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Missed primary care appointments occur frequently among urban, low-income patients—some of the costliest and sickest patients. We conducted semi-structured interviews with 43 patients who reside in West Philadelphia (100% insured by Medicaid, 95% were non-Hispanic African Americans, and 47.1 years old on average) to identify why recent primary care appointments were or might have been missed. Existing transportation options, including public transportation, were considered unreliable and alternative options too costly. In addition, we discovered poor health, family obligations, and work requirements prevented appointment attendance. Intervening on the barriers identified may reduce missed appointment rates among disadvantaged populations.