Transportation, a Destination in Itself

December 09, 2021 | Devon Page

pickup-truck-winding-road-autumn.jpgAccess to quality and reliable transportation is an indispensable aspect of American life. But for too many, social and economic conditions stand in the way. How do residents of Elk County, Kansas—where the nearest hospital is about 70 miles away—obtain necessary care in the face of transportation issues? How do residents of any medical desert bedeviled by transportation issues obtain care? These questions, among others, are difficult to answer for both the individuals who confront them directly and the experts and policy makers who confront them only indirectly.

An estimated 3.6 million people in the United States each year are unable to obtain medical care as a result of transportation issues, which range from lacking access to a reliable mode of transportation to long-distance travel. And disproportionately, those affected are poor, elderly, belonging to an ethnic minority group, disabled or less educated. Further reflecting the relationship between transportation availability and low socioeconomic status (SES), transportation barriers positively correlate with greater disease burden.

Transportation is one of the most significant factors contributing to our health. Reliable transportation to emergency and non-emergency medical services is merely one component of it. The way that people get groceries, sufficient exercise, social contact, good education and employment are all impacted by transportation and have a documented impact on health outcomes. This transverse nature makes transportation an especially worthy subject of public health’s focus in seeking to improve social determinants of health.

As needs vary, so do the strategies aimed at resolving transportation barriers. Telehealth is a medium connecting patients to providers, one that is uniquely positioned to alleviate the need for transportation. While telehealth can remove some barriers by offering an alternative to travel for non-emergency medical care, it cannot assist in getting groceries. Nor can it help someone access a fitness center, meet with family and community members, attend work or school. Furthermore, the digital divide poses major challenges for the efficacy of telehealth. Without addressing broadband access inequities and other user-related issues, telehealth may exacerbate preexisting health disparities.

There is significant promise in public transit. Improving the affordability and reliability of these services would unequivocally result in more low-income individuals being able to obtain necessary services. Correspondingly, community health may improve from this sort of strategic infrastructure investment. However, this solution is, at least at face value, urban-oriented. For much of rural America, a bus would not make much sense.

Like telehealth, non-emergency medical transportation (NEMT) can play a substantial role in abating transportation barriers. And, in fact, it has. Medicaid has provided NEMT since 1965, and in 2020, Congress mandated the same of state programs. Interestingly, NEMT programs are well-positioned to make an even greater impact on public health.

Modernizing NEMT services could boost patient use and satisfaction while saving money. Better data utilization and coordination among providers, strategic partnerships with transportation technologies, and greater emphasis on digitalization offer unique opportunities to enhance the quality, efficiency, and economy of NEMT services. Some providers have already taken steps in this directionlready taken steps in this direction.

Moreover, NEMT could be expanded. In conjunction with the service being offered to a broader array of patients, NEMT could provide rides to non-traditional destinations, such as grocery stores, pharmacies, gyms, and social gatherings. This approach more holistically addresses transportation as a transverse social determinant of health.

Although more attention should be given to the pecuniary, equity, and health impacts of transportation barriers and how we can mitigate them, there are a number of organizations working to make a difference in this space. ASTHO has worked with some of these groups, namely, Trust for America’s Health (TFAH), Transportation for America, American Public Health Association (APHA), National Association of City and County Health Officials (NACCHO). Additionally, members of Congress are increasingly taking interest in the issues of transportation and social determinants of health more broadly.

The newly formed House Caucus on Social Determinants of Health recently held a briefing, which commenced with remarks from Rep. Cheri Bustos (D-IL), Rep. Markwayne Mullin (R-OK), and Rep. Salud Carbajal (D-CA). The representatives were joined by several industry leaders for a panel discussion including ASTHO Past-President Edward P. Ehlinger, MD, MSPH (alumni-MN).

The panel covered best practices and innovative models for expanding access to transportation. All participants shared a sense of urgency and the sentiment that all solutions should be driven by community, creativity, and data. Some participants highlighted examples of their organization’s work to demonstrate the potential success of community-oriented programs supported by data, and some flagged relevant bills.

As the 2021 legislative window begins to close, it’s important to note that the Build Back Better Act (BBB)—if approved by Congress—would allocate $1.75 billion to public health items such as data modernization initiatives and health equity activities, in addition to other key public health investments that address social determinants of health. On top of these needed direct investments in public health, BBB provides $9.75 billion in competitive grants to support projects that provide “access to affordable housing” and “enhanced mobility for residence and riders” of low-income communities along with other benefits for low-income riders related to enhanced transit. Notably, such benefits include better access to job and educational opportunities, to medical care, and “grocery stores with fresh food.”

While transportation-specific solutions offer practical steps in the right direction, it is imperative to look at the broader picture in developing lasting strategies. Neither transportation needs nor social determinants of health occur in a vacuum. Sometimes, evaluating a problem for sustainable fixes requires addressing the underlying systems and conditions that exacerbate or perpetuate it.

Ehlinger echoed this simple yet powerful point: “Transportation cannot resolve everything. Health care itself must change.”