Transportation is a significant social determinant of health in rural communities. The availability of reliable
transportation impacts a person’s ability to access appropriate and well-coordinated healthcare, purchase
nutritious food, and otherwise care for themselves. Rural populations most likely to need transportation
services to maintain their health and well-being include:
People with disabilities
Low-income individuals and families
People with special healthcare needs, who often must travel long distances to access care
This guide focuses on how communities can provide transportation services to support access to rural healthcare,
which may also benefit healthcare providers by decreasing burden on emergency medical services (EMS), improving
utilization of healthcare services, decreasing no-show rates, and increasing access to health-supporting
services. The guide also highlights transportation as a community-based service that can allow the elderly and
people with disabilities to live successfully in a community rather than entering a long-term care facility or
needing to leave the community.
Frequently Asked Questions
Do rural residents experience greater travel burdens in accessing healthcare?
According to Rural-Urban Variations in
Burdens for Care: Findings from the 2017 National Household Travel Survey, rural residents experience
greater travel burdens when accessing healthcare. This national survey of rural and urban populations
demonstrated significant variations in travel burden in a variety of healthcare-related categories. Some of the
highlights of the study found:
Rural residents traveled more than twice the distance (17.8 miles) as urban residents (8.1 miles) for
medical or dental healthcare.
Time spent traveling was nearly 9 minutes longer for rural residents (34.2 minutes) than for urban residents
(25.5 minutes). Travel time was the greatest in the rural West (41.7 minutes), followed by the rural South
(35.4 minutes) and the rural Midwest (31.5 minutes).
Rural residents' travel time occurring after midnight to receive healthcare were longer (67 minutes) and
farther (38 miles) than for urban nighttime trips (42.6 minutes and 15.6 miles).
Well over half of rural residents (55.8%) identified the cost of gasoline and the financial expense of
travel as barriers, compared to 45% of urban residents.
A 2022 article, Travel Burden
Receive Health Care, summarizes findings from multiple studies and concludes that rural
residents experience increased travel burden due to hospital closures, travel farther distances and for a
longer period of time, spend more money on travel with fewer options for public transportation, and have
more probability for injury or fatality while traveling. 2022 Transportation Trends from the National Aging and Disability Transportation Center (NADTC) echoed similar
issues, noting that rural transportation challenges include a lack of available services and a lack of
reliable accessibility for users with disabilities.
These factors related to excessive distance and time spent on travel are why some rural residents delay
healthcare or miss appointments, resulting in reduced preventive care, greater disease burden, and poorer
treatment outcomes. For more information on how travel burden impacts rural populations, see our
Exploring Rural Health podcast episode, Travel Burden for
Rural Populations with Marvellous Akinlotan and Alva Ferdinand.
What are the health-related consequences of not having transportation for rural residents, including older
adults and people with disabilities?
Reliable transportation options can determine whether many people in rural areas have access to healthcare,
is critical for promoting and maintaining health as well as preventing and managing disease. Often elderly
and individuals with disabilities have greater healthcare needs than other rural residents, and living in rural
areas isolated from healthcare providers can have a significant impact on their quality of life, their health,
and their safety.
According to the Transportation
Cooperative Research Program (TCRP) some of the negative impacts of a lack of appropriate, accessible,
transportation services include:
- Reduced access to healthcare services
- Delayed or missed appointments to receive needed healthcare services
- Disruption in ongoing treatments and services for chronically ill patients
- Increased potential for poorer health outcomes
- Higher overall costs for healthcare, impacting healthcare decisions
- Extended travel time to access healthcare can affect patients physically and cause stress
According to a 2023 study, More
than One in Five
Adults with Limited Public Transit Access Forgo Health Care Because of Transportation
Barriers, 7% of rural adults aged 18 to 64 missed a healthcare appointment within a 12-month
timeframe due to transportation difficulties, as opposed to 5% of urban adults. The study states that
lack of access to a means of transportation perpetuates ongoing health disparities in rural versus urban
Studies have shown that providing transportation for medical treatment to low-income, elderly, and disabled
patients is cost-effective and improves quality of life. A 2005 study by the Transit Cooperative Research
Program demonstrated the differences between the cost of poorly-managed and well-managed care, as well as the
differences in quality of life. They found that the reduction in healthcare costs and improvement in quality of
life would more than offset the costs required to provide non-emergency medical transportation (NEMT). Missing a
routine or preventive care service because of transportation can lead to poorly managed care, a need for
emergency care, and preventable hospitalizations.
