Transportation, Access, Dual Eligibility, and COVID-19

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AUTHOR – Allison Rizer

ATI Contributor: Allison Rizer 

The COVID-19 public health emergency continues to accentuate racially- and income-based healthcare disparities in our country. And individuals dually eligible for Medicare and Medicaid (“dual eligibles”) are at the center of it all. Among many other risk factors for negative outcomes associated with COVID-19, dual eligibles (by definition) are low income. Dual eligibles also are considerably more likely than Medicare-only beneficiaries to be from a racial minority, even when you hold income constant:

ATI Advisory’s latest analysis has uncovered additional points of vulnerabilities for the dually eligible population. Using the Medicare Current Beneficiary Survey (MCBS), we found that 55% of full dual eligibles use public transportation or are driven by someone else to medical appointments, compared with 17% of Medicare-only beneficiaries:

Why does this matter? Recent research[1] found that the use of public transportation accounts for a significant portion of the racial disparities occurring with COVID-19. Add this to the list of reasons why dual eligibles are disproportionately impacted by the virus.

Two key factors are at play:

  • Increased risk for exposure. If you’re using public transportation, then you’re around other people using public transportation. Even with social distancing efforts, there’s still increased risk for exposure compared with individuals who can drive themselves or otherwise access services from their home.
  • Decreased access to “needs” generally. During COVID-19, transportation services such as buses and metros have reduced their volume of passengers to prevent overcrowding. This is compounded by decreased demand for transit generally – individuals able to work from home are avoiding public transportation, and transportation services have declined in response to lower revenue. Fewer people are allowed on the bus and fewer buses are running, which means individuals who need public transportation to see their doctor or go to the grocery story may be forced to go without.

What if you rely on someone you know to drive you? According to the MCBS, a quarter of Medicare beneficiaries “driven by someone” to medical appointments live alone, regardless of dual eligibility. And because dual eligibles are more likely to be “driven by someone,” this suggests a larger portion of dual eligibles than Medicare-only beneficiaries may be relying on someone they don’t live with to drive them to appointments (and other places, like the grocery store). Similar to the public transportation points above, dual eligibles relying on someone else to drive them may have increased risk for COVID-19 exposure and decreased access generally.

Access to transportation doesn’t function in a vacuum of course, and during COVID-19, individuals with high-speed internet in the home have been able to replace many in-person needs with online experiences like buying groceries, connecting with loved ones, and appointments with medical providers. But what happens when you lack access to transportation AND the internet? A third of full dual eligibles and a quarter of partial dual eligibles may fall into this category – they rely on public transportation or some other person to drive them to the doctor and they likely don’t have internet in the home:[2]

Policymakers can’t tackle COVID-19 if they don’t address the siloed nature of medical care and other social supports for the 12+ million dual eligibles in our country. Racial and economic risk factors combined with a siloed and complex delivery system result in higher infection rates, hospitalizations, and deaths. Working to integrate medical and non-medical services for dual eligibles may seem like a low priority during the pandemic, when actually it might be one of the most important tools in the toolbox.

For additional ATI Advisory perspectives and work related to dual eligibles, see the following:


[2] Individuals considered unlikely to have internet access in the home are those reporting on the MCBS that they never use the internet or use it a few times per year or less.

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