to force states to expand Medicaid eligibility to all people making less than 138 percent, or even more than that, if the states wished to expand the program further. Before the Affordable Care Act, most states — Pennsylvania included — offered Medicaid to only certain target low-income and disabled populations.
President Barack Obama was counting on the Medicaid expansion to help insure 17 million Americans who were previously unable to obtain or afford health insurance, and via the ACA, the federal government committed to pay nearly $1 trillion to help states pay for the expansion. But two years later, a U.S. Supreme Court decision rendered the Medicaid expansion optional for the states.
Some have opted not to participate in the expansion at all; others, such as Pennsylvania, are hoping to use the cash to revamp the original Medicaid model significantly in a manner more palatable to the state’s Republican politicians.
To do that, the state needs federal permission, and in February Gov. Tom Corbett asked for it, formally submitting its “Healthy PA” Medicaid overhaul plan to the federal government. One of the waivers sought by the state would absolve Pennsylvania of its responsibility to pay for nonemergency medical transportation for new “premium assistance” recipients. (Those recipients would not be enrolled in Medicaid, but instead would be given money to help them pay for commercial health policies.)
Nonemergency medical transportation is what’s known as a Medicaid “wraparound” service. Pennsylvania, in its application to the federal government, has requested waivers “for all wraparound services, including non-emergency transportation and family planning services (to the extent such services are not covered under the private plan)."
States may view the rescission of transportation benefits as an easy way to avoid program costs, but advocates for the poor say that’s a misguided approach. That’s largely because so many of the rides are consumed by people with chronic conditions; and almost half of all Medicaid-brokered rides are taken by dialysis patients and those who need behavioral health and substance abuse treatments.
“It’s not surprising that their rides are the ones that dominate,” said Marsha Simon, president of Simon and Co. health consulting firm in Washington, D.C., and co-author of a recent paper on Medicaid’s medical transportation program.
In other words, trips to and from the doctor’s office — and, just as critical, to the local pharmacy — aren’t ancillary perks of the Medicaid program. For those chronic patients, “It was a critical part of the care plan,” Ms. Simon said.
“Entitlement to health services is meaningless if you can’t access it.”
Pennsylvania cut 18 percent, or $26 million, from its existing Medical Assistance Transportation Program block fund budget two years ago, and put a 12-cent cap on the per-mile reimbursements that drivers can receive for using private vehicles.
Some counties responded by reducing shuttle services, others cut back in different ways (the state later steered supplemental funding back into its Medicaid transportation fund when it became clear that “many counties were on the verge of shutting down crucial, required services to those in need,” according to the state association of county commissioners).
Each state and county runs its Medicaid transportation program differently. Philadelphia County hands out lots of subway passes; the state of Vermont relies heavily on volunteer drivers; Alaska often flies patients to the hospitals where they need to go.
Per-trip costs vary from county to county, and more rural counties usually pay more per trip — about $58 per trip in Armstrong County and $104 in Butler County, according to 2013 state records. Meanwhile, a ride to the doctor or pharmacist averages about $11 in Allegheny County, and a bit over $12.50 in Philadelphia.
In Allegheny County alone, about $9 million was spent last budget year on nonemergency Medicaid trips, and the year before, the program served more than 16,000 individual county residents with more than a million total trips.
In the 2014-15 budget, Mr. Corbett proposed $69.5 million in state transportation funds. The federal government, which jointly funds Medicaid, would then more than double that amount, bringing the total Medicaid transport budget to a proposed $145 million next year.
If 600,000 more people were to be added to the state’s existing Medicaid program, the state’s transportation costs would go up, too.
Kelly Whitcraft, policy coordinator for the Disability Rights Network of Pennsylvania, said Medicaid provides other benefits and rights that just aren’t available through commercial policies.
“We are concerned that when someone is enrolled in the private coverage option, they do not have any of the rights and protections that they should be afforded under Medicaid,” Ms. Whitcraft said.
Among these are state-based due process rights to appeal any decision or denial by their insurance company; these individuals would have to appeal through their insurance company’s process, rather than the Department of Public Welfare’s. This would make it harder for DPW to identify any systemic denial issues by insurance providers, she said.
The federal government is currently reviewing Pennsylvania’s proposed Medicaid overhaul. Mr. Corbett expressed frustration last week with the progress of the talks.
“Frankly, I’m starting to feel like a yo-yo,” he said in regards to discussions with federal officials. “We go down one way, they pull back, we go down one way, they pull back.”
“Right now, the road is getting bumpier, rather than smoother,” he said, though he would not elaborate on any specific issues or concerns that the federal government has highlighted. Mr. Corbett was speaking Wednesday at a health summit in Harrisburg.
Beverly Mackereth, secretary of public welfare, said following the end of the federal public comment period this month, “We’ll have a much better feel.”
Ms. Mackereth said it is still the state’s goal to have Healthy PA up and running by Jan. 1.
Bill Toland: firstname.lastname@example.org or 412-263-2625. Kate Giammarise: email@example.com, 1-717-787-4254 or Twitter @KateGiammarise.