Medicaid waivers put transport benefits on chopping block
Non-emergency medical transportation services are in for a turbulent ride in states seeking to use waivers under the Affordable Care Act to trim Medicaid rolls and available benefits.
The Trump administration is urging states to consider Medicaid waivers to cut costs by imposing work requirements that could throw recipients off the state-federal insurance program. That's putting NEMT, a longstanding benefit newly embraced by Uber and Lyft, on the chopping block.
A handful of states have taken the administration up on its offer to impose work requirements, with mixed results. NEMT benefits prove an easy target for elimination — especially considering the potential for fraud and abuse.
But for many enrolled in Medicaid, NEMT is essential. An Annals of Emergency Medicine study based on National Health Interview Survey data found that Medicaid enrollees are 10 times more likely to have their access to timely primary care barred by transportation issues than those with private insurance.
In Arkansas, where work requirements began in July, NEMT benefits are only provided to premium assistance enrollees who have received prior authorization from the state.
"The Arkansas work requirement is a blunt tool aimed at yanking people off health care, enabling the state to shrink its expenditures on Medicaid, thereby allowing lawmakers to implement more tax breaks and benefits for the wealthy in Arkansas," Jeremy Leaming, director of communications for the National Health Law Program, told Healthcare Dive.
A federal lawsuit filed last month by that group, the Southern Poverty Law Center and Legal Aid of Arkansas seeks to put an end to the state's work requirements. A separate lawsuit from the first two organizations effectively halted Kentucky's Medicaid waiver earlier this summer.
In response, Kentucky dropped NEMT, dental and vison for Medicaid patients, claiming it could not afford to pay if its waiver was not approved. While those benefits were later reinstated after intense pushback, the left-leaning Urban Institute estimated at the time that more than 43,000 people in Kentucky who lost benefits didn't have access to a car.
The writing has been on the wall for NEMT since President Donald Trump took office. In a March 2017 letter to governors, former HHS Secretary Tom Price and CMS Administrator Seema Verma (a long-time NEMT opponent) encouraged states to consider NEMT waivers as a cost-cutting measure. If approved, the administration's fiscal year 2019 budget request would go even further by allowing states the option of dropping the benefit altogether.
Cost-cutting, however, isn't a particularly strong argument for eliminating transportation benefits.
NEMT spending makes up a sliver of overall Medicaid spending, which reached $565.5 billion in 2016. For perspective, the federal government spends $2.7 billion annually on NEMT, according to a JAMA study, or as much as $3 billion annually, according to the Transit Cooperative Research Program, a federally-funded research entity.
With roughly 103 million NEMT trips taken annually, the average trip costs somewhere between $26 and $29.
Given NEMT benefits account for such a light portion of overall spending, advocates and NEMT brokers say it does not make sense for states to shirk on such a small budget item, especially one that yields high returns for patients and payers.
"Cutting the mechanism, particularly for the underserved, to get to their medical appointments ... is foolish," Mark Switaj, founder of NEMT startup Roundtrip, told Healthcare Dive. "They'll absolutely get sicker and turn into expensive ER visits."
That much was echoed by Medicaid enrollees who participated in a recent study commissioned by the Medical Transportation Access Coalition, an association founded by NEMT companies.
Researchers surveyed nearly 1,000 Medicaid recipients suffering from either kidney disease, diabetes or substance abuse, and use NEMT benefits to get to their appointments. Some 58% said they would not be able to keep their medical appointments without access to NEMT and 10% said they "would die" or "probably would die" without that access.
Michael Adelberg, one of the authors of the MTAC study, told Healthcare Dive that while the costs of missed dialysis appointments or wound treatment appointments for diabetes patients are clear, the researchers' methodology didn't apply as well to patients suffering from substance abuse.
The outcome of those patients missing appointments, while certainly bad, doesn't necessarily mean life or death. The rest, however, is "straight math."
"If you have kidney failure, you need to go to dialysis 12 times a month," Adelberg said. "If someone misses consecutive dialysis appointments, they're going into the hospital. That's pretty clear."
While NEMT benefits have been available for Medicaid enrollees since the program's inception in 1965, the sector has seen something of a boon in recent years with the introduction of ridesharing apps. Medicare Advantage payer Cigna-Health Spring claims a resounding 92% of its members who take advantage of its partnership with Lyft have made the service their preferred means of transportation to medical appointments.
Ridesharing's impact on the industry, while nascent, have been mixed. A University of Pennsylvania study published early this year found ridesharing did not reduce missed appointment rates among Medicaid patients in West Philadelphia. More promising was Lyft's pilot at Hennepin Healthcare's internal medicine clinic in Minneapolis, which helped reduced no-shows by 27% over the course of a year.
Ridesharing's impact on missed appointments may have more potential in the managed Medicare arena, where CMS has given commercial payers room to play. The Trump administration has simultaneously argued that Medicaid work requirements would reduce government spending on benefits while incentivizing enrollees to lift themselves out of poverty.
"Unlike the other programs we consider, Medicaid benefits do not gradually phase out as income rises — recipients retain full benefits as long as their income remains at or below the maximum income threshold," reads a report from the President's Council of Economic Advisors defending Medicaid work requirements. "However, passing that threshold eliminates all benefits. This 'benefit cliff' creates a strong disincentive to work for households with incomes near the threshold, as increasing one's earnings slightly can result in complete loss of health insurance."
Some researchers and advocates aren't convinced that is necessarily the case, especially for some of the most vulnerable Medicaid recipients.
"We would hope that states that are considering trimming NEMT look at our data and look at our methodology and apply it to their own scenarios," Adelberg said. "What we believe, what our study proves, is that certainly for people with expensive chronic diseases, this more than pays for itself."
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