By Sean Miskell

As states debating whether to expand Medicaid (and some that already have) consider changes to their Medicaid programs via 1115 waivers, one proposal that keeps popping up is the elimination of non-emergency medical transportation benefits (NEMT). This week, the Government Accountability Office (GAO) released a report on state efforts to waive NEMT benefits.

What We Knew

In many ways, the GAO usefully compiles and summarizes what Say Ahhh! readers likely already know about state efforts to waiver NEMT benefits. CMS has granted such waivers to Iowa and Indiana, and the report also documents Arizona’s stated interested in pursuing the same. You need to read all the footnotes to be reminded that Pennsylvania received approval to waive NEMT before deciding to opt for ‘traditional’ Medicaid expansion instead of expanding via a waiver. Arkansas also expressed interest in waiving NEMT under its private option model until state leaders learned that doing so would not be cost effective.

In this regard, the GAO report helpfully rounds up the body of research that underscores the policy rationale for the NEMT benefit and why it is so valuable for the population served by Medicaid. For example, a study in the Journal of Community Health notes that transportation is a serious barrier for lower income populations in accessing care, a finding similar to a study in Annals of Emergency Medicine that limited transportation disproportionally affects access to primary care for those in Medicaid. Likewise, a study by the National Conference of State Legislatures finds that 3.6 million Americans miss or delay care due to a lack of transportation. In light of this, the GAO concludes that the NEMT benefit “can be an important safety net for enrollees as research has identified the lack of transportation as affecting Medicaid enrollees’ access to services.

In helping Medicaid beneficiaries overcome this barrier, the NEMT benefit is also cost effective. As a study by the Transportation Research Board points out, health conditions may deteriorate when transportation is a barrier to accessing care, leading to more costly treatment down the road. This echoes the findings of researchers at Florida State University finding that transportation programs for disadvantaged populations “are an excellent investment.”

What is New

The GAO report also provides new information to inform the debate over this benefit moving forward. First, in interviews with the GAO, state officials in Indiana, Iowa, and Arizona consistently reflected that they sought to waive the NEMT benefit in an effort to align Medicaid benefits with private insurance. Indeed, officials in Iowa argued that doing so would help to limit disruptions as variation in enrollee income lead to changes in coverage eligibility (often called “churn”), such as fluctuating between Medicaid eligibility for tax credits for Marketplace coverage. It is unlikely that consumers view reducing benefits as a helpful way to align different sources of coverage. Policy prescriptions that seek to foster consistency across provider networks or allow for continuous eligibility in Medicaid are a better way to address concerns regarding churn than reducing benefits, particularly since the NEMT benefit is included to address the specific needs of the low income population served by Medicaid to ensure access to care.

Perhaps the most important element of the GAO’s report is the discussion of the way in which the two states that have already waived the NEMT benefit have been evaluating whether doing so presents a barrier to obtaining services for Medicaid enrollees. The GAO notes that Indiana is still working with CMS to develop its evaluation.

For its part, Iowa’s evaluation compares whether those with coverage under the state’s waiver have more difficulty accessing care than those with access to the NEMT benefit. As we have already pointed out, the state’s claim that those with access to the NEMT benefit experience problems accessing care at levels comparable to those with coverage under the waiver actually reinforces the need for NEMT given that both populations demonstrate high levels of transportation-related barriers to obtaining care (20 percent for enrollees with the NEMT benefit and 22 percent for those without it) – even though the state has been using this data to argue for a continuation of the waiver of the NEMT benefit.

The GAO also points out that the data Iowa has provided indicates that “those with lower incomes—under 100 percent of the FPL—tended to need more transportation assistance and have more unmet needs than those with higher incomes.” In this context, the GAO urges Iowa to improve its evaluation methodology and link survey responses from both groups of enrollees directly to their claims to better illustrate the effect of transportation difficulties with enrollees’ utilization patterns.

Additional Issues

The GAO’s report raises two additional issues that are worth noting. First, the GAO calls for improved coordination at the federal level to reduce fragmentation that can make NEMT programs difficult to navigate for enrollees, citing an earlier report from the agency.

GAO also interviewed state and national organizations that represent vulnerable populations and health care providers. Besides expressing concerns regarding the effect of waiving NEMT on how enrollees access care and the cost of doing so, many of these groups also expressed concern that “HHS’s approvals of state efforts to exclude the NEMT benefit potentially provide other states with an incentive to pursue similar efforts.” This echoes our concern that such approvals set a bad precedent and risks institutionalizing the elimination of NEMT benefit as more states gain waivers to do so.