GOP states embrace Uber, Lyft to take low-income patients to medical appointments

This month, Mississippi becomes the latest state to partner with ride-hailing companies such as Uber and Lyft to ferry residents to their medical appointments.

It's a bid to improve overall health in a state where advocates and medical groups have called health care a crisis that's getting worse.

Ryan Kelly, executive director of the Mississippi Rural Health Association, said groups such as his have been working to promote more regular annual checkups, but added that transportation barriers have contributed to high rates of missed appointments. The no-show rate for some providers can be as high as 75%, he said.

"We're not airlines and can't double-book appointments," he said. "If your practice's calendar is booked solid but 75% of people don't show up? Many providers have gone away from doing a lot of wellness checkups because patients don't show."

In recent years, Uber and Lyft have lobbied states to use Medicaid funding for transporting patients to medical appointments. It's a small but potentially lucrative sector of the health care market: States spend about $2 billion annually, with the federal government spending an additional $3 billion, on nonemergency transportation for Medicaid patients, according to a study by the Texas A&M Transportation Institute for the Arizona Department of Transportation.

Lawmakers, particularly in Republican-led states, have jumped aboard.

In 2019, Arizona became the first state to change its Medicaid regulations to allow companies such as Uber and Lyft to provide nonemergency medical transportation. Lawmakers smoothed the way by carving out a new provider category that removed some safety rules, like requiring drivers to undergo drug testing and first aid training. But the rules only allow companies such as Uber and Lyft to transport Medicaid enrollees who don't require assistance.

Legislators in Texas and Florida relaxed their Medicaid regulations that same year. Medicaid is federal- and state-funded health insurance for people with low incomes and disabilities.

In Mississippi, Kelly and others are cautiously optimistic, but they also have expressed concern that diverting patients to private companies such as Uber and Lyft could hurt those that currently provide nonemergency transportation. Those companies are required to meet certain state guidelines, such as being wheelchair accessible and maintaining safety certifications.

"There are various policies they have to go by that we haven't seen Uber and Lyft have to meet," Kelly said. If such companies siphon off a portion of riders with fewer complex needs, the existing companies are left with fewer patients who are potentially more expensive to transport.

Mississippi's new contract with Uber Health says it will pay the company up to $1 million a year to provide Mississippians nonemergency transportation to and from their local health department.

"The program's goal is to make health care accessible and provide access to opportunities for all Mississippians to live the healthiest life possible," Victor Sutton, chief of community health and clinical services for the Mississippi State Department of Health, told Stateline in a statement.

Health implications

Transportation remains one of the biggest barriers to health care for people with low incomes. About 1 in 5 adults without access to a vehicle or public transit were more likely to forgo needed health care because of difficulty finding transportation, according to a new study from the Urban Institute, a nonprofit think tank focused on social and economic policy. In a separate study, researchers found nearly 6 million people in the United States delayed medical care in 2017 because they didn't have transportation.

Lack of transportation leads to missed or rescheduled appointments, delays in getting prescriptions filled, poorer management of chronic illness and subsequently poorer health outcomes.

Most Medicaid recipients can get a free ride to and from a medical appointment. Nonemergency medical transportation is a mandatory Medicaid benefit, meaning states have to cover free or low-cost transportation to and from appointments if enrollees don't have a way to get there.

Most states contract with third-party brokers that coordinate transportation for enrollees, which is typically public transportation, taxis or private shuttle services. But those brokers have a mixed track record.

"Especially in rural areas, sometimes it's a very long trip to take [patients] from one place to another," said Kelly. "You might be picked up at 6 a.m. for a 10 a.m. appointment, in a van that travels to different locations, like a group pickup or a bus route. It's a service that's available, but not always an overly efficient service."

Riders have filed lawsuits against companies in several states, alleging safety issues, no-show drivers and hourslong waits for rides.

In recent years, Uber and Lyft have entered the market, positioning themselves as a lower-cost solution for patients who just need a ride and don't require specialized services like wheelchair lifts. They advertise benefits over traditional brokers such as on-demand scheduling, an electronic record of rides for transparent monitoring, and customer familiarity with the service.

