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.

Medicaid expansion
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.” [PAGEBREAK]

Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on KCMU Medicaid enrollment data collected by Health Management Associates.

Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on KCMU Medicaid enrollment data collected by Health Management Associates.

Brokerages not good for some
Managed care, however, is not working well for all agencies, as Ed Griffin, VP, MV Transportation, explains.

MV provides Medicaid service in eight Florida counties. The state is recognized as a national model for coordination of services, according to Griffin. Florida Statue 427, in effect since 1989, mandates coordination of all social service transportation. In each county or combined counties, a community transportation coordinator coordinates all social service transportation, including senior affairs, people going to meal sites, adult day care, and developmentally-challenged services and workshops under one provider to gain economies of scale and standardization in contracts. This system has worked well, Griffin says.

A few years ago, the state went from a fee-per-service environment to taking a check from the Medicaid program and allocating funding to each of the community transportation coordinator’s. They issued a total budget capitation — a set amount for each enrolled person assigned to them — of about $63 million, and allocated to each county out of that total to provide Medicaid services.

Once a provider receives funding for a county, it is expected to provide all of the Medicaid demand under that capitation, Griffin explains.

The most problematic issue has been the lack of Medicaid providers, particularly specialists. In St. Lucie County, a small urban area that MV operates in, many medical services aren’t available, so drivers have to take people out of the county to Orlando, Miami or West Palm Beach, to reach medical care, which skyrockets its expense.

Looking ahead to 2014, if the Affordable Care Act Medicaid expansion goes into effect, the state mandated that all Medicaid recipients must belong to a managed care organization: either a provider service network or Health Maintenance Organization (HMO). Although the state statute clearly says that all Medicaid transportation has to be coordinated, the HMOs are contracting out and creating independent transportation networks, contracting with other providers to provide Medicaid services, Griffin says.

“In many cases, HMOs will not contract with coordinators because we have higher standards for insurance and on-time performance, so a lot of that funding is going away,” Griffin says.

Since the commission will no longer allocate most of the funding to coordinators, they will lose that economy of scale associated with having Medicaid funding. The end result is it will drive up the cost of other services.

“If I have fewer trips, I’m going to have to charge more for the services I provide to the other state agencies that aren’t coordinating,” Griffin says. “State agencies will be forced to provide fewer trips. If a trip costs more, they’ll have to provide less service. That’s the bottom line.”

“The result is that the individual is looking to other funding streams for the trips that aren’t being funded,” Griffin says. “That’s a serious trend.”

Up to 70% of the funding of coordinators of some rural counties in Florida comes from the Medicaid program. If that is taken away and they’re not chosen by the managed care organizations as one of the providers, or are only given limited trips, as one of many providers, then that will have an impact. Florida’s small urban and rural counties, particularly throughout the panhandle in Central and North Central Florida, will see the biggest impact from the takeover of managed care.

This also applies to Orlando’s LYNX and its ability to provide paratransit and NEMT. LYNX has a significant amount of Medicaid funding, and if it goes to an HMO constructing its own networks, most of that service will go away.

“If MV contracted with one of the managed care organizations, we might be driving one of the LYNX buses to an area to pick somebody up, and then, taking a private van to the same area at the same time to pick someone else up,” Griffin says. “What once was coordinated is now fragmented.”

Efficiencies increase need
Additionally, the more efficiencies made to the health care system, the more transportation is needed. In an attempt to save money, Medicare, Medicaid and the private sector are pushing patients into outpatient services as soon as possible.

This is especially problematic in rural communities that are overwhelmed with transportation service for dialysis patients, because it’s significantly cheaper to treat them as outpatients, which creates demand issues.

Dialysis patients can leave on schedule for treatment, but they may not be ready to go home on time.

“In the old days, we used to load up a van full of people, take them there, [wait for them and bring them] back,” Marsico recalls. “Now, dialysis patients that are treated longer have more trouble with clotting, and consequently, they can’t come back when everybody else [does] and you have to send somebody else to [pick them up.]”

The factors of eligibility and efficiencies converged at a bad time because there are now so many people who are long-term unemployed or in low-income brackets who don’t have insurance that it’s fallen to Medicaid to be the last line of defense for their health care.

“That isn’t the Medicaid program we knew when we started providing transportation to it 25 years ago,” Marsico says. “Sometimes it seems to us, as providers, the gravitational pull on us from the crisis in the health care financing situation and the recession has really made our lives much more difficult.”

Getting paid and providing service are greater challenges, which is exactly what’s wrong with the health care system, adds Marisco.

“We have this huge need and haven’t caught up to what we need to do to help people create the necessary transportation infrastructure to support it,” he says.

