Medicaid's role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent, by Texas researchers.
Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.
Already, states have wide leeway in how to provide and pay for the transportation.
Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don't include transportation.
They also contend that changes will help curb what government investigators in 2016 warned is "a high risk for fraud and abuse" in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn't have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn't take place. She was sentenced to 30 days in jail and ordered to pay $21,500.
Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with "flexibility." That effort stalled.
Another Republican proposal in 2017 would have reversed the Affordable Care Act's Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.
Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation's governors to consider NEMT waivers, among other actions, in a March letter to them.
"We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges," they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration's more expansive health policies, and has granted some states' requests.
At least three states, Iowa, Indiana and Kentucky, have received federal waivers -- and extensions -- allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.