Transportation gaps affect health care access

While governments and advocates work on eliminating health care access barriers such as complicated forms and lack of outreach, a study by the Children’s Health Fund in Washington, DC, indicates that a major barrier still has not been addressed — transportation gaps.

"In spite of the significant progress made in enrollment, millions of children face substantial barriers to health care that defy broad-based insurance approaches," says a Children’s Health Fund report.

"Specifically, insufficient transportation infrastructure and inadequate public transportation services have emerged as critical factors and determinants of child health access in medically underserved communities. Transportation, as a barrier to child health access, is a critical item of unfinished business in the Children Health Fund’s campaign to secure affordable, comprehensive pediatric care for all children."

Dennis Johnson, vice president for external affairs at the Children’s Health Fund, tells State Health Watch that a 1998 National Child Health Caravan from New York to Mississippi and Arkansas found that in all sites visited along the way, lack of adequate transportation resources was given as the single greatest reason why children were not getting the pediatric care they needed on a timely basis.

Unreliable transportation

In poor urban areas, the organization’s report says, public transportation often is unreliable, inconvenient, and underfunded. And in many rural areas, public transportation is non-existent or severely limited in scope. "For millions of children, health insurance does not automatically mean access to health care. Barriers such as inadequate or nonexistent transportation prohibit these children from receiving the health care they desperately need."

Mr. Johnson says that a March 2001 national survey on children’s health access and transportation conducted by Zogby International for the Children’s Health Fund confirmed the findings from the caravan and reinforced the necessity of developing a national strategy to address transportation as a hidden barrier to health care.

The survey found:

  1. Between 3 million and 4 million children in American families with income up to $50,000 are unable to access routine medical care because of a lack of transportation resources.
  2. For children in families with income at or below the poverty level, 21% miss routine doctor visits because of transportation problems.
  3. Sixteen percent of Medicaid families miss at least one pediatric appointment because of a lack of transportation.
  4. Nearly half of the families responding to the survey did not have any transportation available to access medical facilities, with the percentage increasing to 75% in rural areas.
  5. Sixty percent of families with children enrolled in Medicaid were unaware that federal guidelines requires states to ensure necessary transportation for recipients to and from health care providers.
  6. Nearly one-third of families lived more than 10 miles from their physician, neighborhood clinic, or hospital, with more than 7% living between 25 miles and 50 miles from their nearest health care provider.
  7. One-fifth of respondents did not believe there was an adequate supply of physicians in their area.

Fund officials say there is a need for federal designation of areas that lack an adequate transportation infrastructure and thus are unable to support access to health services.

They say the designation, similar to that for health professional shortage areas, should be created for areas that lack transportation resources and are unable to support access to health services.

Congressional hearings needed

A General Accounting Office (GAO) study could determine the scope and causes of transportation inadequacies and recommend strategies to overcome the barriers. The officials say there should be congressional hearings following the GAO study.

Clearly, funding will be a major issue in resolving the problem. The Children’s Health Fund says resources must be made available to support development of health care transportation infrastructure in areas where a lack of transportation presents a barrier to health care access for children.

Resources also should be made available, the report says, to designated medical transportation shortage areas to develop transportation strategies and coordinate available transportation resources.

Also, public/private partnerships should be encouraged to pilot and support innovative child health programs that are designed to meet the challenge of transportation barriers.

The report calls for greater efforts to educate and inform Medicaid- eligible families and their health care providers about the availability of nonemergency medical transportation assistance.

Best practices in contracting for transportation assistance services should be followed to maximize transportation resources and efficiency. For example, the report says, transportation needs should be coordinated with TANF Workfare transportation initiatives. In addition, all states should be strongly encouraged to include transportation services as part of their State Children’s Health Insurance Program (SCHIP) benefits package.

The Children’s Health Fund says that initiatives and incentives must be expanded to ensure that pediatric and primary care resources are appropriately distributed, and that physicians and other health care providers are sufficiently available to provide care in underserved rural and urban areas.

The maldistribution of health care resources disproportionately affects rural communities and the urban poor, who also are more likely to have inadequate access to transportation. Efforts should be made to ensure that adequate support is given to community health centers and other local providers of health care.

Follow-up appointments missed

The Zogby study found that as a result of transportation problems, children with manageable, chronic medical conditions get sick more often and children who need critical follow-up care after surgery or a major illness can’t get it. Asthma was the most frequently cited chronic child health condition, according to the survey. Fund officials say they also have seen instances in which obtaining chemotherapy has been a problem for children without access to transportation.

"While enormous state resources have been channeled into state-based initiatives to successfully enroll children in SCHIP and Medicaid, millions of children face other barriers — like transportation access — that compromise the value of being insured," explains Irwin Redlener, MD, founder and president of the Children’s Health Fund.

"For as many as 4 million children, health insurance does not mean access to health care because they literally can’t get to the doctor. This is not about health insurance. It’s about the hard-core realities for families who want to do the right thing for their children, but are stymied by the lack of affordable, reliable transportation."

Mr. Johnson tells State Health Watch the Children’s Health Fund has been very active in advocating for transportation reform. Transportation is a cornerstone of the Fund’s Kids First/Kids Now campaign.

"There are a number of areas for remedies," he says. "We believe the federal government certainly has a role to play. We need to get more resources to communities that need support. We’d like to see a federal-state-private partnership whenever possible."

Mr. Johnson says transportation will be one of the important issues discussed at child health summits the Fund is planning at which policy-makers, legislative staff, and advocates will discuss how best to proceed on key child health issues.

He says interest in the problem has been expressed by other groups such as the Community Transportation Association of America and the American Academy of Pediatrics.

"It’s hard to deal with the nonfiscal barriers to care," Mr. Johnson explains. "Everyone recognizes the importance of insurance. We need to pay as much attention to the nonfiscal barriers."

[Contact Mr. Johnson and Mr. Redlener at (212) 535-9400.]