Over at the Georgetown Health Policy Institute blog, Dr. Marsha Simon
has a post up
on a new study
finding that limiting non-emergency medical transportation
(NEMT) hurts the most vulnerable low-income patients.
For more details on this issue, see our report
from last month on Arkansas seeking a waiver of the NEMT requirement for the private option
policy.The private option uses Medicaid funds to purchase private health insurance plans for low-income Arkansans. Private plans typically do not offer NEMT, but that is a guaranteed Medicaid benefit; under current policy, if a private-option beneficiary can prove they have no way to get to the doctor, the state has to offer transportation. One of the amendments to the private option passed during this year's fiscal session
would eliminate that guaranteed benefit, pending federal approval.
That could lead to consequences for the state's sickest citizens, says Simon:
A new report, published by the Community Transportation Association of America, details how the decision to drop transportation benefits will lead to worse health outcomes, increased hospitalization, and more preventable deaths for a state’s sickest individuals.
Millions of chronically ill individuals rely on Medicaid-provided transportation to access behavioral health, substance abuse and dialysis services. If CMS approves these waiver requests new beneficiaries will go without NEMT benefits even as evidence suggests they have a greater need for care because many have never had insurance and have untreated conditions.
Eliminating NEMT will shut out the chronically ill from life sustaining services and will increase future costs for state Medicaid programs through increased hospitalizations and overuse of expensive ambulance services.
Two big caveats as it relates to Arkansas:
1) The private option, by design, aims to send people determined medically needy
— about ten percent of the total gaining coverage — to the traditional Medicaid program. In other words, some of the "state's sickest individuals" will end up in traditional Medicaid, where they would still receive the NEMT benefit. That said, the screening process will not catch everyone (many enrollees never even took the screener) and inevitably, some people will slip through the cracks. The nightmare scenario here is someone who needs care but cannot realistically access it without transportation assistance. Insurance won't do folks any good if they don't have a way to consistently get to a health care provider, a real issue for some of the low-income Arkansans who have gained coverage.
2) Unlike Iowa, whose path Arkansas followed in seeking a waiver of the NEMT requirement, Arkansas will not seek a full blanket waiver of the benefit. According to both DHS officials and the Republican backers
of the amendment, the state will still be required to to offer NEMT in certain cases (likely based on distance from the necessary provider, type of visit, etc., perhaps with particular consideration for rural areas). This is worth monitoring closely; the devil's in the details. Can the state design an NEMT waiver that still ensures that those in real need will have full access to care?
As we've noted
, the NEMT waiver is an example of the funny way that the battles over implementing Obamacare have, as Sarah Kliff has put it, made the Medicaid program "more Republican." With the Medicaid expansion decision left up to states and the Obama administration showing flexibility to try to lure in more states to participate, conservative health care reformers are angling to see how much they can re-shape Medicaid at the margins. States piggyback off of each other — when Iowa got the NEMT waiver, Sen. David Sanders responded by saying
, "we want what they have."
For Republicans like Sanders
and Rep. John Burris
waiving NEMT represents what they believe is an opportunity to save money and nudge the private option one more step toward being similar to private insurance (they also believe that the transportation providers, profiting from the current NEMT benefit, may contribute to waste and fraud...so I'm guessing they would express skepticism re: the Community Transportation Association that published the study). But advocates for beneficiaries — such as Arkansas Advocates
and Joan Alker
of the Georgetown Center for Children and Families — argue that the NEMT benefit actually saves money
by providing access to primary and preventative care and keeping people out of ambulances and emergency rooms.
Whatever the ultimate financial impact, eliminating or limiting the NEMT benefit presents real risks to the state's neediest citizens. Arkansas is pursuing the private option via an 1115 waiver of federal Medicaid rules, a "demonstration waiver" explicitly designed as an experiment. If cutting back on NEMT is to be part of that experiment, it's important that the impacts — including potential harm to low-income Arkansans without access to transportation — be part of evaluating the private option.