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Research Letter
April 2014

Transportation Barriers to Child Health Care Access Remain After Health Reform

Author Affiliations
  • 1Children’s Health Fund, New York, New York
JAMA Pediatr. 2014;168(4):385-386. doi:10.1001/jamapediatrics.2013.4653

The Affordable Care Act will improve access to pediatric care by expanding health insurance coverage.1 The law has provisions to increase primary care provider supply to meet increased demand but not to improve access for families without resources to travel to health care providers. Lack of transportation is a known barrier to children attending well care visits and receiving preventive health services.2

Nationally, regardless of insurance status, 4% of children (approximately 3 million) missed a health care appointment each year because transportation was unavailable; this includes 9% of children in families with incomes less than $50 000. Thirty-one percent later used a hospital emergency department for the health condition associated with that missed appointment. Rural areas are especially affected, having significantly fewer available public transit resources compared with metropolitan areas. Low-income households may not own a working vehicle, further limiting their options.3

Many rural areas experience severe and protracted health professional workforce shortages. In a study of federal health professional shortage area (HPSA) designations over time, 85% of rural counties were HPSA-designated at some point during a 7-year period. One-third were designated a full-county HPSA for at least 6 of the 7 years.4 An estimated 10.5 million US children live in an HPSA.5


Using a newly developed and validated tool, the Health Transportation Shortage Index (HTSI),3 we quantified and stratified the degree of risk for transportation-related access barriers for each of the 82 counties in Mississippi, which was selected as a rural state with high child poverty rates. Numeric HTSI scores (from 0-14) reflect factors associated with health care access barriers. A score of 8 or higher indicates highest risk of transportation barriers. Each county was geomapped with Geographic Information Systems software to precisely locate population centers by Census Bureau blocks, and federally qualified health centers and rural health clinics (“clinics”) by longitude and latitude. Straight-line distances were calculated from population centers to the nearest clinic, including those in contiguous counties. Census Bureau data were used to ascertain county demographics.


Based on its HTSI score, 55 Mississippi counties (67%) were identified as being at the highest risk for transportation barriers to health care access (mean score, 9.1; range, 8-13). All but 2 had full-county HPSA designation; 18% had populations less than 10 000 and 71% had populations between 10 000 and 30 000. All had no (13%) or limited (87%) public transit resources. The mean child population was 4709 (range, 281-9103); mean child poverty rate was 31.8% and uninsured rate was 11.8%. In 78% of these counties, the most populous areas were within 6 miles of a clinic. Mean distances from outlying population centers to clinics ranged from 6 to 14 miles.


These results suggest that for most families in this very rural state with high child poverty rates and health workforce shortages, nonemergency medical transportation to facilitate child health care access would involve transports within a relatively narrow radius from a clinic. Additional planning would be needed to assist residents of outlying areas. While there are costs associated with the development of new transportation services, these could be offset over time by savings associated with reduced emergency department use. In a 2005 study done for the Transportation Research Board of the National Academies, nonemergency medical transportation services were found to be cost-effective especially for patients with chronic conditions.6 While health reform can be predicted to improve access to child health care for millions of currently uninsured children, geospatial barriers will persist. Only by resolving these barriers with new transportation resources will children reliably benefit from health reform.

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Article Information

Corresponding Author: Roy Grant, MA, Medical Affairs, Children’s Health Fund, 215 W 125th St, Ste 301, New York, NY 10027 (roygrant.roy@gmail.com).

Published Online: February 10, 2014. doi:10.1001/jamapediatrics.2013.4653.

Author Contributions: Mr Grant had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Study concept and design: Grant, Gracy, Johnson.

Acquisition of data: Grant, Gracy, Goldsmith.

Analysis and interpretation of data: Grant, Gracy, Goldsmith, Sobelson.

Drafting of the manuscript: Grant, Gracy.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Grant, Goldsmith.

Obtained funding: Johnson.

Administrative, technical, and material support: Grant, Goldsmith, Sobelson, Johnson.

Study supervision: Gracy.

Conflict of Interest Disclosures: None reported.

Funding/Support: The Children’s Health Fund Transportation Initiative is supported by The W. K. Kellogg Foundation and The Kresge Foundation.

Role of the Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Correction: This article was corrected on February 11, 2014, to update the corresponding author’s e-mail address.

Health reform for children: the Affordable Care Act gives parents greater control over their children’s health care. The White House website. http://www.whitehouse.gov/files/documents/health_reform_for_children.pdf. Accessed September 12, 2013.
Riportella-Muller  R, Selby-Harrington  ML, Richardson  LA, Donat  PLN, Luchok  KJ, Quade  D.  Barriers to the use of preventive health care services for children.  Public Health Rep. 1996;111(1):71-77.PubMedGoogle Scholar
Grant R, Johnson D, Borders S, Gracy D, Rostholder T, Redlener I. The Health Transportation Shortage Index: the development and validation of a new tool to identify underserved communities. Children’s Health Fund website. http://issuu.com/childrenshealthfund/docs/chf_htsi-monograph__2_?e=6796486%2F1866261. Published 2012. Accessed August 15, 2013.
Doescher MP, Fordyce MA, Skillman SM, Jackson JE, Rosenblatt RA. Persistent primary care health professional shortage areas (HPSAs) and health care access in rural America. Rural Health Research and Policy Centers, University of Washington website. http://depts.washington.edu/uwrhrc/uploads/Persistent_HPSAs_PB.pdf. Published September 2009. Accessed August 15, 2013.
Hoffman C, Damico A, Garfield R. Insurance coverage and access to care in primary care shortage areas. The Henry J. Kaiser Family Foundation website. www.kaiserfamilyfoundation.files.wordpress.com/2013/01/8161.pdf. Published February 2011. Accessed August 15, 2013.
Hughes-Cromwick P, Wallace R, Mull H, Bologna J. Cost benefit analysis of providing non-emergency medical transportation. Transportation Research Board of the National Academies website. http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_webdoc_29.pdf. Published October 2005. Accessed August 15, 2013.