Uber launched its health care division, Uber Health, in 2018, following Lyft's entrance into nonemergency medical transportation in 2016.

Connecting with patients

There are several ways a company such as Uber Health can connect with patients, depending on state regulations and how Medicaid benefits are administered. In Georgia, for example, third-party brokers can set up Uber rides for Medicaid beneficiaries. In Arizona, Uber works directly with Medicaid managed care organizations. The company says more than 3,000 health care organizations across the United States use its Uber Health platform to coordinate nonemergency transportation.

Some research backs up their lower-cost pitch. A 2019 analysis by Stanford University researchers found that "modern" alternatives such as Uber and Lyft could save Medicaid programs around $268 per expected user and $537 million annually if scaled nationally. That would be a 30%-70% savings over traditional nonemergency transport services.

In 2017, the largest Federally Qualified Health Center in Texas signed a contract with Uber for a pilot program in coastal Beaumont, Texas, to offer patients free rides to and from their appointments if they lacked access to transportation.

"A huge issue in Beaumont is transportation and security," said Lindsay Lanagan, vice president of governmental affairs at Legacy Community Health, which operates 54 health care facilities across Southeast Texas.

Nearly all of Legacy's patients live at or below the federal poverty level. The majority are either uninsured or are children and pregnant people who have coverage through Medicaid. Most are Black or Hispanic, and many are people who don't speak English as a first language.

After starting the pilot program with Uber, Legacy's clinics saw a large decrease in missed appointments, Lanagan said. Clinic providers supported the 2019 measure that cleared Uber Health to provide rides for Medicaid recipients through third-party brokers. To pass the bill, Uber worked directly with Republican Rep. Dade Phelan, who's from Beaumont and is now speaker of the House.

"To be honest, that was the easiest bill I've ever worked on," Lanagan said. "We had the data to reflect how important it is to offer these services. [Legacy] could always offer them by piecing together grants … but at the same time it's really nice to have it available as a state program for everybody."

Phelan said in a tweet that he wrote the bill "to place more power in the hands of Medicaid recipients to make their medical appointments." He called the partnership with Uber a cost-effective use of Medicaid funding that would cut down on fraud, waste and abuse.

That year, Uber spent about $710,000 on lobbyists in Texas, according to data compiled by OpenSecrets, a nonprofit research and government transparency group. Uber has a lobbying presence at state and local levels in 46 states and the District of Columbia, according to its 2022 political engagement report, and spent about $6.6 million that year on state lobbyists.

Legacy Health continues to use grant funding to provide about 300 rides per month via companies such as Uber and Lyft that it schedules using third-party software, said William Lyons, senior manager for social determinants of health programs at Legacy Community Health.

A small percentage of rides are still booked through specialized medical transport vehicles. Those tend to be for patients who live in rural areas where Uber and Lyft drivers are sparse, or who require specialized services such as a wheelchair lift.

Before Uber and Lyft were available, patients who lived farther from their nearest clinic might have had to ride a bus for two hours or more to get to an appointment, Lyons said.

"That could mean a whole day of traveling for a medical appointment that may last 30 minutes," he said. "Many people don't have paid leave to go to medical visits and they're missing out on work to go to the appointment."

As with any program, it's only as good as its coverage area, Lyons said. There are still gaps, particularly in rural areas where Uber and Lyft aren't available.

But overall, he said, "this is definitely a more cost-effective way to make sure that patients can not only participate in their medical care, but also maintain a job and have their children still in school."

Mississippi is likely the first state to offer rides specifically to appointments at county health departments, rather than to private providers, according to Sutton, the agency's community health and clinical services chief. The state has one of the worst physician shortages in the nation, and county health departments are the only option for primary care in many areas of the state.

Mississippi's program will offer Uber rides when available. To address concerns about whether enough Uber drivers are operating in rural areas, Sutton said the company will work with the state health department to create a marketing plan to recruit more drivers. And because the health department is the one scheduling rides, people without smartphones should be able to take advantage of the service.

For a rural state such as Mississippi, transportation has a significant effect on "access to care, social services and educational opportunities," Sutton said.