Transportation for the Medically Vulnerable During COVID-19

Vaccinations are offering restored hope, but questions remain about whether transportation access will restrict an equitable vaccine distribution strategy. According to Pew, millions of people who may be higher-risk for contracting COVID-19 also don’t have a reliable transportation option to a vaccine location. Older adults, medically frail individuals, and those living in communities hardest hit by the pandemic often overlap with those with limited transportation access.

Vaccination campaigns across the U.S. are addressing these transportation challenges. In Los Angeles, New York, Boston and Denver some programs are offering door-to-door vaccine distribution. These vaccine distribution programs may be the ticket to address the fact that COVID-19 has disrupted all forms of transportation, and particularly harmed the vulnerable in a number of ways. UC Davis research on the impacts of COVID-19 shows that the pandemic has exacerbated income inequalities.

Those who need periodic non-emergency healthcare have been particularly vulnerable during the pandemic. Even now, during the transition back to normalcy, this group is facing many new challenges, as well as some unique opportunities.

Illustration of person exiting a bus and pushing another person in a wheelchair

Who has Access to Telehealth

The COVID-19 pandemic has transformed healthcare delivery in the United States. The Centers for Medicare and Medicaid Services rapidly expanded telehealth services for many patients in response to the COVID-19 public health emergency. Telehealth has been promoted as a way for patients to minimize their risk of infection and to reduce exposures to healthcare teams.

Despite these expansions, many patients and clinics, particularly those that service vulnerable populations, have not benefited from this rapid transition to telehealth. Some patients lack the technology (computer, tablet, phone), broad-band internet, or comfort to access these services. In addition, language barriers add an additional barrier at times. Finally, despite the rise of telehealth, certain patients require continued in-person visits. Clearly, vaccines or physical treatments cannot be administered digitally. Given the changing landscape of transportation due to the pandemic, this may be placing already vulnerable patients at even higher risk.

Addressing the Unique Needs of Dialysis Patients

Individuals with End Stage Kidney Disease (ESRD) on hemodialysis are one such group of patients who need in-person medical care despite the ongoing pandemic. The vast majority of patients on hemodialysis need to travel to a dialysis center about three times a week for their scheduled treatment. The pandemic transformed clinical practice for dialysis centers and patients. Additionally, with changing public transportation schedules and opportunities during the pandemic, these patients potentially face additional challenges. Many patients on dialysis may require shared rides or non-emergency medical transportation (NEMT) services, such as paratransit services. Such services typically combine multiple riders into one van. Given the increased risk of COVID transmission in enclosed spaces and the higher risk of COVID to patients with ESRD, many paratransit operators are offering single-ride service. Some paratransit operators are restricting rides for non-essential trips to keep service vehicles available for people who need medical appointment support. The CDC also suggests considering the use of larger cutaway buses for paratransit vehicles to ensure adequate distance between riders.

Is Paratransit Service Meeting the Need?

However, as the pandemic wanes, these strategies may have a profound and long-term effect on paratransit riders, and delayed or avoided healthcare visits may harm those most vulnerable. Increasing paratransit service vehicles can be cost prohibitive for many cash-strapped transit agencies because paratransit service is typically the most expensive option.

Several cities and agencies have partnerships that divert paratransit trip requests to taxi or ridehailing companies to provide additional service options and reduce costs of paratransit service, which can be as much as $45 for a wheelchair accessible ride. In Boston, paratransit riders can call an Uber or a Lyft ride for as little as $2 with the MBTA covering up to $40 of the ride costs. In Southern Nevada there is a similar program offering $3 rides on Lyft, with the rest of the ride cost subsidized by the Regional Transportation Commission.

Public private partnerships may offer a blended model, allowing agencies to keep operating service vehicles or employing drivers in-house, and relying on private companies to fill in  the gaps. This can address concerns from labor advocates and ensure community control over the service provision.

Via microtransit offers such a blended service, providing an on-demand app for riders and drivers to connect, drivers, shuttle vans, or a combination of these options. In Ohio, COTA Plus is operated by Via, and provides area residents with an on-demand transit option. In the past year, COVID-19 protocols caused the COTA Plus service to limit only 2 passengers in their 6-9 seat vans. While this may be less efficient, it highlights how the  community can continue to use them safely, changing the service to meet the needs of the pandemic.

Looking Forward

Now may be a time of enormous reinvention on the part of cities, agencies and governments. It may be a time to think creatively about solutions that can prevent the type of transportation access challenges that become more deadly during emergencies like the pandemic. Agencies must look for new solutions to improve mobility options for vulnerable populations, while reducing  costs for paratransit service.

The full-scale effect of the pandemic on mobility, health, and ease of access to health services is still unknown. But if the pandemic results in improved mobility for dialysis patients, better telehealth options for patients with chronic health needs, and improved vaccine distribution methods, the challenges of the COVID pandemic may indeed have a silver lining.

Na’amah Razon is a Clinical and Research Fellow at the Philip R. Lee Institute for Health Policy Studies in the Department of Family and Community Medicine at the University of California, San Francisco

Mollie D’Agostino is Policy Director of the 3 Revolutions Future Mobility Research Program at ITS-Davis

At the time of writing, Austin Brown was Executive Director of the Policy Institute for Energy, Environment, and the Economy at ITS-Davis.

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