The Transportation Barrier

Many low-income people in urban and suburban areas struggle to find reliable transportation. The result is missed appointments and poor illness management, even when care is readily available.

Around midnight on a rainy Saturday two summers ago, a 60-year-old man wandered into the waiting area of the North Carolina hospital where I worked as an emergency-room volunteer. He had just been discharged, he told me, adding that his vision was messed up from medication. He had arrived in an ambulance several hours ago, but didn’t have money for a bus ride home. He lived with his disabled mother, who was unable to drive, and had no family close by.

I pointed him towards the admissions-and-discharge station to see if someone there could help him. He went over to explain his situation to the nurse in charge—but the hospital, she told him, could not pay for his bus or cab fare: “The system just cannot handle that expense for everyone,” she said.

The man grew visibly frustrated. After getting the same answer from a few more members of the hospital staff, he seemed to give up. He paced the waiting room, looking out the windows at the rainy night outside. It wasn’t obvious what condition had brought him to the hospital, but now he was off-balance and staggering. I watched him from my station across the waiting room, concerned that the hospital could do nothing to help him get home.

When my shift ended a few minutes later, the man was still standing near the window, seemingly without a plan. I approached him and asked whether the hospital had figured something out for him. He said they had not.

“Where do you live?” I asked.

He described an area that was about eight miles away, on the other side of town from the hospital but not far from my home.

“I might try to walk,” he said.

A vision-impaired, older man trying to walk eight miles, at night, in the rain—no part of it seemed like a good idea. “Do you want me to give you a ride home?” I asked. “My shift just ended.”

Around 20 minutes later, I pulled up in front of his home, and we shook hands and parted ways. It was lucky, I thought as I drove away, that I was in the right place at the right time. But how often do patients stranded at the hospital experience the same good fortune?

Past research on health care access has examined the ways in which distance can present a problem for people in rural areas, but poorer people in suburban and urban settings, even though they may live closer to a doctor or hospital, can still have trouble with transportation. Some households don’t have a vehicle, or share one among multiple family members. As Gillian White noted in The Atlantic in May, low-income neighborhoods are hit particularly hard by shoddy transportation infrastructure—subways may not service areas on the fringes of a city, buses may be unreliable, and both are vulnerable to strikes or service suspensions. And for those who are disabled, obese, or chronically ill, riding the bus or the subway can be a difficult undertaking.

As a result, some people may find themselves without a way home after an emergency trip to the hospital, or miss a doctor’s appointment simply because they don’t have a way to get there. In a 2001 survey of 413 adults living at or below 125 percent of the federal poverty level in Cleveland, Ohio, published in the journal Health & Social Care in the Community, researchers found that almost one-third of respondents reported that it was “hard” or “very hard” to find transportation to their health care providers—a problem that can mean more than a few missed checkups. A survey of 593 cancer patients in Texas, published in the journal Cancer Practice in 1997, found that in some cases, trouble with transportation led patients to forgo their cancer treatments. The problem was especially prevalent among minority survey respondents; 55 percent of African American and 60 percent of Hispanic survey respondents reported that transportation was a major barrier to treatment, compared to 38 percent of white respondents.

More recently, a 2012 survey of 698 low-income patients in a New York City suburb reported that patients who rode the bus to the doctor’s office were twice as likely to miss appointments as patients who drove cars. And in 2013, a review published in the Journal of Community Health found that around 25 percent of lower-income patients have missed or rescheduled their appointments due to lack of transportation. The patients who reported issues with transportation also missed filling prescriptions more than twice as often as patients without that same problem. “These consequences may lead to poorer management of chronic illness and thus poorer health outcomes,” the study authors wrote.

In some situations, patients without transportation access may wait for a medical emergency just to be able to see a doctor, explained Shreya Kangovi, a professor of medicine at the University of Pennsylvania. “Mr. Jones might have a disability that makes it difficult for him to use public transportation, so he has been waiting until he’s really sick, short of breath, and then calling an ambulance because there is no other good way to get care,” she said.

“If a patient can’t get to see their health-care team, then it’s a domino effect,” said Samina Syed, the lead author of the 2013 study and an endocrinologist in Madison, Wisconsin. “Missed appointments mean that they can’t address their questions and concerns, or update physicians on changes in their health history or life circumstances,” a situation that can be particularly worrisome for patients with diabetes and other chronic diseases that require ongoing active care.

Some health-care providers are trying to lessen the problem by employing community health workers (CHWs), people who help patients navigate the health care system. CHWs, who typically don’t have health-care backgrounds, will coordinate transportation for patients to and from appointments, motivate them to take their medications, and help them implement positive lifestyle habits. In 2014, there were an estimated 50,000 CHWs in the U.S.

A 2003 report on health disparities from the Institute of Medicine praised the CHW model, declaring that it “offer[s] promise … to increase racial and ethnic minorities’ access to health care” and improve their quality of care. Some research has supported this idea: One 2007 study found, for example, that CHWs can help patients better manage their hypertension, and a 2014 study found that patients who worked with CHWs scheduled more primary-care follow-up appointments than those who didn’t.

Some hospitals and physicians also use care coordinators: people who, unlike CHWs, are trained in a health-related field, most often social workers or nurses. These coordinators support groups of low-income or chronically ill patients, helping them to understand their care plans and schedule primary-care visits instead of making trips to the E.R.

Although a significant number of patients, especially those with few resources, struggle to find consistent and reliable transportation, there are some options for those who know how to find them. Each state has a “non-emergency medical transport” benefit for people with Medicaid, covering a certain number of rides per month, and some Medicare Advantage plans also cover a limited number of trips each year (eligibility for this benefit varies by state). Some states contract with local companies to provide rides; others enlist volunteers, or hire taxis. Some private insurers have followed suit, taking similar steps to make transportation more accessible for their clients, though this may involve co-pays or put policyholders through a lengthy bureaucratic process to prove their need for the benefit. In many cases, non-emergency rides must also be requested several days in advance.

In some cases, the restrictions surrounding these transportation programs can prevent patients from taking advantage of them. The patient I encountered in the ER at midnight, for example, did not have the luxury of planning his ride home in advance. No one who undergoes emergency hospitalization has the benefit of foresight for planning how they might leave. And patients who are receiving planned care at the doctor’s office or in an outpatient setting might not be aware of the resources available to them through their public or private insurance plan. Low-income patients—the same group most affected by transportation barriers—are also likelier to lack health literacy, making it harder for them to navigate the web of regulations required to get a ride.

“If you have health-literacy issues and if you don’t have good access to care to begin with, you’re not going to be able to fill out the application and get your provider to fill out their side of it,” Kangovi said. “Barriers like that, which seem small and detailed, end up being insurmountable barriers for patients.”

Often, doctors may not even realize that their patients have problems with transportation, Syed said, since patients can be embarrassed or otherwise hesitant to raise the issue. “There are things patients might not tell you, or that you don’t ask them, and so they just hear from the doctor that you shouldn’t miss your appointments, and they say, ‘Okay,’” she said. “But there is more to it that is beyond their control.”

“You can provide the best care in the world,” she added, “but it doesn’t matter if the patient has no way to get to it.”