In this dissertation I have examined how transportation can hinder or facilitate access to medical care. Using nationally representative data (Chapter 2), locally-sourced data (Chapter 3), and primary data (Chapter 4), I found evidence that transportation availability plays a critical role in people’s ability to access medical care. Findings suggest that transportation to health facilities should remain an important consideration in health care delivery at the federal level, at the level of local and state government in North Carolina, and among new and existing
transportation companies in the U.S.—especially as health disparities persist. Summary of Research Findings
Chapter 2 of the dissertation documents that nearly 6 million people in the U.S. delayed medical care because of a lack of available transportation in 2017. This provides an update to the limited amount of published research estimating the population affected by this barrier to care on a nationally representative scale. People with lower incomes, especially those living below the poverty threshold, were more likely to report a transport barrier to care. People who are
Hispanic, who have a functional limitation, who are older, or who have a history of stroke were more likely to report this barrier. Despite Medicaid’s NEMT benefit, Medicaid beneficiaries were also more likely to report a transportation barrier to care compared to those who did not receive Medicaid.
Chapter 3 demonstrates how transportation to medical care drove the majority of trip demand for the sole public transit provider in one rural North Carolina county in 2019. While
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Medicaid funding was essential in this context, it does not paint the whole picture of health care access facilitated by community transportation in Anson County. State and federal funds
(through the Rural Operating Assistance Program [ROAP]) made possible a substantial proportion of medical trips in 2019—above and beyond the transportation that was funded through Medicaid NEMT. This study showcases how the health needs of a community ultimately influence the behavior of a rural transit agency. As the health of North Carolina’s residents changes over time, the picture of transit provision—along with the resources required to sustain it—will also change.
Chapter 4 characterizes the rapidly evolving landscape of technological advances in health care transportation provision. Through a nationwide review of emerging health care transportation services and qualitative analysis, I developed a typology of innovative health care mobility strategies, identifying three core models: 1) health care providers leveraging
ridesourcing technology, such as Uber and Lyft, to book rides for patients; 2) insurers formally partnering with a ridesourcing company to expand transportation offerings to their beneficiaries; and 3) paratransit providers offering ridesource-based trips through pilot projects. This
investigation shines a light on the ways in which the proliferation of ridesourcing technology is reshaping paratransit and dial-a-ride services in the U.S. New mobility services tout their cost- saving potential for insurers and increased reliability and convenience for patients; however, it is unclear whether these services could be financially viable in low-density, nonurban areas. Implications for Policy and Planning
Access to health care lies at the juncture of public health and transportation planning. How people travel—or don’t travel—to doctor’s appointments, hospitals, and pharmacies is a
matter of pressing policy importance to local planning agencies, health care providers, and the federal government.
For most Americans, driving alone, riding with friends or family, or taking public transit are sufficient options for traveling to medical appointments. Yet for many individuals with physical or financial barriers, specialized transportation options like paratransit, hospital shuttles, and even Uber Health, offer critical access for these trips. While support for these mobility options is growing in some cases, such as when accountable care organizations offer non- medical benefits like transportation to their members, Chapter 2 of this dissertation found that nearly 2% of the U.S. population persistently reports transportation barriers to care. This is evidence that at least some current mobility options do not work for a large number of people.
There is a robust focus on addressing social needs that drive health outcomes and costs, with special attention to initiatives that address transportation as a SDOH. These initiatives work broadly in two ways: some efforts seek to increase the focus on health within transportation planning while other efforts aim to draw attention of the health care system to the issue of transportation availability and accessibility for patients. This dissertation found evidence that both approaches deserve attention.
Regarding the first approach: the field of transportation planning maintains a strong focus on health. Health-promotion efforts often target improved safety outcomes and planning for walking and biking as a means of increasing physical activity. Within this same vein,
transportation planners should consider how and when people can travel to medical care and what happens when a lack of viable transportation is the only thing coming between a person and their health care provider. One way to do this is to adopt a health facility connectivity index as a metric to be considered in the transportation project prioritization process. This can help state
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departments of transportation explicitly consider health access as a criterion in the process for selecting and funding transportation projects. Transportation planners can also crossover into public health by playing an active role in the process of community health needs assessments, such as those required of not-for-profit hospitals under the Affordable Care Act.
Several health policy reforms in North Carolina demonstrate examples of the latter approach: to draw attention of the public health sector to the issue of transportation. Under North Carolina’s Medicaid managed care, newly-formed Prepaid Health Plans will be responsible for screening all beneficiaries to assess their social needs and make necessary connections to
resources like transportation. Other proposed reforms in North Carolina include NCCARE360, a statewide coordinated care network that digitally connects health care and human services organizations in order to coordinate delivery of care and community resources.7 There will also be “Health Opportunity Pilots,” in which parts of the state will test evidence-based interventions that address SDOH. Each pilot must address all areas of need including housing, food,
transportation, interpersonal violence, and toxic stress, tracking enrollee health outcomes and costs to determine intervention effectiveness in both rural and urban areas.
Beyond these state initiatives there are also health care provider-level efforts to identify transportation needs of patients. Hospitals and health systems are increasingly including transportation as a consideration along the care continuum. Efforts include integrating support for transportation access into the organization’s mission; screening patients’ transportation needs at intake or discharge; and directly providing transportation through partnerships, such as those with ridesourcing companies discussed in Chapter 4.
