Background
Transportation problems are known barriers to health care and can result in late arrivals and delayed or missed care. Groups already prone to greater social and economic disadvantage, including low-income individuals and people with chronic conditions, encounter more transportation barriers and experience greater negative health care consequences. Addressing transportation barriers is important not only for mitigating adverse health care outcomes among patients, but also for avoiding additional costs to the health care system. In this study, we investigate transportation barriers to accessing health care services during the COVID-19 pandemic among high-frequency health care users.
Methods
A web-based survey was administered to North Carolina residents aged 18 and older in the UNC Health system who were enrolled in Medicaid or Medicare and had at least six outpatient medical appointments in the past year. 323 complete responses were analyzed to investigate the prevalence of reporting transportation barriers that resulted in having arrived late to, delayed, or missed care, as well as relationships between demographic and other independent variables and transportation barriers. Qualitative analyses were performed on text response data to explain transportation barriers.
Results
Approximately 1 in 3 respondents experienced transportation barriers to health care between June 2020 and June 2021. Multivariate logistic regressions indicate individuals aged 18–64, people with disabilities, and people without a household vehicle were significantly more likely to encounter transportation barriers. Costs of traveling for medical appointments and a lack of driver or car availability emerged as major transportation barriers; however, respondents explained that barriers were often complex, involving circumstantial problems related to one’s ability to access and pay for transportation as well as to personal health.
Conclusions
To address transportation barriers, we recommend more coordination between transportation and health professionals and the implementation of programs that expand access to and improve patient awareness of health care mobility services. We also recommend transportation and health entities direct resources to address transportation barriers equitably, as barriers disproportionately burden younger adults under age 65 enrolled in public insurance programs.
Keywords: COVID-19, Health care transportation, Health equity, Health services accessibility, Medicaid, Medicare, Non-emergency medical transportation, Social determinants of health, Survey study, Transportation barriers
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Background
Transportation barriers create obstacles to health care and are known to result in delayed and missed appointments as well as medication use [1]. 5.8 million people in the United States delayed medical care in 2017 because they did not have transportation [2]. Groups that are already prone to greater social and economic disadvantage, including individuals who are poor and/or under or uninsured and who have chronic conditions, are more likely to encounter transportation barriers to care and experience negative health consequences [2–5]. Addressing transportation barriers that result in delayed or missed care is important not only for mitigating adverse health care outcomes among patients, but also for avoiding additional costs to the health care system stemming from increased use of emergency departments and hospitalizations [6–9].
The COVID-19 pandemic widely disrupted health and transportation systems in the US. Beginning in March 2020, many health systems deferred non-emergency medical procedures and other elective care [10]. The postponement of medical care remained high throughout 2020. Giannouchos et al. found that 26.9% of adults 18–64 reported having foregone medical care from August to December 2020, while 35.9% reported having delayed care [11]. Though in-person appointments have resumed, many fields face unprecedented patient care backlogs [12]. Public transportation systems reduced service in many cases during the early months of the pandemic response, and riders reported hesitation using public or shared modes due to concerns about infection risk [13]. This likely exacerbated transportation barriers to health care for people without access to a personal vehicle, including some individuals with disabilities [14].
Using mobile device data to explore temporal patterns in visits to health care points of interest during 2020, Wang et al. found census block groups in North Carolina with higher population density and those with higher percentages of older adults, low-income individuals, racial and ethnic minorities, and people without household vehicles had lower rates of medical visits during the pandemic and experienced a slower recovery in visits after the state’s most restrictive lockdown period spanning from mid-March to May 2020 [15]. This may indicate that problems accessing transportation and other barriers to health care are disproportionately affecting populations already known to experience transportation and health disadvantages, particularly during the pandemic.
Synthesizing knowledge on transportation access to health care during the pandemic, Chen et al. found that some patients seeking care required additional support, particularly those who already experienced socioeconomic and transportation disadvantages such as low-income individuals, people of color, and people with disabilities [10]. They were not always able to rely on others or on public transportation for rides like they had in the past, experienced added challenges because of economic hardship due to COVID-19, and found it more difficult to fulfill their health care needs using telemedicine. The authors suggested that partnerships between health and transportation systems hold promise for addressing transportation barriers during and after the pandemic but noted that these partnerships, i.e., arrangements to provide non-emergency medical transportation (NEMT) services, are largely limited to low-income patients enrolled in Medicaid. They reviewed alternative strategies for addressing patients’ transportation needs, including new models for providing NEMT though health care partnerships with ridehailing companies (e.g., Uber and Lyft) as well as innovations in health care coordination and policy, and concluded that such strategies might reduce transportation barriers and promote equity in health care access.
In this study, drawing on results of a survey conducted with high-frequency health care users in North Carolina, we investigate transportation barriers to accessing health care during the COVID-19 pandemic. We examine if and how adult North Carolina residents in the UNC Health Care (“UNC Health”) system who had at least six outpatient medical appointments between April 2020 and April 2021 and are enrolled in Medicaid or Medicare encountered transportation barriers. We explain how barriers affected respondents’ care due to having delayed, missed, or arrived more than 20 minutes late to appointments because of transportation problems. Using demographic and other information collected for respondents, we analyze what factors were associated with reporting transportation barriers that resulted in negative care outcomes. We conclude by making recommendations regarding strategies to address transportation barriers that might meet the needs of high-frequency health care users who have greater health care-related transportation burdens and are more likely to encounter transportation barriers to care.
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Methods
Sampling and recruitment
The goal of this research was to examine transportation-related barriers to accessing health care among groups known to have greater health care and health care-related transportation burdens, including low-income people, older adults, and individuals with chronic conditions. We thus purposively sampled from these groups, i.e., people with low incomes and those aged 65 and older, and individuals that needed to access care multiple times during the previous year. We recruited participants using data provided by the Carolina Data Warehouse for Health (CDW-H), a central data repository containing clinical, research, and administrative data sourced from the UNC Health system. UNC Health is a not-for-profit medical system owned by the state of North Carolina; while based in Chapel Hill, UNC Health operates hospitals and medical practices across the state. At the recruitment stage we selected from 34,387 individuals to generate a sample of ~ 15,000 people who met the following inclusion criteria: (1) have Medicaid or Medicare as their primary insurance; (2) are North Carolina residents; (3) are over age 18; (4) have a valid email address; and (5) had six or more outpatient visits between April 2020 and April 2021.
Our first inclusion criterion, having Medicaid or Medicare as one’s primary insurance, predictably skewed our sample toward people aged 65 and older. To achieve greater representation of adults aged 18–64, we oversampled from this age group. We then quota-sampled amongst older adults so that the recruitment sample of individuals aged 65–79 and over 80 approximately matched the population of North Carolina; 15.9% of the state population is aged 65–79 and 4.5% is 80 plus according to recent Census estimates [16]. A total of 14,723 people were ultimately included in the recruitment sample, comprising 6945 individuals aged 18–64; 6201 individuals aged 65–79; and 1577 individuals aged 80 or older (Table 1, column 1).
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