By Mimi Hutchinson
In 1974, a man with cerebral palsy sued the state of Texas over a simple question: what good is Medicaid if you don’t have a way to get to the doctor?
The court agreed that Medicaid’s promise of care was meaningless without transportation; in other words, access to the social safety net is just as important as the safety net itself. The result of Smith v. Vowell was a statutory guarantee that medical mobility be covered by Medicaid for enrollees who probably have no other way to reach their appointments. Medical mobility thus became a kind of rolling public infrastructure: a shared, collectively financed space designed to transport people to and from medical care.
That statutory guarantee grew into a program called Non-Emergency Medical Transportation, or NEMT, which all states now offer as part of Medicaid. Not to be confused with emergency transport services like ambulances, over 3 million people in the U.S. use Medicaid NEMT to travel to appointments for primary care, dialysis, chemotherapy, preventative care, and more. The aim of the program is to ensure that access to healthcare is not out of reach simply because someone lacks money, a car, or both.
But today, the right to rolling public infrastructure like Medicaid NEMT is being hollowed out again by the converging harms of privatization, defunding, and surveillance. What started as a judicial recognition that healthcare and transportation are inseparable has devolved into a fragmented system in which medical mobility is outsourced to private intermediaries, squeezed by austerity, and weaponized through surveillance. It is primarily Mediciad NEMT riders who pay the price for this dysfunction, most of whom simultaneously grapple with low incomes (by virtue of being Medicaid beneficiaries), chronic illness and disability, advanced age, precarious immigration status, and marginalized racial identities. Planners play an important role—both in abetting the current condition of Medicaid NEMT and in forging a better way forward.
Part 1: Medical mobility outsourced
NEMT is a mandated Medicaid benefit and a vital component of the public safety net, yet it is increasingly delivered by private firms. This delegation has intensified in recent decades with the advent of managed care organizations and transportation brokers—both artifacts of the late twentieth-century shift toward market-oriented governance in U.S. social policy. NEMT brokers are essentially middlemen who handle trip intake and scheduling. They are incentivized to control costs, which can create tension between efficiency goals and riders’ individual needs or mobility constraints. Thus, outsourcing weakens accountability and transparency structures in two ways. First, it causes Medicaid NEMT delivery to become administratively detached from local transportation planning structures. For example, Madison, Wisconsin’s human services transportation plan (the official planning document for all things NEMT) states that “local coordination of NEMT has not been possible since the commencement of the statewide NEMT transportation broker. […] During the development of this plan multiple attempts to communicate with the state’s NEMT liaison went unanswered.” In other words, outsourcing can weaken connections between NEMT and local planning institutions meant to coordinate transportation services.
The second way that outsourcing impacts Medicaid NEMT is by creating a double standard in service delivery. Private providers operating under Medicaid brokerage arrangements are often not subject to the same federal transit oversight requirements as public providers. For example, public providers must comply with Title VI reporting, ADA complementary paratransit standards, drug and alcohol testing for vehicle operators, and public engagement requirements tied to federal transit funding. Private providers, on the other hand, are only subject to Medicaid contractual standards, which vary by state and are often much less prescriptive. The uneven regulatory landscape has created opportunities for firms big and small—from Uber Health to small NEMT startups to “how to build an NEMT business” consultancies. The result is a system where the most regulated providers often receive the least work, thereby limiting the availability of high-quality options for riders. The outsourcing of medical mobility provision adds layers of complexity to what was once a streamlined, statutorily guaranteed right to healthcare access. In their book Foundational Economy, Julie Froud and Karel Williams put it bluntly: “how can the new corporate powerholders be controlled?”
Part 2: Medical mobility defunded
As private intermediaries expand through outsourcing, the public obligation to guarantee medical mobility is eroding due to austerity measures. Most notably, the recent passage of H.R. 1, or the One Big Beautiful Bill Act, proposed Medicaid reimbursement cuts ranging from 3 to 10 percent. Medicaid reimbursement impacts NEMT because the cost of providing each NEMT trip is borne in part by Medicaid reimbursements. When the reimbursement rate is lowered, providers must scramble to either scrounge up the reduced amount elsewhere or reduce their service to compensate. Since public providers are held to higher regulatory standards than private providers, the latter group tends to cut costs by skimping on service quality.
Despite not being held to the highest service standards like public providers, private NEMT providers are much better equipped to deal with the fallout of Medicaid reimbursement cuts than public providers. Because of the regulatory unevenness, private providers can easily adjust their service quality to preserve profit margins. Public providers, on the other hand, cannot skimp on service quality as a cost-saving measure because their regulatory standards are fixed at a higher bar. Thus, they must choose between absorbing reimbursement cuts internally (i.e., by cutting operator wages) or exiting the market altogether.
Defunding and outsourcing are distinct but intertwined processes. Defunding is less about oversight and more about financial stability: it manufactures failure by squeezing public providers into financially precarious positions that private providers can easily pivot to accommodate, thereby providing a pretext for outsourcing.
Part 3: Medical mobility surveilled
Even as Medicaid transportation has increasingly shifted toward brokered and privatized models, the public remnants are being leveraged in unforeseen, often inhumane ways. Public provision of Medicaid NEMT is increasingly governed through suspicion, which impacts who avoids care, who feels unsafe, and whose access to healthcare is diminished—all without the formal revocation of Medicaid eligibility. For example, in Minnesota, high-profile fraud investigations involving Medicaid-linked and other safety net programs have become intertwined with racist rhetoric targeting Somali communities, putting a vital service in the crosshairs of defunding threats. As another example, a new federal court ruling now allows ICE to access basic Medicaid enrollee data to locate people for deportation purposes, which puts people seeking lifesaving healthcare at risk. As a result, immigrant families report avoiding medical care, including prenatal care, because they fear their Medicaid enrollment could expose them or their relatives to ICE enforcement. Through the surveillance and scapegoating of Medicaid enrollees and other vulnerable communities, access to NEMT is threatened further.
A new way forward
The recent threats against NEMT and its parent program, Medicaid, as well as the new vulnerabilities faced by their beneficiaries, demand a call for alternatives. People need safe, affordable, reliable transportation to healthcare without exposure to harmful racial stereotypes, deportation, or other forms of harm. In response, there are practical steps planners and policymakers can take to improve Medicaid NEMT today. These include (1) forming volunteer driver programs to fill gaps where transit or NEMT providers are scarce (especially in rural areas), (2) using fixed-route transit as a default option when feasible, (3) strengthening collaboration among Medicaid agencies, brokers, and transit providers, and (4) responsibly leveraging technology to coordinate rides, track performance, and reduce missed trips.
Pragmatic and locally derived solutions are useful (and more are needed!), but the deeper question is why access to medical transportation is treated as a narrow Medicaid benefit rather than a broadly accessible public service. Calls for more radically inclusive public programs, like universal basic services, remind us that NEMT is a workaround—not a systemic solution. In The Case for Universal Basic Services, authors Anna Coote and Andrew Percy write that the state has four key functions in the provision of public services: “ensure equality of access, set and enforce standards, collect and invest funds, and coordinate functions across sectors.” But what happens when those functions are captured by private actors seeking profit and by public institutions that no longer reliably serve the public? According to authors of The Foundational Economy, “one proper response […] is to insist that private corporate actors be brought within the constitution.” In other words, the double standard must end: democratic control needs to extend not just to private providers of Medicaid NEMT but also to the public institutions that oversee them.
Mimi Hutchinson is a doctoral student in the Community and Regional Planning PhD program at UT Austin. Her research critically examines the privatization of urban systems like transportation and housing, with a special focus on the health impacts that ensue.