Providing effective public transportation options to healthcare services for low-income, elderly, and disabled
residents decreases hospitalizations and nursing home stays, allowing them to remain contributing members of the
community and lead healthier lives while keeping health costs down. In addition, transportation allows rural
residents to avoid social isolation, as discussed in the Rural Monitor article Social Isolation and Loneliness:
Insights from Rural Clinical Providers and Other Experts and the Exploring Rural Health podcast
Rural Social Isolation, with Carrie Henning-Smith. The July
2020 report, The
Role of Transportation in Addressing Social Isolation in Older Adults, recommends increasing
collaboration between the transportation, health, and aging sectors at the state and local levels, conducting
additional research on public transportation, and meeting the social needs of older adults.
What strategies can rural communities and healthcare facilities use to provide non-emergency medical
According to a 2010 study funded by
the Federal Transit Administration (FTA):
“The greatest problems for people using public transportation for healthcare trips are inconvenient
the need to match transit and medical schedules, and infrequent service.”
Many strategies have been implemented in rural communities across the country to provide non-emergency medical
transportation services. Strategies for communities who have some kind of transportation service available may
Hiring a mobility manager to streamline scheduling and dispatch efforts
Creating a website and customer service contact center for direct trip requests
Centralizing staff for trip eligibility determination and reservation requests
Setting schedules for medical trips to specialty care centers to reduce travel times and to provide
Implementing an interactive voice response (IVR) system that calls the night before to confirm or allow a
cancellation, as well as same day notification when the vehicle is near rider location
Broadly disseminating information about the availability of transit services
Forming partnerships between ridesourcing companies, healthcare providers, public health agencies, transit
agencies, and insurers
In some communities where formal transportation services are not available or are insufficient, healthcare
facilities or community organizations have chosen to fill the healthcare transportation gap by:
Offering transportation services for healthcare appointments using paid or volunteer drivers
Coordinating a shared ride/cost transportation program (a door-to-door, advance-reservation, ride-sharing
Brokering out coordinated trips to qualified vendors
Using telehealth to decrease the travel required for local patients to access specialty care
Starting a mobile clinic to take healthcare services to patients in remote areas
Providing some services in local schools to reach low-income or high-needs children
Having Community Health Workers or Community Paramedics visit people in their homes, which may
decrease the frequency of trips for medical care
Examples of non-emergency transportation programs in rural areas include:
HealthTran – A non-emergency transportation service that offers
rides for patients demonstrating a transportation need for timely primary and preventive care access in
South Central Missouri. HealthTran was also profiled in a 2016 Rural Monitor article.
Angel Flight West – A network of more than 1,400 pilots donate
their skills, aircraft, and all costs associated with flying to help families and individuals in need in the
13 western states of the United States. Angel Flight West was one of several charity flight services
highlighted in a 2018 Rural Monitor article.
Tri-Valley Opportunity Council Rural Transportation – A
coordinated public transportation and volunteer driver system which serves a rural 8-county area in
Garrett County Regional Cancer Patient Navigator Program – A
comprehensive cancer-centric program offering transportation to provide access to radiation
treatment for residents within an 8-county, 3-state area in Appalachia.
Hampshire Mobility Management Network – A statewide coordination effort to reduce duplication
of transportation services, enhance scarce resources, and provide transportation options to the aging
and rural population, as discussed in the Exploring Rural Health podcast episode, Partnering for Rural Transportation with Alisa Druzba
and Steve Workman.
New Growth Transit: Community-Based Transit for Rural Communities – A volunteer driver network that
provides transportation for mobility-challenged clients in rural Missouri.
Family Health Services (FHS) – a clinic that offers free transportation services to
better serve their patients.
For more information on the development of rural transportation programs, see the Rural Transportation Toolkit. Also, TCRP's Guidebook
and Research Plan to Help Communities Improve Transportation to Health Care Services discusses
selecting, developing, and modifying transportation services to meet the healthcare needs of a community.
What issues should facilities and organizations consider when providing transportation?
Screening and training of drivers
Whether using volunteer or paid drivers, care should be taken to screen the drivers and their vehicles to
ensure the safety of
patients. In addition, drivers should be adequately trained just like any other staff member, on
topics such as safety, how to assist patients, and the necessity of confidentiality.
