The Inadequate State of American Medical Transportation

Entrance to the North Berkeley Senior Center, which partners with Berkeley Rides For Seniors and the Disabled (Nico Savidge/Berkeleyside).

The North Berkeley Senior Center receives a steady stream of calls from older adults across Alameda County, requesting rides to the doctor. Despite the senior center’s ongoing partnership with Berkeley Rides for Seniors and the Disabled (BRSD), a city-run program designed to address this very problem, center staff have to send them away. The program is at capacity and was forced to stop taking new riders in the Spring of this year. It continues to receive nearly 50 applications each month. 

Four years ago, with the signing of the 2021 Consolidated Appropriations Act, states became formally required to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries. Medical transportation, formerly the optional and unregulated responsibility of the states, was elevated to a mandatory benefit that state governments had to provide to Medicaid recipients. 

In theory, this formalized recognition of the connection between access to transportation and quality of care represents an important step towards addressing environmental and structural aspects of health inequality. However, this guarantee of access on paper has not turned into comprehensive or effective coverage in practice. In a nationally representative CDC study from 2022, the year after the requirement for NEMT coverage was signed into law, 4.6% of respondents reported skipping or delaying medical care because they did not have a way to get to their appointments. Lack of transportation represents a significant barrier to full and equitable access to medical care, and as such, our medical transit system requires urgent reexamination. 

The patchwork method of medical transportation delivery in the United States fails to meet the transportation and health needs of the American people in ways that reflect broader structural problems with the administration of American healthcare. The world of NEMT, characterized by a chaotic collision of public and private forces, unpredictable funding and program longevity, and an outsized burden on municipal governments and nonprofit organizations, is a microcosm of the American healthcare system. 

Some states seem to have found their preferred solution to medical transportation in private ride-sharing companies like Lyft and Uber. 28 state Medicaid offices across the country either contract directly with these corporations, or more frequently outsource this responsibility to transportation brokers who use Lyft Healthcare and Uber Health software to schedule rides. 

On the surface, this partnership seems like a no-brainer. Lyft and Uber have unmatched dominance in the ride-sharing market (owning 98% between the two of them). They have effective technology for matching drivers to riders, and are able to do it at a baffling scale for unbeatable prices. As the entrance of Lyft and Uber into the medical transportation world was cemented in the late 2010s, these programs went largely uncriticized. A few journalists raised concerns about ride-share companies being unable to provide high quality care in a medical setting, but it was generally seen as a win-win situation. 

The choice to subsidize ride-sharing with Medicaid funding was, at the very least, misguided when it comes to improving community health. Lyft and Uber are a transportation duopoly, operating on similar business models that keep costs low by outsourcing vehicle costs and maintaining (through unprecedented lobbying power) their drivers’ status as contractors rather than employees. Uber and Lyft escape responsibility for their drivers' well-being, providing limited health coverage assistance and paying well below minimum wage. The access to healthcare provided by Lyft and Uber is facilitated by the exploitation of underpaid drivers. 

But contracts with mega corporations are not the only way to go about providing medical transportation. Let’s take Medi-Cal (California’s Medicaid program) as an example of a flawed alternative. 

For those with Medi-Cal health plans, coverage of medical transportation is subject to physician recommendation. Each new provider a patient sees is required to separately approve and request medical transportation for a set number of appointments. The threshold a patient must meet to qualify for free transportation is very high, requiring them to have no other reasonable option to get to their appointment. The definition of reasonable is left up to interpretation, and this review process guarantees that some people who would benefit from transportation assistance will be denied transportation coverage. 

For Medi-Cal recipients without health plans, provision of medical transportation falls to county governments. County programs have several strengths, namely the freedom to flexibly define necessary rides, expand eligibility, and experiment with delivery strategies. Their biggest limitation is funding. Counties use money secured through property taxes and federal funding passed down by the states to fill in the gaps left by health plan coverage. What does this mean? First, since property taxes dictate transportation budgets, there are more options for patients living in wealthier counties. Second, this system of ad hoc funding is not guaranteed. There is no assurance that the benefits that exist one year will continue into the next, even when funding has been explicitly earmarked for medical transportation. This lack of guaranteed funding is what sealed the fate of Berkeley Rides for Seniors and the Disabled. Transportation in Oakland and Sunol has faced similar financial challenges. 

Theoretical access to medical transportation has seen major strides in the last decade, seen in the recent codification of NEMT as a required component of Medicaid and the expansion of ride-sharing technology into the medical sphere. However, in practice, the multi-tiered system of transportation coverage, intersecting at every turn with for-profit insurance companies, transit brokers, and health plans, continues to let people in need fall through the cracks.