7Implementation of NCCARE360 began in January 2019 and had onboarded 50 counties by February 2020
Statewide implementation will be complete by December 2020. There is authorized federal funding of $650 million over five years (NC Department of Health and Human Services, 2019)
It remains to be seen how successful these policies can and will be in addressing health disparities across North Carolina. Ultimately, these programs do not address the spatial
distribution of homes and health care facilities. Researchers have emphasized that the effectiveness of coordinated care depends on the health care delivery infrastructure within a community (Kadakia et al., 2019). While there has been rapid growth in the relative supply of physicians in metropolitan regions of North Carolina, the rate in most rural counties of the state has remained almost stagnant (Holmes, 2018). While technology promises new ways for people to see their health care providers, through telehealth and ridesourcing apps, these services are not silver bullet solutions in rural areas where broadband may be scarce or Lyft drivers non-existent. Land use and distribution of health care infrastructure will persist as a factor in facilitating health care encounters.
Future Research Needs
It is encouraging that there is no shortage of research efforts to investigate SDOH broadly. With growing attention to the role of SDOH as explanatory factors in the performance of the U.S. health care system, the deployment of evidence-based interventions necessitates the need for specific research on the impact of transportation on health outcomes, among other social needs. There are three areas in particular that deserve increased investigation.
First, research can add important nuance to our understanding of transportation barriers. While there is a growing evidence base identifying transportation as a real and perceived barrier to care, it is less clear what qualities of various transportation options are most influential in creating a barrier. For example, women who are also responsible for child care likely experience transportation barriers differently than others without children. Qualitative research can improve our understanding of these distinctions and contribute to more targeted solutions. One way to
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facilitate this type of research is to increase efforts to monitor barriers to care. Surveillance systems like the National Health Interview Survey (Chapter 2), can expand its response options for people to report on various aspects of a transportation barrier rather than only asking about the binary presence or absence of this barrier.
Second, there is a need for research on transportation barriers to care that incorporates greater place-based information. This dissertation uncovered some differences in transportation barriers to care across census regions, but analysis at a more granular scale would be helpful, especially given health disparities that map to smaller geographies. With improved spatial research, transportation solutions can be tailored to target residents by geographic region.
Finally, it would be advantageous to adopt systems thinking approaches in future studies of transportation to health care. Barriers to health care are the result of wider economic, social, cultural, and political forces and are driven by complex interactions at multiple socioecological levels. Transportation accessibility is one of many risk factors for missed care, and these risk factors commonly co-occur (Chaiyachati et al., 2018). Housing, food insecurity, and lack of transportation are interconnected and can be mutually reinforcing. An improved understanding of how barriers relate to and influence one another will inform ideas about potential interventions. Approaches to increase access to care that only target transportation options might fall short, while solutions that do not consider transportation viability at all are missing part of the picture. Barriers to care are complex and deeply interrelated, and systems-based approaches to analyzing them empirically have the potential to improve our understanding and bolster the success of programmatic support and interventions.
APPENDIX
Table A1. NHIS Sample Characteristics, 2017 (n=24,947; N=229,389,370)
Unweighted Frequency Unweighted Proportion (or Mean) Weighted Proportion (or Mean) Sociodemographics: Female 13,629 54.6% 51.6 Age 24,297 50.6 47.2 Race/ethnicity Hispanic 3,026 12.1% 16.0% NH White 17,650 70.7% 65.0% NH Black 2,675 10.7% 11.8% NH Asian/multiracial/other 1,596 6.4% 7.2% Educational attainment
High school or less 8,679 34.8% 35.4%
Some college 7,826 31.4% 30.6%
Bachelor's degree or higher 8,442 33.8% 34.0%
Family income, $
0-34,999 8,527 34.2% 27.0%
35,000-74,999 7,614 30.5% 30.2%
75,000-99,999 2,910 11.7% 13.1%
≥100,000 5,896 23.6% 29.7%
Below poverty level 3,373 13.5% 11.6%
Medicaida 3,573 14.3% 14.6% No health insurance 2,227 8.9% 10.0% Unemployed 699 2.8% 3.2% Veteran status 2,472 9.9% 8.4% Region Northeast 4,017 16.1% 18.1%
North Central or Midwest 5,958 23.9% 21.9%
South 9,152 36.7% 36.1%
West 5,820 23.3% 23.9%
Health Characteristics:
Self-reported health status
Poor 779 3.1% 2.7% Fair 2,662 10.7% 9.8% Good 6,782 27.2% 26.5% Very good 8,377 33.6% 32.8% Excellent 6,347 25.4% 28.3% Currently pregnant 170 2.7% 2.8% Diabetes or prediabetesb 3,332 13.4% 12.1% Asthma 3,506 14.1% 13.4%
Ever told have cancer 2,837 11.4% 9.3%
Heart condition or diseasec 2,235 9.0% 7.7%
Hypertension 8,684 34.8% 30.3%
71 (continued)
Weak or failing kidneys 617 2.5% 2.0%
Ever had stroke 922 3.7% 3.1%
Functional limitationd 10,449 41.9% 37.0%
# of ER/ED visits in last 12 mos.
0 20,077 80.5% 81.4%
1-3 4,366 17.5% 16.8%
≥4 504 2.0% 1.8%
Notes:NH = Non-Hispanic; ER/ED = Emergency Room/Emergency Department a Has any Medicaid/other public assistance/State sponsored plan or CHIP, excluding Military coverage, Medicare, or Indian Health Service
b Includes respondents who reported being "borderline" diabetic (n=8,831)
c Ever diagnosed as having any kind of heart condition or disease other than coronary heart disease, angina pectoris, or a heart attack (myocardial infraction)
d Adults who had difficulty doing any of several specific activities because of a health problem
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