Driver’s License Suspension Policies as a Barrier to Health Care

In 43 states, courts can suspend a driver’s license for non–driving-related events, such as failure to pay a fine or appear in court. In this editorial, we describe the history of license suspensions in the United States and discuss the implications of a suspended license for access to health care. We conclude by advocating that license suspension policies should viewed through the lens of a “Health in All Policies” approach, requiring coordination across sectors outside the traditional health care system.

BACKGROUND

For as long as states have required a license to legally drive, they have reserved the right to suspend or revoke that license in the event of unsafe driving. However, it was not until the 1980s when harsh penalties, including license suspensions, were routinely enforced. Since then, license suspensions, along with improvements in vehicle and road design, alcohol taxes, and increases in the legal drinking age, are credited with a dramatic decline in motor vehicle crashes. As a result, suspensions for unsafe driving enjoy widespread public support as they are perceived as an effective means of removing high-risk drivers from the road.

Given the importance of driving for participation in modern society, a license suspension can significantly limit social and economic opportunity. Nevertheless, when implemented in the name of safety, a suspension may be viewed as a necessary tradeoff or, at a minimum, a tradeoff worth debating. However, since the 1990s, states have used the threat of a suspended license to incentivize compliance with laws and regulations unrelated to traffic safety. In 1991, states were required to automatically suspend the license of anyone convicted of a drug offense or risk a 10% cut in highway funding, and, in 1996, federal legislation authorized license suspensions for failure to pay child support. Over the past 25 years, states have approved suspensions for a variety of other non–driving-related offenses, including failure to pay a fine or appear in court.

State-level evaluations of suspension rates suggest that approximately 7% of all licensed drivers have a suspended license (though in some states, like California, it has been as high as 17%), of which approximately 80% are for a non–driving-related event. The unsafe driving behaviors commonly associated with a suspended license constitute a minority of all suspensions. For instance, only 3% of suspensions are for driving under the influence.¹

Underlying the use of non–driving-related suspension policies is the assumption that an individual is able to comply with the regulation but has chosen not to. Yet, research suggests that there is a sizeable portion of the suspended population for which this is not the case.² The most commonly reported reason for a suspension is failure to pay a fine or appear in court. In California, a $100 ticket rises to $490 after assessments are included and almost doubles to $815 if the driver misses the initial deadline (http://bit.ly/2l9hNcO). In 2018, the Federal Reserve reported that 44% of US adults would be unable to afford an unexpected expense of $400. Thus, it is likely that many unpaid fines are the result of inability, as opposed to unwillingness, to pay.

IMPLICATIONS FOR THE PUBLIC’S HEALTH

Each year, approximately 3.6 million Americans miss or delay health care because of transportation barriers, resulting in increased health care costs and potentially serious long-term health consequences. Because the majority of individuals use a personal vehicle for medical-related trips, lacking access to a vehicle has become the most commonly reported transportation-related barrier to care.³

Despite the importance of access to a vehicle, little attention has been paid to licensure as a transportation-related barrier to care. Yet, individuals caught driving without a license risk significant fines or incarceration and thus are forced to weigh the importance of the trip against the risk of getting caught. Although few completely cease driving, most limit their trips to those considered “essential.” The direct impact of the suspension on access to health care (e.g., to what extent drivers consider health care “essential”) has been difficult to assess because of a lack of relevant data. Some of the only empirical information comes from an evaluation of a program in Utah that allowed undocumented immigrants to apply for a driver’s license. Program participants had rates of inadequate prenatal care similar to their documented counterparts, while those not participating in the program had rates almost twice as high.⁴

Non–driving-related license suspensions may also exacerbate disparities in access to care as low-income and racial/ethnic minority drivers are substantially more likely to receive a suspension for a non–driving-related event. A recent study in New York found that non–driving-related suspensions were nine times greater in the poorest as compared with the wealthiest zip codes, and 2.5 to 4 times greater in communities with the highest as compared with lowest percentage of racial/ethnic minorities.⁵ Importantly, these are also the populations most likely to face other barriers to accessing health care. Thus, non–driving-related suspensions appear most prevalent in those populations for whom access to health care is already a challenge.

A “HEALTH IN ALL POLICIES” APPROACH TO PUBLIC HEALTH

In June 2011, the National Prevention Council released the National Prevention Strategy—a roadmap of priorities for improving the nation’s health.⁶ At the roadmap’s core was the emphasis on a “Health in All Policies” approach, highlighting the need for collaboration across sectors not traditionally associated with public health, such as housing and transportation. The strength of this approach is not only its recognition that health is determined by factors outside the medical establishment but also that the authority to address those factors also frequently lies outside the medical establishment. For instance, in addition to incorporating transportation into public health policy, we should work to also incorporate public health into transportation policy.

In the past two years alone, five states (California, Michigan, Idaho, Virginia, and Minnesota) plus the District of Columbia have passed legislation ending the practice of suspending licenses for non–driving-related events. The challenges to the policy have centered mainly on issues of justice (e.g., racial/ethnic disparities in the traffic stops that generate the initial fee or fine) and social and economic opportunity (e.g., the necessity of a license for participating in a modern economy). To our knowledge, no policy evaluation has addressed the impact on access to health care.

A constraint to the Health in All Policies framework has been the limited data linkage across different agencies. This is particularly true for transportation and health, in which linkage of large-scale administrative databases is lacking, and surveys rarely ask detailed-enough questions on both transportation and health to be effective. To understand the impact of a suspended license on access to health care, we must address the critical and unmet need for more information on the population of suspended drivers, what kind of access to health care they had before the suspension, and what resources are available to them to mitigate the impact of a suspension.