CTAA pushed for legislative changes to the Deficit Reduction Act, the Affordable Care Act and in appropriations in the Moving Ahead for Progress in the 21st Century Act (MAP-21) bill, including flexible funding to help rural and urban transportation programs and public transportation agencies; suggesting greater payments and guarantees for seniors; and increasing income eligibility for dialysis patients.

Another argument CTAA made in the last two authorizations was for strengthening the infrastructure of community and public transportation, especially in smaller communities and rural areas to help lower costs and offer alternatives, eliminating, for example, a significant problem with ambulance services being used unnecessarily because they are paid under Medicaid and Medicare.

“If a person needs to get somewhere and they’re sick and can’t find another cheaper alternative, they’ll dial 911,” Marsico says. “There has been a series of Inspector Generals saying ‘we’re being charged for all this ambulance service and it wasn’t an emergency.’ That’s what happens when you don’t have enough community and public transportation.”

Marsico doesn’t see the situation improving any time soon, especially if there’s not some progress on insurance coverage for all Americans.

“Something has to happen, because we’ve reached a point where the current systems don’t work,” he adds. “If the Affordable Care Act was one attempt to get at this, some discussion about changing Medicaid is another. If Congress repeals the Affordable Care Act, we have to come up with something else…because you can’t resolve this issue locally…there are going to have to be changes in the ability of Medicaid [to accommodate] this.”

Marsico is urging transportation coordinators to sit down with health care and ambulance providers and people in the community who are affected, to build more support and understanding of each of their roles and figure out if they are providing medical transportation services as efficiently and affordably as possible.

He also says coordinators have a broader responsibility to look at the medical transportation needs of people who aren’t covered by a government program like NEMT.

CTAA is also concerned that transit systems are forced to keep raising their prices, significantly impacting people who use fixed-route public transit to and from health care. Specialized services, Marsico says, such as paratransit and NEMT, are a second line of defense; the first is helping people get to the doctor in any situation via public transit.

“Every time you raise fares, you complicate it for those folks, too,” he says.

The Jule/East Central Intergovernmental Association paratransit service in Dubuque, Iowa, is seeing an increase in ridership and seniors that need rides, but also in the number of seniors moving to the disabled population.

The Jule/East Central Intergovernmental Association paratransit service in Dubuque, Iowa, is seeing an increase in ridership and seniors that need rides, but also in the number of seniors moving to the disabled population.

Serious medical outcomes
Greater need for already underfunded Medicaid and less money available per capita to meet the need is an issue of real concern, Susan Polan, executive director, American Public Health Association, says, because it can be cost-effective or even a cost savings to use medical transportation to get to health and prevention services and ongoing treatment.

There is information that suggests that with every 1% increase in the unemployment rate, Medicaid goes up by about one million people, Polan says.

Availability, however, is often so limited that needed treatments, screenings and immunizations are delayed.

“The truth is that funds aren’t going to be there,” Polan says.

The solution, she adds, will lie in figuring out how to be more cost-efficient and, for example, not using an ambulance in a non-emergency situation, being better coordinated in non-emergency medical situations and allowing for the best use of resources that are currently available.

That means thinking about how to make Medicaid dollars work more broadly while some states are looking at shrinking their dollars to the Medicaid population, making it very likely that “we’re going to see some very unfortunate outcomes that don’t have to happen,” Polan says. “That’s not the way we should be treating our vulnerable populations. There needs to be an increased focus on these issues.”

More riders, funding the same
Dubuque, Iowa’s Jule/East Central Intergovernmental Association (ECIA) paratransit service is seeing an increase in ridership and seniors needing rides, as well as the number of seniors moving to the disabled population.

“I don’t know if it’s just the more people you have, the greater the chances are of having a particular kind of category, or as people are aging, they’re becoming disabled,” Barbara Morck, director of transportation, The Jule/ECIA, says.

People in rural areas use Medicaid waivers to get from town to University of Iowa hospitals and clinics in Iowa City with service provided primarily by the RTA.

The Iowa Department of Transportation is also working with the DHHS to help members of the IowaCare Program with plans to assist with the cost of operating a route between Dubuque or the outlying areas and the University of Iowa Hospital and Clinics. Residents who live outside of Dubuque in one of the three counties served can access that program to get to the Dubuque Regional Community Health Center.

The Jule also goes beyond ADA guidelines, traveling outside the three-quarter-mile radius from its fixed route, which is required for complimentary paratransit services, going all over the city, Morck says.

Dovetailing with that challenge, Morck points out, is that paratransit is more expensive to operate on a per-ride basis than fixed route, primarily because it is demand-response. Depending on scheduling and how much territory is being covered, there may be only a few or even one person on the bus, so the cost per ride goes up dramatically.

The Jule is supported by federal operating assistance; a memorandum of agreement with East Dubuque, Ill., to provide service to its population, giving it some money through the state of Illinois by way of the federal government; formula state assistant funds through the Iowa DOT; and money from the city of Dubuque.

