By Sean Miskell
As we near the end of the first year of expanded Medicaid under the Affordable Care Act, it is also time to revisit state proposals to alter their Medicaid programs through Section 1115 Medicaid waivers. Last week, the Center on Budget and Policy Priorities, Georgetown CCF, and 20 other national and state groups submitted comments calling for the Centers for Medicare and Medicaid Services (CMS) to reject Iowa’s request to continue waiving the Non-emergency Medical Transportation (NEMT) benefit.
Last year, CMS chose to conditionally grant Iowa’s request to waive the NEMT benefit by allowing the state to do so temporarily for one year with a planned evaluation. But the data that Iowa provided in its own waiver amendment request suggests that CMS would be wise to reject Iowa’s request. Rather than justifying its NEMT waiver amendment, Iowa presents data collected by the University of Iowa Public Policy Center that actually demonstrate unmet need for transportation that is affecting access to care among members of the Iowa Health and Wellness plan. For example, 20 percent of those in the Iowa Wellness program and 10 percent of those in Medicaid reported that they were unable to obtain needed transportation to access health care services. In addition, 50 percent of those in the Wellness program and 37 percent of those in Medicaid expressed some level of concern regarding their ability to pay for the cost of transportation to a health care visit.
This data is consistent with peer-reviewed research that finds that transportation provides a greater barrier to access to care for the low-income population served by Medicaid than those with private insurance. The existence of such disparities are why benefits such as NEMT services are built into Medicaid in the first place. Rather than improving upon the Medicaid program, Iowa’s waiver amendment request limits access to care for the low-income population that Medicaid is intended to serve.
The data that Iowa presents in its waiver request also suggests that Medicaid beneficiaries utilize NEMT benefits in order to obtain care that is crucial or preventative. The most frequent member-reported reason for utilizing the NEMT benefit for trips of 30 miles or more was to access mental health services, with other top reasons including hospital discharges, rehabilitative services (e.g., physical and occupation therapy), screenings, and testing services. Continuing to waive the NEMT benefit per Iowa’s request could forestall Medicaid beneficiaries from accessing the primary, specialty, and preventive services that enable them to identify and address their health needs as they arise and reduce the need for more costly care later.
Finally, waiving the NEMT benefit sets a bad precedent for other states looking to craft their own unique ways to expand Medicaid. Since CMS allowed Iowa to temporarily waive the NEMT benefit last December, Pennsylvania has been allowed to waive its NEMT coverage temporarily and a similar request is pending from Indiana. Meanwhile, some policy makers in Arkansas, whose private option model of Medicaid expansion was the impetus for similar requests from other states, look upon Iowa’s NEMT waiver covetously, noting that Iowa “got something that we didn’t” and “we want what they have.” Just as is the case here, many state and national groups expressed concern for Arkansas’ proposed waiver amendment. CMS would be wise to keep the existing suspension of NEMT benefits in Iowa temporary and prevent the unfortunate precedent set by Iowa’s Medicaid waiver from becoming institutionalized, thereby undermining Medicaid beneficiaries access to care.
