Mardell Brand used to walk to the Primary Health clinic near her home in Aliquippa.
When it moved from Franklin Avenue to a new location, she did not go for several years. It was too far to walk, and Ms. Brand, 57, does not have a car.
Study after study shows that in every setting throughout the nation – urban, suburban or rural – transportation is a barrier to health care. Those who can’t easily get to health care facilities and can’t afford transportation often end up postponing care, failing to obtain medication and getting sicker.
Transportation: A major issue for the poor
No matter where you are, what clinic or hospital you visit, transportation issues for the poor are a big issue as a barrier to healthcare. (Video by Nate Guidry; 7/28/2014)
A study in the Journal of Community Health released last year by researchers at the University of Illinois at Chicago reviewed 61 separate studies on the issue of transportation and health and concluded: “Overall, the evidence supports that transportation barriers are an important barrier to healthcare access, particularly for those with lower incomes or the under/uninsured.”
Pittsburgh area health providers have long known this without reading studies.
From the largest health systems to neighborhood health centers to free clinics, the transportation gap for the poor and working poor shows up daily in no-show appointments.
“An $8 round-trip bus fare may not be much for those of us who are paying $4 for a cup of premium coffee,” said Cheri Rhinehard, executive director of the Pennsylvania Association of Community Health Centers. “But it could be insurmountable to a person in poverty.”
The closures of hospitals meant many people lost a health facility in their neighborhoods, contributing to the problem of access.
After Aliquippa Community Hospital closed in 2007, the Primary Health Network health center became even more critical to residents in the area who had relied on the hospital’s emergency room for primary care. Now, the nearest emergency room was about 10 miles, two bus routes and up to 90 minutes away.
In 2010, when the health center wanted to expand and had trouble finding a building near its original site in downtown Aliquippa, it moved to a strip mall six miles away on Autumn Street in Center. Even though a bus stop was located a block away from the new location, the health center knew it needed to provide help with transit.
“We noticed patients weren’t returning for their second appointments,” said Seth Donovan, the manager for the Autumn Street Health Center. “We found out some people were losing their insurance or they had transportation problems.”
After a few years of planning and fundraising (including donations from managed care organizations) the health center in 2013 began offering free, door-to-door van service in the Aliquippa area, as it had at some of its more rural locations in Lawrence and Mercer counties. Primary Health spent about $350,000 last year on transportation, with about $44,000 going to a dedicated van and a part-time van serving the Aliquippa area. This year, the center is expanding to two dedicated vans at a cost of about $85,000.
The van quickly became a popular service, providing 1,303 rides to patients in Beaver County, more than a third of them to the Autumn Street location, and the rest to other medical facilities to which they were referred.
No-show rates for the Autumn Street site dropped from a high of 33 percent in 2010 to 17 percent last year, even as the clinic’s clientele almost doubled from 3,900 to nearly 7,200.
Ms. Brand was one of them.
“I was upset when it moved,” she said. “But now they send the van for me.”
Brian Archer, 44, of Aliquippa, said he chose his doctor at Primary Health in large part because of the van service.
He lost his job, his health insurance, and eventually his car, when the furniture company he worked for for 14 years went bankrupt in 2011. Now, with multiple back problems related to his years as a stocker lifting heavy furniture, he has to get to various medical appointments as close as three miles away in Center, but as far as 35 miles away in New Castle.
“I’d be lost” without the van service, he said.
Given the popularity of the service, John Laeng, Primary Health Network’s longtime CEO, said he intends to add more vans as the organization gets more funding.
Though it’s clear that helping people get to the doctor helps them stay healthy and reduces costs, the problem persists.
“After many years of doing this, I’ve found one truth: Bus passes just aren‘t sexy,” said Robert Lindner, executive director of the Travelers’ Aid Society of Pittsburgh, which helps about 10,000 Medicaid recipients get to appointments each year. “It’s really not viewed as a vital service in most cases unless you understand that the service we want them to access [healthcare] doesn‘t work unless they can get there. And most people don’t appreciate that.”
His nonprofit organization has a contract with Allegheny County to provide bus passes, bus tickets and sometimes pre-paid gas cards to residents on Medicaid who need to get to and from medical appointments.
Mr. Lindner said he and his funders — primarily the United Way, government agencies and a couple foundations — know there are many more poor and working poor residents who don’t have Medicaid who could use help with transportation. But there’s just not funding for it.
There are public services designed to provide free or reduced transportation to people, but they are almost exclusively focused on helping the elderly, the disabled, and to get people to work. Free rides to doctor appointments rarely happen unless a health system or clinic paid for it themselves.
And if the health systems or health centers do pay for it, Ms. Rhinehard said: “The demand usually exceeds the supply.”
The check-in window at Downtown’s Catholic Charities Free Health Care Center on Ninth Street displays a laminated white notice with an illustration of a bus and a trolley that says: “Are you having trouble making it to and from Appointments? Please talk to a Front Office Volunteer if so.”
In early 2013, the health center lost its funding that had been paying for bus passes for patients. Staff noticed a quick increase in no-shows for appointments, reaching 14 percent at its peak.
“We track and review [no-show rates] on a monthly basis and if we see it going up we need to ask why,” said Annette Fetchko, the center’s administrator. “What we found was that transportation costs had gone up” not only with gas and parking, but bus fares and it was impacting the health center’s patients.
Ms. Fetchko worked with the Massey Foundation to get a grant to help the health center buy a block of Zone 1 and Zone 2 Port Authority bus passes.
Within weeks, the no-show rate for both the health center’s medical and dental services fell to 8 percent, rivaling the region’s best hospitals and private physician offices.
Catholic Charities and Primary Health have heard complaints from some that responsible adults should be able to make their doctors’ appointments on their own; that they shouldn’t give a free ride to people who would probably manage to make it to a Steelers’ game or a day at Kennywood without help.
“It comes up a lot: Are we enabling patients” by providing free transportation? asked Mr. Donovan, the manager of Primary Health’s Autumn Street health center. “But that doesn’t matter. A healthy patient is a win-win for everyone.”
“It’s easy to say people should be more responsible,” he said. “But if they’re healthier, it costs the taxpayers less money.”