Double-kidney-transplant recipient Denise Ruck lives miles from the hospitals of Pittsburgh and Cleveland, in an area where public transit options are few. So the Crawford County resident, like many rural Pennsylvanians with chronic health issues who are unable to drive long distances, relies on Medicaid funding to underwrite her travels to the hospital and the doctor's office.
But when the state, prompted by increasing costs and decreasing federal contributions to the low-income health care program, made changes to its Medicaid benefits last year, one change was a $26 million, or 18 percent, cut in transportation money doled out to Pennsylvania's counties.
And that means some Medicaid recipients, such as Ms. Ruck, are having a tougher time getting to the hospital.
"People like myself are just getting thrown under the bus," she said.
After the state budget went into effect last year, Crawford County's Medical Assistance Transportation Program notified some Medicaid recipients that their contractor would no longer be shuttling program beneficiaries to non-contiguous Pennsylvania counties.
For Crawford residents who get all of their services at Meadville Medical Center or one of Erie's hospitals, that arrangement is fine. For those getting services in Pittsburgh or at the Cleveland Clinic, as Ms. Ruck does, the new rules are problematic.
Medicaid, which is funded jointly by the state and federal governments and administered by the state, issues Medical Assistance Transportation Program block funding to counties. The money can then be spent on private shuttle services, public transportation vouchers or mileage reimbursement checks to friends, relatives or volunteers who use their own vehicles to drive patients.
Rides are generally meant for patients who can't drive themselves and who have no other transportation resources.
One of the more notable Medicaid funding cuts came in money allocated for mileage reimbursements for drivers. While some counties used to reimburse Medicaid drivers up to 30 or 40 cents a mile, the state installed a cap of 12 cents per mile.
That new rate took effect in October and should save the state $5 million or so this year.
Reduced shuttle service in Crawford, meanwhile, took effect Dec. 10.
The one-two punch -- the lack of a shuttle to Cleveland, plus the reduction in mileage reimbursement -- meant Ms. Ruck had trouble finding a ride to the Cleveland Clinic, where her transplants took place and where she prefers to go for her regular appointments. The pool of drivers dried up, she said.
"People aren't going to do it for 12 cents. That doesn't even cover the gas," she said. (The IRS-approved rate for work-related driving costs, by contrast, is 55.5 cents per mile, while the standard rate for charitable-related driving is 14 cents a mile.)
Ms. Ruck enlisted the help of Kevin Burke, an attorney with Northwestern Legal Services, a nonprofit legal clinic. With the shuttle no longer making trips to Cleveland, he and Ms. Ruck went to the county's assistance program.
They argued that even if the contractor were unwilling to make the trip to Cleveland, the county still had to find a way to pay for it because Medicaid is an entitlement program and she's entitled to its benefits.
Eventually, she found a ride, with the county's help. But others aren't going to be as fortunate, Mr. Burke said.
"While this client was able to find a work-around, most clients will not have the tenacity she does and their health may suffer," he said. "In the end, transportation costs may appear to go down, but people will not get the care they need and then will need more expensive care."
Medicaid transportation services are particularly important for "disabled individuals, elderly persons, children who are receiving counseling, [and] individuals who travel regularly to medical appointments such as dialysis, mental health treatment, chemotherapy or physical therapy," according to a paper on the issue by the American Public Human Services Association.
Each state and county runs its Medicaid transportation program differently. Philadelphia County hands out subway passes; the state of Vermont relies heavily on volunteer drivers; Alaska often flies patients where they need to go.
Before the funding cuts, Pennsylvania covered the cost of rides for about 140,000 Medicaid patients each year. The per-trip costs vary from county to county; more rural counties usually pay more per trip -- about $42 per trip in Carbon and Cameron counties and $52 in Elk County.
Meanwhile, a ride to the doctor costs about $9 in Allegheny County and a bit over $6 in Philadelphia, according to state records.
The cuts seem to be hurting those in rural counties most, but all counties are affected, said Fran Chervenak, a senior attorney with the Pittsburgh branch of the Pennsylvania Health Law Project.
"They're trying to figure out how to deal with this reduction," she said. "Every county is kind of handling it differently, but all of them are re-configuring how far they'll go."
Indiana County's Medical Assistance Transportation Program, for example, used to offer rides to Pittsburgh's hospitals and clinics every day. But now that's down to a few days a week, and patients have to build their appointments around the new shuttle schedule.
Similar cutbacks are being put in place this month at the Area Transportation Authority of North Central Pennsylvania, which runs the Medicaid transportation program in Cameron, Clearfield, Elk, Jefferson, McKean and Potter counties.
The authority's "out-of-area" travel -- that is, mid-distance trips to Dubois or Pittsburgh -- have been cut from five days a week to one day, meaning sometimes there may be more demand for the trips than there is space on the shuttles.
And long-distance trips to Montour County where the Danville-based Geisinger Medical Center is found are no longer offered. Medicaid patients who get treatment there either have to find care closer to home or go to the county's assistance office to make alternate travel arrangements.
"This has been much on our minds," said John Lacny Sr., marketing head of the Area Transportation Authority.
The reduction in transportation funding comes at a time when more people are signing up for Medicaid than ever in Pennsylvania, 2.2 million enrollees as of the end of 2011.
"We do our best to make sure our clients have access to [their care], but getting to your provider can sometimes be a major challenge," Mr. Lacny said.
He and other transit officials and patient advocates also noted the funding method has changed. Instead of getting Medical Assistance Transportation Program money from the state quarterly -- which allowed for a bit more flexibility in the final, end-of-year payment -- all of the money is now disbursed at the beginning of the year.
Once you're out, you're out.
"We are concerned," Mr. Lacny said, "that there aren't enough funds to complete the current year."
The state Department of Public Welfare, which runs the Medicaid program, said it is working with the counties ad transit agencies to help "identify efficiencies" by way of cutting hours, reducing costlier long-distance routes and trying to move the riders who have multiple transit options into the least-expensive mode of transportation.
Meanwhile, Ms. Ruck, whose rides are now paid for directly by the state instead of through the Crawford County transportation program, wonders about the wisdom of nickel-and-diming Medicaid patients on transit costs:
"What good is it to give me a transplant if you're not going to pay for my [ride to follow-up] appointments?"
Bill Toland: firstname.lastname@example.org or 412-263-2625.