By Marsha Simon, PhD.
Even with the federal government’s official evaluation forthcoming, Indiana’s evaluation of its waiver to drop non-emergency medical transportation (NEMT) benefits is telling. The evaluation found a significant number of individuals on Medicaid are missing appointments because they lack transportation. According to survey results, 6 percent of Medicaid recipients under the waiver missed an appointment because they lacked the transportation benefit states are required to provide to Medicaid beneficiaries throughout the country. Even though this accounts for a relatively small proportion of enrollees, this figure nonetheless suggests there is unmet need for transportation to care among a portion of enrollees in the Healthy Indiana Program. Addressing this unmet need is the very rational of the federal NEMT policy, a feature of the Medicaid program for the poor since it’s beginning in 1965. An entitlement to medical services is meaningless with no way to access the services.
Further, the question of whether an appointment was missed is too narrow a measure of access to care, as it fails to identify Medicaid enrollees that do not schedule an appointment because they know they cannot get to the doctor’s office. With this in mind, those evaluating Iowa’s NEMT waiver asked beneficiaries whether they had an “unmet need for transportation to or from a health care visit.” There, researchers found that 15 percent of those with incomes under 100% of poverty had an unmet need for transportation.
Fortunately for some beneficiaries in Indiana, one of the states three Medicaid, managed care health plans, Anthem, is providing NEMT as an added benefit even though the state refuses to reimburse for the cost of the service. Beyond being a positive for health outcomes, NEMT has proven to be a long-run cost-saver by preventing high cost emergency rooms visits via ambulance. When considering a similar waiver, Arkansas hired The Stephen Group (TSG) to offer a recommendation on waiving NEMT benefits. Their recommendation warned against dropping the benefit. Far from being an additional expense, TSG argued that NEMT benefits were a good investment for the state, citing a Florida State University study showing a return on investment factor of 11:1 for as well as a Transportation Research Board study finding a 10:1 return on investment. Providing Medicaid enrollees with transportation benefits allows them to access preventative care that forestalls more costly interventions down the road. After this recommendation, Arkansas quickly dropped their proposal to waive NEMT.
Indiana’s NEMT waiver expires at the end of November and Iowa’s is set to expire at the end of May. With data pointing toward potential harms to beneficiaries whom states have denied NEMT and evidence that NEMT is a cost-saver, both Iowa and Indiana’s NEMT waivers should be allowed to expire and the NEMT benefit restored to all Medicaid patients.
Dr. Simon is the President of Simon & Company and an adjunct professor in the Department of Health Policy and George Washington University