Medicaid 1115 waivers must reach budget neutrality. This means that the cost to the federal government cannot exceed the amount the federal government would have spent absent a waiver. One way that states achieve this budget neutrality is by cutting the benefit that provides transportation services to eligible Medicaid enrollees. This benefit is not transporting patients via an ambulance; those services are usually covered under the hospital charges. This benefit covers patients for the most part who are unable to transport themselves to and from their appointments often because they are medically frail. It was estimated that $2.9 billion was spent to provide 103.6 million rides in 2013. While one concern is that the benefit allows for significant amounts of fraud, there are ways states can work with licensed venders (uber, lyft, taxi companies) and monitor patient appointments to ensure that the benefit is not being used fraudulently. Transportation has been shown to reduce costs associated with unnecessary hospitalizations. People living in rural areas are primary users of these services and more than half of those requiring non-emergency transportation have high needs because of a chronic condition such as cancer, HIV, or dialysis.
One more fragile portion of this population is people receiving dialysis treatment. Medicare covers the treatment of dialysis under most circumstances but Medicaid is a major payer for the medical care and transportation for patients requiring dialysis services. Many people believe that Medicare covers all of the costs related to dialysis treatment, but for low-income patients transportation to and from the dialysis center is necessary to achieve health. The process of dialysis is so extreme on one’s body that it leaves people incapable of driving and for those that lack the social support network to be driven to and from their regular appointments, the lack of transportation services could be a matter of life or death for certain populations.
In 2017, Congressman Bishop of Georgia introduced a bill that would protect dialysis patients from cuts to the transportation benefit. Like many bills introduced in Congress this bill lacks a vehicle for passage and has not been acted upon since its introduction.
While this effort is necessary for many people with dialysis, the merits of the transportation program should be protected more universally. There has been much discussion of a growing sense of loneliness and isolation in this country in recent years. This has an impact of making it harder for people who suffer from chronic illnesses to have the support networks through churches, volunteer community groups or even friends and family to be able to get to and from important doctor visits. This makes the benefit even more important today than in the past. While reorienting our social fabric to build greater community may the best solution, people who have chronic conditions that require medical care cannot wait for more community focus social norms.
The transportation benefit also becomes more important with the latest effort to require Medicaid beneficiaries to work as a condition of enrollment in Medicaid. People with certain chronic conditions and health needs may work full time and depend on the transportation benefit to maintain their ability to work and stay healthy. If states were to implement work requirements as well as eliminate the transportation benefit, people with chronic conditions may have a harder time maintaining full time employment because of the lack of ability to get to their needed appointments would make them miss more work hours and in turn they may lose their Medicaid benefits because of an inability to work. It is crucial that CMS ensures they maintain or protects the transportation benefits for Medicaid beneficiaries when evaluating waivers that require work as a condition of eligibility, specifically for individuals with chronic conditions.
There are many benefits like this one that would be impacted by the work requirements proposed in many states. We have little evidence as to how the work requirements would impact people who are on the cusp of having a disability. Living on the cusp of disability means that they are people require regular medical attention and depend on their medical care in order to live a normal life and maintain a job but disruptions in this delicate life balance, for instance a change in their health status, could cause loss of their job and in turn their access to health insurance yet they do not qualify as disabled under Medicaid law. This situation is reality for millions of Americans with employer-sponsored insurance as well as for beneficiaries of Medicaid. Medicaid currently serves as a safety-net for families and individuals who may have an unforeseen disruption in their work or health status. Large majorities of people who receive Medicaid benefits are on the program for short periods of time for moments like these when they lose a job or need additional help during life transitions. These people face the greatest risk when work requirements and other limitations on services are applied to the Medicaid program. These individuals are at the most risk from being very close to leaving poverty to falling deeper into lower financial status.