Impacts of North Carolina’s medicaid transformation on community transit systems: A qualitative analysis with policy implications

Abstract

North Carolina began its Medicaid Transformation implementation process in July of 2021. The Transformation shifted responsibility for arranging non-emergency medical transportation (NEMT) for transportation-disadvantaged Medicaid beneficiaries from county Departments of Social Services (DSS) to private transportation brokers. Brokers also decide NEMT eligibility and select transportation service providers that best meet beneficiaries' transportation needs. Before this transition, county DSS offices relied on community transit organizations (CTOs) to coordinate NEMT and other human transportation services. This is a significant shift from North Carolina's coordinated transportation model, which emphasized coordinating medical and other trips using local transit providers. This paper examines how the Medicaid Transformation in the state has altered CTOs' ability to continue coordinating individual human service transportation programs. Findings from interviews and policy content analyses indicate that the Medicaid Transformation has negatively affected CTOs' ability to coordinate between individual human service transportation programs. Control of several mechanisms CTOs historically used to coordinate transportation programs has shifted to brokers, who are neither prepared nor intended to take on the coordination role. Since these programs serve various transportation-disadvantaged residents in the state, including those enrolled in Medicaid, obstacles that CTOs encounter while coordinating transportation affect these communities disproportionately. Several factors explain CTOs' diminished ability to coordinate transportation, including goals and policy misalignment between health and transportation state authorities, regional location disadvantages, and logistical constraints that emerged with the Transformation.