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A Road Awakening: Americans Cannot Access Healthcare Without Reliable Transportation
This past summer, I began working at a physical therapy clinic in a low-income, rural area. A lot of our patients were poor, some homeless or living in mobile homes, and I observed that many patients used government-issued insurances like Medicare and Medicaid. There seemed to be a strong association between using government insurance and being assigned the “Ride” label, highlighted and bolded on our patient schedule to grab employees’ attention. This label notified our staff of patients who did not own a personal vehicle or were unable to drive. This meant that they were either given a ride or relied on public transit. However, in this small rural town, there were few to no options for public transportation. Additionally, no free rideshare or shuttling options were available.
Predictably, patients without consistently reliable transportation canceled or did not show up for their appointments much more frequently. When calling patients who did not show up in hopes of rescheduling, I repeatedly heard the excuse, “I could not find a ride.” Many of these no-show patients were in desperate need of rehabilitation, and receiving therapy was essential to improving their quality of life. My experience working in healthcare made me understand the harm that unreliable transportation causes to medical treatment. Unfortuntately, unreliable and inaccessible public transportation, the lack of widespread hospital-rideshare partnerships to provide free rides, and the rising cost of owning and maintaining a personal vehicle have made it increasingly difficult for people to reach the doctor’s office.
Public transportation can be the only option for those without personal vehicles to reach medical appointments, but it is wholly unavailable in many areas of the United States. As reported by Lam, Broderick, and Toor, data science researchers at the Pew Research Center, “18% of Americans live more than 10 miles from their nearest hospital” (Lam et al.). This shocking statistic shows that distance limits over fifty-nine million Americans from reaching emergency or outpatient care. Despite the glaring need for public transit, it is generally unavailable in some areas where people may rely on it the most: rural towns. Rural areas often do not have hospitals or clinics within walking distance since the town layout is more scattered and less urbanized. Lam, Broderick, and Toor found that the nearest hospital is 10.5 miles away for those living in rural areas, but 5.6 miles for suburban areas and 4.5 miles for urban areas (Lam et al.). Those living in rural areas face a severe handicap in overcoming health conditions due to a larger travel burden and less transportation accessibility. Furthermore, according to Akinlotan and other researchers at Texas Agricultural and Mechanical University (Texas A&M) and the University of Texas MD Anderson Cancer Center, “On average, U.S. residents traveled 9.9 miles one-way for medical/dental care in 2017. Rural residents traveled more than twice the distance for care than urban residents (urban, 8.10 miles; rural, 17.8 miles…)” (1). They also found that rural residents were more dependent on public transportation than urban residents, but had lesser access to it (1). Rural residents are at an extreme disadvantage due to an underdeveloped public transit system. Reliable transportation is a widespread public need, yet it continues to be unavailable for those who may utilize it the most.
Regardless of the displayed need for increased public transportation, some argue that public transportation is funded excessively in proportion to decreasing ridership. A policy analysis by Randal O’Toole, a former Senior Fellow at the Cato Institute, debates the demand for public transportation. He claims that in 2018, public transit ridership in forty of the United States’ fifty urban areas fell by 215 million transit trips, but yet in that same year government funding for public transport increased by almost four billion dollars. He declares, “Most low‐income workers have given up on transit as a method of commuting and have purchased cars” (O’Toole 1). He believes that public transportation only aims to help the rich, or those with an annual salary of seventy-five thousand dollars or more, and even describes the relationship between urban areas and public transit as “parasitic,” as funding transit takes a large amount of taxpayer dollars while providing most no benefit (O’Toole 2).
However, this analysis overlooks several crucial factors. It focuses solely on urban data, neglecting the significant repercussions of the public transportation shortage in rural areas. This omission is critical, as the lack of accessible transportation in these regions can exacerbate chronic diseases, delay preventive treatments, result in later-stage cancer diagnoses, worsen treatment outcomes, increase the overall disease burden, and diminish quality of life (Akinlotan et al. 1). Additionally, the claim that low-income workers have universally abandoned public transportation in favor of purchasing cars is both unsubstantiated and questionable.
O’Toole’s argument also prioritizes the financial aspects of public transportation without adequately considering its broader social benefits, particularly for underprivileged communities. While financial efficiency is important, it should not overshadow the essential role of public transport in ensuring access to healthcare and other critical services, which can be a matter of life and death. A more comprehensive analysis that includes the needs of all population segments, particularly the most vulnerable, is necessary for a well-rounded understanding of public transportation’s value.
