This week, the Center on Budget and Policy Priorities, CCF and 10 other organizations submitted a comment letter regarding Iowa’s proposed section 1115 amendment to extend their waiver of the non-emergency medical transportation (NEMT) benefit. While we continue to support Iowa’s decision to provide coverage to newly eligible low-income adults, we hope that CMS will reject Iowa’s request to continue waiving the NEMT benefit for Medicaid beneficiaries.

The waiver of the NEMT benefit has been part of an ongoing dialogue over the past few years. Back in 2013, when CMS initially approved Iowa’s plan to expand Medicaid, CMS also approved Iowa’s request to waive the NEMT benefit through a Section 1115 waiver. CMS’ conditional approval stipulated that the NEMT benefit would be waived for a limited amount of time (one year) and planned for an evaluation to assess the merits of the waiver.

In September 2014, Iowa presented preliminary data on how Iowa Health and Wellness Plan enrollees were faring without the NEMT benefit. The data illustrated an unmet need for transportation that is affecting access to care for enrollees.

CMS stated that the data “raised concerns,” but agreed to temporarily extend Iowa’s NEMT waiver while the state collected additional information. As time runs out on this short extension, Iowa has submitted a request to extend this waiver to December 31, 2016, despite evidence that the waiver of the NEMT benefit created barriers to healthcare.

As noted in our letter, survey data that Iowa provided in its application actually reinforces the need for NEMT benefits, rather than justifying the state’s request to continue waiving them. Indeed, according to the data that the state provided, “nearly 20% of Medicaid and [Iowa Health and Wellness Program] members reported usually or always needing help from others to get a healthcare visit and nearly 13% reported an unmet need for transportation to or from a health care visit in the six months prior to the survey.” In addition, 13 percent of Medicaid and Iowa Health and Wellness Plan beneficiaries expressed concern about their ability to pay for the cost of transportation to or from a health care visit. All of this information shows that waiving the NEMT benefit is unnecessary and actively undermines access to care.

Based on these data and findings, Iowa’s demonstration underscores the importance of the NEMT benefit as a critical component of access to care. Moreover, in the highly politicized environment in which CMS and states negotiate the terms of expansion, exemptions granted to one state often set a precedent for states that follow at the negotiating table. CMS would be wise to avoid setting a bad precedent, as available data examining the NEMT benefit (or lack thereof) signals an important message as we consider state choices in Medicaid expansion. We urge CMS to restore NEMT benefits to Iowa’s Medicaid program to avoid this waiver becoming institutionalized, and perpetuating unnecessary barriers to care for Medicaid beneficiaries.