By Sean Miskell

Most observers expect that remaining states that have not yet expanded Medicaid are likely to seek changes to the program via waivers as they move forward on expansion. A few states that have already expanded Medicaid are also seeking to make changes through waivers. But these changes are not always for the better. Unfortunately, the same ideas keep popping up despite evidence that they are not good policy.

For example, Michigan recently submitted a waiver request that called for complex changes to the Medicaid program, as required by its state legislature. Similarly, legislators in Arizona have also passed legislation requiring the state to seek specific changes to its Medicaid program that require a waiver. While CCF, the Center on Budget and Policy Priorities and other groups will post our own comments on Arizona’s waiver request in the coming days, one aspect of Arizona’s request – the elimination of non-emergency medical transportation benefits (NEMT) is particularly noteworthy as a bad idea that has been raised in other states. But while Arizona is considering eliminating this service for Medicaid beneficiaries, Arkansas has reversed course on the same question – as a result of a report submitted to a legislative task force in Arkansas that found that eliminating the NEMT benefit would not be cost-effective.

State action regarding non-emergency medical transportation

Iowa was the first state that that CMS allowed to waive non-emergency medical transportation benefits through a waiver. At the time, CCF and other groups warned that doing so would set a bad precedent for other states considering expanding Medicaid. These concerns proved valid, as CMS later gave Indiana permission to waive NEMT temporarily. Shortly afterward, Iowa was given an extension on its waiver even though the state provided data indicating unmet need for transportation to or from a health care visit among both Medicaid beneficiaries and Iowa Health and Wellness Program members.

After CMS gave Iowa permission to waive NEMT benefits, Arkansas lawmakers expressed interest in the same. In January of this year then newly elected Arkansas Governor Hutchinson called for the continuation of Arkansas’ approach to Medicaid expansion via the ‘private option’ along with changes to the program. In addition to establishing a task force to consider what changes to make, the Governor laid out his own principles, which included the elimination of NEMT. 

Arkansas report: Never mind, NEMT is a good idea 

However, in its recommendations to the Arkansas Health Reform Task Force regarding the future of the state’s private option approach to Medicaid expansion, consulting firm The Stephen Group recommended not eliminating the NEMT benefit. Rather, the report found the NEMT benefit in Arkansas is “very cost effective” and cited additional research from Florida State University and the Transportation Research Board for the National Academies which found that offering the NEMT benefit actually provides a sound return on investment for states.

For example, the University of Florida study noted that providing transportation to preventive medical care yields substantial benefits based as doing so forestalls costlier services including hospital stays and assisted living costs. Similarly, the National Academies study demonstrates that while people without access to affordable transportation may miss or postpone routine care or preventive services, and that access to NEMT benefits reduces emergency room and hospital visits. This is especially important for the low-income population that Medicaid serves, which is more likely to suffer from chronic health problems. In this regard, the National Academies find that NEMT benefits are “highly cost effective” for a providing access to care for a those with a number of chronic conditions as well as “cost saving” for those with asthma, heart disease and diabetes as well as for preventive services such as prenatal care.

These findings underscore not only the important role of NEMT services but the policy rationale for Medicaid expansion more generally. Providing people with health coverage and removing barriers to accessing care – such as transportation – improves health outcomes and saves states money.