More people in the U.S. are having difficulty obtaining health care. This is impacting paratransit, non-emergency medical transportation (NEMT) and rural systems more and more, as funding continues to shrink and their ranks grow.
This is happening in part because more people have found themselves without health insurance through the loss of a job, their job no longer offering health insurance benefits, or not being able to afford an individual plan and in need of medical transportation.
There is a parallel between the crisis in paratransit and NEMT services and health care that the most vulnerable Americans need.
Meanwhile, studies from the Urban Institute and the Harvard School of Public Health estimate that an expansion in Medicaid eligibility in the Affordable Care Act, designed to cover more people in need, that is set to go into effect on Jan. 1, 2014, will add about 17 million enrollees.
Dale Marsico, executive director, Community Transportation Association of America (CTAA), says the U.S. is spending more money on Medicaid with each passing year, because there are so many people now eligible for the program. Part of that is a result of the recession, which caused a spike in prolonged unemployment, making more people eligible.
Additionally, a decade before the recession, Congress increased the number of different categories of people who are eligible for Medicaid and they all carry with them a piece of the transportation benefit, Marsico says.
One of the most important things about the proposed Affordable Care Act, if it goes into effect, is it resolves a significant percentage of the uninsured and working poor population by putting them into expanded Medicaid, which is one of the major points of disagreement between some of the states, the U.S. Department of Health and Human Services (DHHS), and the Obama Administration.
“It used to be that Medicaid was a government program to pay the bills of poor people,” Marsico says. “It’s slowly been morphing in the last decade into an insurance program.”
There are more people eligible and participating than ever before, he adds. The financial situation was at its most critical during the first two years of President Obama’s administration. The states didn’t have enough money to make ends meet, so in the stimulus bill, the federal government provided almost all the match for Medicaid for them. After the stimulus ended, the Administration offered to help the states control costs by moving people into managed care, which has a higher reimbursement rate. More money would be spent, but more people would be served.
“In a time of excruciatingly high health care costs — which was the whole business behind the Affordable Care Act originally before we all lost track of what it was about — part of the problem is health care costs in the U.S. were growing by leaps and bounds,” Marsico says. “States and the federal government had to look into ways to make the system cost less by putting in efficiencies and outcome measures and squeezing every nickel and dime to stretch it as far as possible.”
Changes in eligibility and delivery are happening so fast that it’s hard for people at the state and local levels to keep up, he adds, because money is becoming much tighter, in part because there are so many patients in managed services.
Medical transportation services, from NEMT to paratransit, are in the same position that hospitals, nursing homes, doctors and pharmacies are in: the federal and state governments are asking them to perform at greater and greater discounts, stretching every dollar as far as possible because more people are eligible. “We’re all in this together,” Marsico says.
Shift to managed care
California’s Medicaid program, being the nation’s largest, may be setting a trend with trying to get people into managed care to control cost. The state has led the way in trying to deal with the crisis since it has the greatest financial need.
Marsico points to California Gov. Jerry Brown, who, a couple years ago, started moving the state’s Medicaid patients to managed care. Many states are following suit, shifting their Medicaid programs to managed care to ease the cost burden, replacing fee-for-service care as the main insurance model for low-income Americans, according to “Stressed States Open Doors to Medicaid Managed Care,” by John Carroll, contributing editor, Managed Care Magazine.
“In many parts of the country, the provision of medical transportation is often done by the for-profit community with the use of paratransit vehicles, taxis, ambulettes and stretcher vans. It is important [for nonprofit providers] to include these private providers in coordination plans,” Valerie Miller, medical transportation specialist, CTAA, writes in a report titled “Connecting Health Care and Transportation.”
Miller stresses public and nonprofit providers work to coordinate with private providers of NEMT, despite competition. “True coordination cannot exist without acknowledging not only their existence but their position in the transit industry,” she writes.
Miller adds that brokerages are often overlooked and coordination planners should find ways to include them, “even if only to keep them informed and show them ways coordinated transportation could benefit them.”