In response to public transportation’s inadequacy, a new competitor has emerged in the transportation market: rideshare services. Uber and Lyft are the two biggest names in the American rideshare industry, and hospitals are beginning to develop advantageous partnerships with these companies to provide rides for patients. Predictably, use of rideshare services appears to be positively associated with increased appointment attendance and treatment completion. Chen and nine other researchers from the University Hospitals Seidman Cancer Center and Case Western Reserve University conducted a study on ridesharing’s impact on the completion of radiation therapy. They found that “… completion rates were significantly higher for rideshare vs non-rideshare utilizers at 96 vs 81% … overall, and 98 vs 78% … for patients undergoing treatment with curative intent” (Chen et al. S17-S18). This study affirmed the efficacy of dependable transportation in improving treatment completion and health upkeep. Free rideshares rid patients of the burden of searching and paying for transport which limits their appointment attendance. A similar study was conducted by Krisda Chaiyachati, a professor of medicine at the University of Pennsylvania, and six other researchers from the University of Pennsylvania, Yale-New Haven Hospital, and Massachusetts General Hospital. These researchers studied the influence of hospital-provided rideshare services on primary care visit attendance for residents of western Philadelphia using Medicaid (Chaiyachati et al. 863). Their research echoed Chen’s findings and revealed that patients who used rideshare services attended appointments more consistently than before. The show rate increased from fifty-four percent to sixty-eight percent after implementing rideshare services (863). According to the Journal of General Internal Medicine, “the odds of showing up for an appointment before and after the intervention increased 2.57 … times more in the rideshare practice …” (Chaiyachati et al. 863). Extending these services throughout the U.S. and into rural areas would assist patients in keeping up with critical care. Additionally, eliminating the stress of finding transportation will not only increase patient attendance, but will lead to better health and financial outcomes for patients without having to find or afford a ride. With free and reliable transportation provided by hospitals and clinics, patients are able to keep up with their conditions and attend appointments regularly, leading to lessened disease burden and higher recovery rates.
Regardless of the studied benefits of hospital-rideshare partnerships, critics of the collaboration believe it does not establish an effective long-term solution. Deana Bell and Cameron Gleed, actuaries at the Seattle Health Practice of Milliman, propose potential gaps in the rideshare system. They insist that rideshare services and drivers are not equipped to handle potential emergency situations, since most drivers lack any sort of medical training or knowledge (2). They explain that the vehicles driven by rideshare employees may not be prepared to handle wheelchairs due to size and limited accessibility, which could complicate rides for the disabled and handicapped (2). Additionally, they also note a recurring theme when researching transportation’s effect on healthcare: those in rural areas may not have access to ridesharing if they live outside of the drivers’ service areas (2).
I do agree with Bell and Gleed that the rideshare partnership could potentially have problems. Nevertheless, I am convinced that these are easily solvable, as rideshare services for most hospitals are never used to handle emergency situations, but rather for outpatient visits and treatments. In case of an unexpected emergency, rideshare drivers could benefit from a training video with recommended safety protocols and procedures. When ordering rides for handicapped patients, hospitals could request a driver with a van or bus. To address the accessibility of the service for rural patients, rideshares could offer bonuses for drivers willing to extend their service areas into rural communities. These companies could also work on expanding their platform into new service areas and hiring drivers from rural communities. With the proper systems in place, hospital-rideshare partnerships will prove incredibly efficient in providing patients the ability to receive medical services.
