The Public Health Case for Addressing Transportation-Related Barriers to Care

The many ways in which the US health care system does not fully meet the needs of the population are well documented. Issues abound in health care encounters, but problems with the system are most pervasive when people cannot even get inside the door. Access to care, encompassing availability, accommodation, affordability, acceptability, and accessibility,¹ is an enormous challenge in the United States, with its fragmented system of payers, providers, and types of care. An inordinate amount of time is spent thinking about how to improve access to care by expanding insurance coverage and reducing out-of-pocket costs. Yet, it is equally important to consider the basic mechanics of how people get to health care settings, an essential component of physical accessibility to care. In this issue of AJPH, Wolfe et al. (p. 815) show that millions of Americans delay health care every year simply because they do not have the transportation to get to the doctor’s office. Despite all of the efforts to improve access to care and address social determinants in recent years, the percentage of Americans with transportation-related barriers to care did not change between 1997 and 2018, stubbornly holding fast at 1.8%. As the US population has grown, the number of people affected by transportation barriers to care has risen from 4.8 to 5.8 million annually.

RISK OF TRANSPORTATION-RELATED BARRIERS

Like most public health issues, the risk of transportation-related barriers to care is not uniformly distributed and has strong structural, socioeconomic, and demographic correlates, with variation by race, ethnicity, age, poverty status, educational attainment, employment status, health status, and functional status. In adjusted models, Wolfe et al. found that Hispanic adults, adults living in poverty, and adults who rely on Medicaid had the highest odds of experiencing transportation-related barriers to care. Consistent with previous research,² the authors also found that having a disability or health problem was associated with more transportation barriers. The latter finding may lead to exacerbation of those very health issues among the people who need care most.

Wolfe et al. also identified significant differences in the likelihood of there being transportation-related barriers to care by US census region, with the West, South, and North Central–Midwest all having higher prevalence of such barriers than the Northeast. The authors were not able to examine geographic differences in transportation-related barriers to care beyond census region, but they allude to inequities. In my own work at the University of Minnesota Rural Health Research Center, I can almost guarantee that whatever health or health care issue I set out to study, transportation will emerge as a persistent challenge. Transportation is distinctly linked to geography. And it depends on good roads, access to vehicles and fuel, availability of public transportation with affordable fares and accessible routes, weather, traffic patterns, and sound public policy and infrastructure investment. The authors rightly point out the need for more research on transportation barriers to care by specific geographic context, as transportation is inherently and uniquely geographically constrained.

I have identified rural-specific transportation barriers in my work, including limitations to public transportation systems connecting across local municipal or state lines, limited funding, struggling infrastructure, difficulty affording fuel and maintenance for private vehicles, and long travel distances to reach appropriate health care.^3,4 Certainly, many of these issues show up in urban areas, too, but they do so differently, with urban areas having the population density to support a wider array of transportation options. Furthermore, many of the other characteristics that Wolfe et al. identified as being related to transportation barriers, including age, functional status, and socioeconomic status, intersect with geography in ways that exacerbate risks of poorer health outcomes.

Finally, no discussion of transportation-related barriers to care would be complete without a mention of telemedicine. This shows some promise for reducing how long someone needs to travel for care, instead bringing care closer to home—or even into the home. Still, we have a long road to go in the United States, as rates of telemedicine use hover at extremely low rates.⁵ Any improvements in telemedicine access will need to come with investments in broadband Internet, cellular connectivity, and access to technological devices, especially in rural areas, where all of those are scarcer.⁵ Even with robust telemedicine capacity, not all health care can—or should—be delivered remotely, and transportation will remain an integral component of how people access care.

BEYOND ACCESS TO HEALTH CARE

The most striking piece of the Wolfe et al. study for me, however, is not the number of individuals who face transportation-related barriers to health care (although that is deeply concerning). I worry, instead, that the number of Americans struggling to access health care because of transportation is dwarfed by the number of American who struggle to access other resources because of transportation-related barriers. Although there are pernicious transportation-related barriers to health care in the United States, there have also been systematic efforts to address some of those through the programs that Wolfe et al. list (e.g., nonemergency medical transportation for Medicaid recipients, transportation for people in the Veterans Health Administration).

Far less has been invested in helping individuals connect with other areas of their life, relegating those to private concerns. However, living full and healthy lives requires more than showing up for health care appointments. It involves any number of reasons for travel, including getting to the grocery store, running other errands, picking up children from daycare, attending a place of worship, participating in community events, voting, socializing, and maintaining a job. Perhaps with the exception of those in the most walkable neighborhoods, doing any of those activities requires some mode of nonpedestrian transportation (e.g., biking, driving, carpooling, public transportation). Again, challenges related to transportation for such activities are not randomly distributed, with some populations facing greater barriers because of maldistribution of resources based on demographic, socioeconomic, geographic, and health characteristics.

As efforts continue to move further upstream in addressing social determinants of health in both public health and health care, transportation needs to remain an urgent priority. Addressing any other determinant—education, employment, housing—requires high-quality, safe, and sustainable means of transportation to connect people with resources and with one another. Furthermore, curbing the public health impact of climate change requires attention to transportation and its effect on the environment.⁶ Transportation systems and policies, including urban planning, policing roads and highways, and accessing drivers licenses, are also intrinsically linked with structural racism.⁷ As a field, we urgently need to address all facets of transportation to make progress on our most urgent threats to public health. The good news is that addressing barriers to transportation for health care will have positive spillover impacts into other areas of people’s lives, and vice versa.

CONCLUSIONS

Ultimately, this is a story of connection, both in health care and beyond. More work is needed to ensure that people have the means to connect with health care, with one another, and with their communities. If someone cannot even get in the door, it is a missed opportunity for all of us.