Before implementing a transportation program, liability issues must be fully investigated and considered,
particularly when using volunteer drivers or personal vehicles.
Funding the program
How will the program be funded and maintained? Facilities might approach state transportation departments or
local foundations regarding potential funding. In addition, facilities can explore partnerships with other
organizations or agencies serving the community.
For additional information about volunteer driver programs, see the National
Volunteer Transportation Center Map of Volunteer Driver Programs and the National Volunteer Transportation Center Resource Library.
Can Medicaid be used to cover non-emergency medical transportation?
Yes. States are required to cover non-emergency medical transportation (NEMT) to Medicaid beneficiaries who need
transportation in order to access medically needed services. This includes both local providers of care and
tertiary healthcare facilities. See the Kaiser Family Foundation's Medicaid
Benefits: Non-Emergency Medical Transportation Services.
For further information on Medicaid coverage for NEMT, see the following resources:
What resources are available to assist my rural community in planning, developing or expanding public transit
services that would help elderly, disabled, and low-income individuals access healthcare services?
Organizations that can assist rural communities with transit planning include:
- State departments of transportation
- Local councils of government
- Community based organizations
- Private transportation companies
- Economic and community development corporations
- Regional planning organizations
Transit Assistance Programs (RTAPs) provide workshops, on-site training, educational materials, and
peer assistance. Contact National RTAP and your state's department of transportation for information on
your State RTAP resources. National RTAP also provides a list of State
RTAP website links.
The Community Transportation Association of America (CTAA), a national
organization, offers a variety of technical assistance and guides for communities looking to initiate and/or
expand transportation services and programs that link people to jobs, medical care and other destinations
necessary for quality of life.
The Transportation Research
Board (TRB) offers detailed information on selecting an appropriate approach to managing and operating
transportation services, including a continuum of solutions to consider when matching patients with
In addition, SBA.gov provides assistance with the development of small
businesses that could include a non-emergency medical transportation business.
Examples of transportation models that address the transportation inequities of elderly and low-income
individuals in rural communities include:
SMiles Senior Transportation – SMiles was implemented in Blount
County, Tennessee to provide transportation to rural seniors who are no longer able to drive.
Kid One Transport – Provides rides to medical appointments for
children and expectant mothers who otherwise have no other means of transportation in rural Alabama.
Age-Friendly and Dementia-Friendly Winnemucca and Humboldt County
– Monthly community meetings are
held to discuss topics around health, housing, transportation, social events, and how their rural community
could be more inclusive for older adults.
The Exploring Rural Health podcast episode Public
Role in Rural Healthcare Access with Carol Wright Kenderdine has further discussion about
rural transportation needs of the elderly and people with disabilities.
What are the types of accommodations rural transportation providers must support to comply with the Americans
with Disabilities Act (ADA), and who is eligible for these special accommodations?
Rural transportation providers are not required to provide fixed-route service in any rural area. However, if
they do provide a fixed-route service, they are required to comply with ADA and be accessible. They must provide
ADA complementary paratransit service for those individuals with disabilities who cannot use fixed-route
service. If another type of transportation service is offered such as a taxi, shuttle, or ride-share, or any
form of demand-response transportation, ADA regulations will apply and servicers are required to provide
equivalent and reasonable accommodations. For additional information about compliance with federal requirements,
see Federal Transit Administration's (FTA) Shared
Mobility FAQs: Americans with Disabilities Act (ADA).
Regulations and technical assistance materials are available from the
Americans with Disabilities Act website. Also, the FTA's Topic
Guides on ADA Transportation provide detailed information on equipment maintenance, stop announcements,
and route identification. National RTAP also provides an ADA Toolkit.
According to the section Eligibility for ADA
Paratransit, individuals are eligible for paratransit service if they meet one of these criteria:
- Navigation of the transit system requires assistance
- Individual needs an accessible vehicle
- Bus routes or bus stops are inaccessible
- Travel is prevented if a reasonable person with the disability would be deterred from making the trip
What is FTA Section 5310, and how can it help provide transportation services in rural areas?