Unfortunately, in recent years the cost of personal transportation has skyrocketed, making it more burdensome for Americans to maintain and use a personal vehicle. In response, many have given up driving on their own due to the expense of upkeep and gas. In August of 2023, Benjamin Preston, an automotive reporter for Consumer Reports, reported that “… the average price of a used car hovers around $27,000.” However, in the same year, the U.S. Department of Health and Human Services outlined that the federal poverty line qualifies an annual income of $14,580 or less for a single person (Bundrick 3). This disparity makes purchasing a personal vehicle impossible for poverty-stricken Americans. Foreseeably, the cost of maintaining a vehicle unequally affects rural residents’ ability to receive care. As Akinlotan and other researchers unearthed, “More than half (55.8%) of rural residents agreed or strongly agreed that the price of gasoline affects their travel” (Akinlotan et al. 1). This statistic indicates that rural residents are at a higher risk of delaying care due to personal transportation costs. The rising price of transportation extends far beyond economics and has a huge effect on the medical field, keeping patients from reaching the doctor’s office. Cochran, an assistant professor at the University of Nebraska-Lincoln, and six other researchers from the University of North Carolina-Chapel Hill and Texas A&M conducted a study relating the cost of transportation and the COVID-19 pandemic to trouble receiving medical care. Out of 323 respondents, about fifteen percent (49) responded that transportation costs prevented them from receiving care. Their study also found the cost of traveling combined with lack of a personal vehicle to be the primary barrier to medical services. To quote one respondent of the survey, “‘It costs 3/4 tank of fuel, $28, to do a round trip to the hospital plus $12 for parking. If I don’t schedule my appointments the right way, sometimes money is very tight when my monthly check is running out before I get the next one’” (Cochran et al. 6). Without adjustments, the rising cost of vehicles, gas, and upkeep will continue to limit individuals from receiving medical care.
Despite the rising cost of vehicle ownership, various free or subsidized options for reliable personal transportation already exist. Most municipalities in the United States have organizations that provide assistance to those without a personal vehicle. State health departments can provide rides to and from medical appointments for qualifying patients. Governmental agencies also exist to take care of those struggling with lack of transportation. Services like the Department of Aging create programs to assist needy individuals in receiving rides to medical services. One example, specifically in Maryland, is the Department of Human Services’ Transportation Assistance Program. This initiative provides low-income families with well-kept personal vehicles for two years or twenty-four thousand miles (“Transportation”). Additionally, some may naively claim that patients without a car could just ask a friend or neighbor for a ride since plenty of people own vehicles. There are a number of points made to argue that ownership of a personal vehicle should not affect one’s ability to receive medical care, but the validity of these arguments remains questionable.
While there are options that intend to provide medical transportation, many factors make these services less reliable than a personal vehicle. Health departments do provide rides, but there are only so many shuttles to go around, and many run solely on weekdays. Services like the Transportation Assistance Program are great in theory, but have some significant problems. These programs are challenging and time-consuming to apply for, and it takes a long time for applicants to hear back. There also may be individuals who desperately need a vehicle, but do not meet the set criteria to demonstrate this need to the state. This setback leaves people desperate simply because the state does not believe they are worthy of assistance since they are not struggling “enough.” It is well known that dealing with government bureaucracies can be time-consuming and frustrating. For those who are lucky enough to be accepted, what should they do when they reach their time or mileage limit? Getting a ride from a friend or neighbor is not a consistently stable option either. There are plenty of people living in poverty who do not have neighbors, friends, family, or even acquaintances who own a car. For those lucky enough to know someone owns a car, they cannot solely rely on this method of transport. Owners of personal vehicles are not always available to drive around their friends and family. Evidently, the proposed solutions to combat the rising cost of personal vehicles are impractical since government programs have limited availability and time constraints, and relying on a neighbor is not a consistently dependable option.
Put yourself in the shoes of a victim of unreliable medical transportation. You cannot afford a personal vehicle, and none of your friends or family live in the same town as you do. Your neighbors do not own vehicles either. There is no public transportation or medical shuttling in your rural area, and your nearest doctor’s office is a thirty minute drive, one way. Rideshare platforms do not extend into your community since it falls outside of service areas. Your town’s transportation assistance programs are impossible to apply for, and very few people actually receive such relief. Therefore, you are left with no transport options, completely isolating you from receiving any sort of medical care. This scenario sounds like a nightmare, but it is reality for many disadvantaged individuals in America. Until the United States takes the necessary steps to bring public transportation into underserved areas, develop far-reaching hospital-rideshare partnerships, and find ways to lower the cost of personal vehicles or fund car assistance programs, citizens will continue to suffer from untreated diseases and conditions solely because they cannot get to the doctor’s office.
Author: Gracen Carter, Class of 2027, Honors College
Before beginning my first year at the University of Delaware, I spent the majority of my summer working at a physical therapy clinic. Besides my new insights on the medical field, I was also exposed to the challenges and disparities that come with accessing healthcare for disadvantaged individuals. I noticed a critical difference in health outcomes between patients that attended all of their appointments versus those who often canceled due to lack of reliable transportation. A lot of these patients who could not afford their own personal transportation relied on rides from family members or the public transportation system, neither of which was consistently reliable. After these experiences, I knew that I wanted to explore how transportation disparities come to exist and their dire effects on underprivileged communities.
Professor Hillson’s English 110 class was the first class that I attended at the University of Delaware. I instantly connected with the class topics, unlocking my interest in the historical mistreatment of and unequal opportunities for underprivileged groups in U.S. history. When given the opportunity to research an issue facing Americans today, I knew immediately what I would write about. As an aspiring healthcare provider and pre-medical student, researching and writing this paper with the help of Professor Hillson has shaped the way that I will provide patient care in the future. I hope that those who take the time to read this paper come to understand the challenges and devastating consequences affecting rural and impoverished Americans in receiving healthcare, hopefully inspiring readers to pursue change and advocate for better healthcare transportation in their communities.
Instructor: Franklin Hilson
This Honors English 110 course (Fall 2023), “Bestsellers and the Marginalized Voice,” examined minority voices and themes in selected bestsellers, and as you might have noticed, the title is a bit of a paradox because the marginalized voice is being “heard” by millions of readers. But is anyone really listening? Obviously Abigail Rus and Gracen Carter did, for they wrote insightful papers regarding mathematics & the gender gap and the challenge of physical access to healthcare, respectively. These and other issues emerged from our discussions of several blockbusters, to include Ann Petry’s The Street (1946), the first bestselling novel by an African American female, which concerns a single black mother trying to escape the streets of Harlem, and Maxine Hong Kingston’s The Woman Warrior (1976) with its crisscross of female, immigrant, American, Chinese identities and challenges. The students started with a one-page research proposal on the “So what” of the topic, “why is the significant”? Then, they examined the issue with a four-page exploratory essay with sources, all while maintaining their voice. Later, they presented their “elevator pitch” in a multimodal presentation to the class. Writing is a process, and they processed the information and ideas very well, indeed.
Works Cited
Akinlotan, Marvellous, et al. “Rural-Urban Variations in Travel Burdens for Care: Findings from the 2017 National Household Travel Survey.” Southwest Rural Health Research Center, July 2021, srhrc.tamu.edu/publications/travel-burdens-07.2021.pdf.
Bell, Deana, and Cameron Gleed. “Considerations When Adding Ride-Sharing to a Healthcare Benefit Plan.” Milliman, 22 Feb. 2019, us.milliman.com/en/insight/2019/considerations-when-adding-ride-sharing-to-a-healthcare-benefit-plan/.
Bundrick, Hal M. “What Is Considered Low Income?” NerdWallet, 7 Mar. 2023, www.nerdwallet.com/article/finance/what-is-considered-low-income.
Chaiyachati, Krisda H., et al. “Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program.” Springer Link, Journal of General Internal Medicine, 29 Jan. 2018, link.springer.com/article/10.1007/s11606-018-4306-0.
Chen, E., et al. “Impact of Free Hospital-Provided Rideshare Service on Radiation Therapy Completion Rates: A Matched Cohort Analysis.” Red Journal, International Journal of Radiation Oncology, Biology, and Physics, 1 Oct. 2023, www.redjournal.org/article/S0360-3016(23)04363-8/fulltext.
Cochran, Abigail L., et al. “Transportation Barriers to Care among Frequent Health Care Users during the COVID Pandemic.” BioMed Central – Springer Nature, BMC Public Health Journal, 20 Sept. 2022, bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-14149-x.
Lam, Onyi, et al. “How Far Americans Live from the Closest Hospital Differs by Community Type.” Pew Research Center, 12 Dec. 2018, www.pewresearch.org/short-reads/2018/12/12/how-far-americans-live-from-the-closest-hospital-differs-by-community-type/.
O’Toole, Randal. “Transit: The Urban Parasite.” Cato Institute, 20 Apr. 2020, www.cato.org/policy-analysis/transit-urban-parasite#.
Preston, Benjamin. “Used-Car Prices Remain High, Making Buying a Challenge.” Consumer Reports, 29 Aug. 2023, www.consumerreports.org/cars/buying-a-car/when-to-buy-a-used-car-a6584238157/.
“Transportation Assistance Program.” Maryland Department of Human Services, 2023, dhs.maryland.gov/weathering-tough-times/transportation-assistance-program-tap/.