While the federal and state governments have been able to maintain The Jule’s funding, the difficulty is that it’s not increasing along with cost of living and operation costs.

“That burden falls on the city,” Morck says. “My money comes through a transit levy. The more money that I need from city funds, the higher the taxes [are] people will have to pay that year. It doesn’t make for a good mix, especially when people are trying to not increase peoples’ cost of living any more than they need to. The lack of change is affecting us.”

Maine’s Medicaid cuts
Looming state Medicaid cuts are threatening Sanford, Maine’s York County Community Action Corp. (YCCAC), which provides transportation for seniors, people with disabilities and other medical issues, and children in impoverished areas to and from foster homes. Without the service, many are in danger of abuse and neglect.

YCCAC also helps people with low incomes and the general public: people that don’t fit into any of the other categories prescribed by the Medicaid program. The general public is an important group because what they bring to the table is fares or other streams of revenue that may not be attached to human service-funded riders.

Connie Garber, transportation director, YCCAC, says the key to operating a functioning rural transportation system is to bring many different funding sources together, which has been state law since the late 1970s. Like Florida, Maine identified one designated provider in each region to coordinate all the different streams of transportation funding. Whether it was coming through the U.S. Department of Transportation (U.S. DOT), DHHS, local funding or county funding, all the revenues were consolidated within each of the eight regions of the state as a way to minimize inefficiencies and maximize service for all of the population groups.

In the 12-month period from July 1, 2011 through June 30, 2012, YCCAC transported 4,052 individuals. Of those, the percentages of seniors, people with disabilities and children combined account for slightly less than 33% of its riders. The remaining 67% are low-income and general public.

For that same 12-month period there were 597 people, or 14%, of those unique riders, that YCCAC transported without MaineCare, the state Medicaid program, who needed to get to medical appointments.

While some former MaineCare patients seem to be picking up commercial health care coverage, more are becoming uninsured, Marty Sabol, director of health services, YCCAC, says. This group is likely non-categorical adults — people who are low-income without children, but not in a specific category — who missed their renewal dates and were dropped from the program per changes in state funding. In Maine, a large group of people seeking aid fit into that definition, Garber says. YCCAC anticipates that the number of non-categorical adults is expected to increase in the coming years.

Meanwhile, YCCAC has had to adjust staff, reduce hours of service on the road and increase fares on some of its routes, similar to what all systems, urban and rural, across the country have had to do as demand has gone up and revenues have not kept pace.

The problem, she adds, is that like every other state, Maine “has a lot red ink flowing around its state Medicaid program.”

Maine is currently discussing with the federal government what it can do to limit eligibility, Garber says, and whether it is consistent with the Supreme Court’s ruling on the Affordable Care Act to drop coverage for people who are currently covered.

“We have a governor who is pushing back,” she adds.

Maine Gov. Paul LePage and the legislature recently passed changes to the state plan, including cutbacks in YCCAC’s coverage. The state will no longer accept any new people under the non-categorical definition, and, if somebody who is currently covered loses their eligibility for any reason, they can’t be reinstated.

Sabol says that between now and early 2014, most parents with household incomes between 133% and 200% of the federal poverty limit (FPL) will also lose their coverage. The LePage Administration also wants to drop coverage for parents who are between 100% and 133% of the FPL and all 19- and 20-year-olds.

However, if the Medicaid expansion component of the Affordable Care Act is implemented in January 2014, individuals from all coverage groups will again be eligible for MaineCare.

Then again, a federal process that oversees Medicaid- and Medicare-instituted regulations threatens YCCAC’s coordinated provider approach, making it impossible for Maine to continue its coordinated method without getting waivers.

“The coordinated approach that we had in place for 32 years does not fit with any of the models the federal government is used to seeing at a state level, so our state has issued an NEMT RFP that will force the state to handle all trips funded by [its]Medicaid program differently than all other trips,” Garber says. “The effort to bring all the funding sources into one entity to achieve efficiencies in economies of scale will be undone by this RFP.”

Providers who have worked hard to come up with the alternative coordination system for decades are trying to figure out a solution so that they don’t lose all of the progress and benefits to riders and the state.
Maine expects the new system to be up and running by January 2013.

“[That] is beyond being an ambitious timeline,” Garber says. “It is one that I believe, in my professional opinion, is unachievable.”

With the implementation of the RFP, Garber says she is concerned that many of the riders YCCAC serves will lose a large amount if not all of the service they need. “It is a scary time,” she adds.

As she sees it, the more people covered by Medicaid by the Affordable Care Act, the more who have access to NEMT.

The question is, she says, what resources are available for transportation providers to prepare for the increase if they are going to supply Medicaid transportation in 2014?

“That’s a big question. There’s no answer, and the clock is ticking,” says Garber.

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