Section 5310 (49
U.S.C. 5310) is a program that funds projects for enhanced mobility of older adults and people with
disabilities. Section 5310 funding is allocated to states based on the population for the two target groups in
rural and urban areas. States then have flexibility in deciding how the funds are distributed to sub-recipients,
which may be formula-based, competitive, or discretionary. Sub-recipients may be private nonprofit
organizations, state and local government authorities, and operators of public transportation. Each state must
publish a management plan for how sub-recipient funding decisions are made.
Traditional uses of funds include:
- Buses and vans
- Wheelchair lifts, ramps, and securement devices
- Transit-related information technology systems, including scheduling/routing/one-call systems
- Mobility management programs
- Acquisition of transportation services under a contract, lease, or other arrangement
Examples of less traditional projects include:
Volunteer driver programs
Building an accessible path to a bus stop, including curb-cuts, sidewalks, accessible pedestrian signals, or
other accessible features
Improving signage, or way-finding technology
Incremental cost of providing same day service or door-to-door service
Purchasing vehicles to support new accessible taxi, ridesharing, and/or vanpooling programs
Coordinating with other programs and assisting in regularly providing meal delivery service for homebound
Additional information about FTA
Section 5310 funding is available from the National Aging and Disability Transportation Center.
To learn more about how Section 5310 funds are distributed in your state, contact your Regional FTA Office.
Are there programs or grant opportunities to help tribal communities improve transportation services?
There are several programs that fund tribal communities' transportation needs, including:
In addition, the majority of the funding opportunities for general rural transportation projects are applicable
to tribal communities. For more information on forgone medical care, employment difficulties, tribal
sovereignty, funding and
coordination, community engagement, and economic development related to tribal transportation, as well as
case studies illustrating successful programs, see
Tribal Transportation: Issues and Successful Models.
Are there grants or programs to assist veterans in rural areas with transportation to VA medical centers and
other VA and non-VA facilities for medical care?
The U.S. Department of Veterans Affairs program, Highly Rural
Transportation Grants (HRTG), awards grants to veterans service organizations that use innovative
approaches to assist veterans in rural areas with transportation to VA medical centers and other VA and non-VA
facilities for medical care. For information about this program and other programs that may assist veterans in
accessing medical care, see Rural
Veterans and Access to Healthcare – Funding & Opportunities.
Disabled American Veterans (DAV) Hospital Service Coordinator Directory provides a state-by-state list
of Hospital Service Coordinators (HSCs), their affiliated VA Medical Centers, and contact information. HSCs
manage DAV transportation programs for veterans needing medical care.
Where can I get help planning and funding transportation projects?
The following organizations provide resources and technical assistance related to rural transportation
Community Transportation Association of America (CTAA)
Provides a wide variety of information on economic development, financing, and technical assistance, as well
training related to rural and urban public and community transportation. Its Health Care and Transportation page offers
resources, policy updates, and information focusing on the issues, opportunities, and challenges impacting
non-emergency medical transportation professionals.
National Rural Transit Assistance Program (National
Provides training and technical assistance products and services that are developed nationally, for
distribution and replication by the states to local transit agencies. Offers a National RTAP Resource Library
with access to information and expertise, and an online list of State RTAP contacts.
National Aging and Disability Transportation Center (NADTC)
A cooperative agreement supported by the Federal Transit Administration (FTA), administered by Easterseals
USAging, with guidance from the Administration for Community Living (ACL). NADTC provides communities
training, information and referral, and community grants focused on the availability and accessibility of
transportation for seniors and people with disabilities.
Center for Mobility Management (NCMM)
Provides technical assistance, training, and community grants to help communities implement transportation
policies and mobility opportunities that enable people to live independently, as well as promote health,
economic vitality, and self-sufficiency. NCMM hosts a Health
and Transportation Resources Center that provides resources to assist mobility management
professionals and their communities in understanding the intersection among health care, public health, and
NCMM is funded through a cooperative agreement with the Federal Transit Administration, and is operated
consortium of three national organizations, the Community Transportation Association of America, the
American Public Transportation Association, and Easterseals.
National Center for Applied Transit Technology (N-CATT)
Offers technical assistance including practical and replicable resources for small-urban, rural, and tribal
transportation agencies supporting innovative and technological solutions enabling communities to offer
efficient, multi-modal, and on-demand transportation.
Where can I get help finding local transportation programs and services?
The list below provides transit options in local areas to help rural residents find transportation: