You have probably seen the statistic in this post’s headline repeated numerous times in different places. Indeed, it is the most reliable national estimate available. But a true understanding of the problem and who it affects necessitates a deeper dive than just labeling it with a number. Where did the number come from? What assumptions inform it? What do we know about the millions of people it describes – and the millions more who might have been missed?
Just like within any large group, there is important heterogeneity that should shape the way we approach solutions. These 3.6 million (at least) people are of all ages, genders and races; live in both urban and rural areas; have diverse reasons for needing help with transportation; and they contend with a vast array of different medical conditions. Using a data-driven, patient-centered approach will help technology organizations such as Ride Health – and the healthcare providers and public stakeholders with whom we partner – learn where best to direct our efforts.
The 3.6 million number has its origins in a 2005 study conducted by researchers at the Altarum Institute, a non-profit research and consulting firm in Michigan. Their research was supported by the Transportation Research Board of the National Academies of Science. The authors combined several sources – the National Household Travel Survey (NHTS), the National Health Interview Survey (NHIS), the Medical Expenditure Panel Survey (MEPS), and the National Transportation Availability and Use Survey (NTAUS) – to converge on a confident and conservative estimate as to the number of people who “do not obtain medical care because of a lack of transportation in a given year." (1) That is the often-repeated 3.6 million figure.
There are several interesting things to note here. First off, it has been 15 years since the surveys upon which this estimate is based were conducted. The total population of the United States has grown from 285 million in 2001 to almost 325 million in 2016, tallying a 13.7 percent increase. If that increase were applied to the 3.6 million number, the estimate would become 4.1 million. Even without adjusting for population growth, the figure might be higher. In fact, the authors of the original study state that the number might be as high at 15.5 million based on one of the data sources used. While the 3.6 million is the likeliest figure, it by no means represents a maximum. That maximum is instead almost five times higher.
The bottom line, then, is that several million people miss medical care because of transportation access challenges. What do we know about these individuals? They tend to poorer: 55 percent of them have household incomes below $20,000 per year, compared with 18 percent (remember, in 2001) among the general population. They tend to be older: 16 percent are over age 70 compared with 11 percent among the general population (although children also comprise almost one third of those who struggle with transportation barriers). They tend to be women: 63 percent compared with 52 percent. They tend to be minorities: 35 percent compared with 19 percent. They are half as likely to have a 4-year college degree.
Let’s turn to geography. You might think that transportation barriers are more of a problem in rural areas, but that is not supported by data. The distribution of adults who face transportation barriers across urban and rural areas is just about identical to the general distribution of adults across urban and rural areas. For children, transportation barriers are disproportionately an issue in urban areas, as measured by metropolitan statistical areas (MSAs) with more than 1 million people. None of this is to say that we should not devote more resources to rural areas – wherein transportation barriers might be more durable from year to year, creating a compounding effect – but that we must also give attention to urban neighborhoods that we might overlook.
What about the medical effects of transportation barriers? The burden of disease, across many acute and chronic conditions, is higher for those who face transportation barriers than among the general population. The nature and degree of difference is striking. Across 39 major diseases – from diabetes to cancer to heart disease to depression to asthma – the prevalence among those who miss care due to transportation is measurably higher than among the general population. Every single condition. Without exception.
Furthermore, 92 percent of adults who miss care due to transportation suffer from multiple medical conditions, compared with 64 percent of the general adult population. 24 percent of children who miss care due to transportation barriers suffer from asthma compared with 12 percent among the general child population. These children also experience higher rates of ADHD/ADD, frequent headaches, colds and learning disabilities.
While transportation barriers do not explain all of the difference here – socioeconomic measures such as income, education, nutritional intake and housing security are influential determinants – the lack of transportation compounds hardship and reduces physical access to care.
The data available might not capture the full scope of the problem. Since the specific individuals within the group of 3.6 million (or now 4.1 million) change from year to year, we are aiming at a moving target. We cannot simple identify a cohort of several million individuals, come up with a targeted intervention, and expect the problem to end. Transportation can be for some a long-term issue – related to neighborhood conditions, disabilities or financial constraints – but it can also be a temporary, one-time issue where the daily inconveniences of life interfere with getting to and from medical care.
If we intend to build a more resilient healthcare system that is patient-centered and responsive to emergent needs, providers must have the tools in hand to help those who have both chronic and acute transportation needs. It will take time and will not be easy, but with reliable data in hand, new technologies and partnerships emerging each week, and growing institutional and political awareness of the problem, we are finally moving in the right direction.
(1) Wallace R, Hughes-Cromwick P, Mull H, Khasnabis S. “Access to health care and nonemergency medical transportation: Two missing links.” Transportation Research Record: Journal of the Transportation Research Board. 2005; 1924:76–84.