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15Chapter 2 NATIONAL TRANSPORTATION POLICIES AND SERVICES FOR VETERANSTo establish a context for understanding the mobility challenges facing veterans, one needs to examine some key policies and procedures. This chapter reviews the veterans’ health care system(which is the major provider of transportation services to veterans), current transportation servicesfor veterans, and recent legislative actions that may influence veterans’ transportation.VETERANS HEALTH CARE The major transportation program for veterans in the Department of Veterans Affairs is the Beneficiary Travel program, which is administered by the Veterans Health Administration (VHA). Therefore, to understand the Department’s transportation services, it is first necessary to understandthe overall VHA health care program.

16EligibilityEligibility for VA health care is generally determined by a combination of factors including, amongothers, veteran’s discharge from military service (e.g., honorable, other than honorable, dishonorable), length of service, VA-adjudicated disabilities (commonly referred to as service-connected disabilities), income level, and available VA resources.16 Benefits to veterans range from disability compensation and pensions to hospital and medical care. The VA provides these benefitsthrough three major operating units: the Veterans Health Administration (VHA), the VeteransBenefits Administration (VBA), and the National Cemetery Administration (NCA). The VHA, often referred to as “the nation's largest integrated health care system,” is primarily a direct service provider of primary care, specialized care, and related medical and social support services to veterans. Except for certain veterans with service-related conditions or special disability, individuals must enroll in the VA health care system to receive medical care, service, or treatment.VA provides cost-free inpatient and outpatient medical care and medications to veterans for service-related conditions and to certain low-income veterans. VHA recorded 73 million medical visits and 662,000 hospital admissions in FY 2009. Distribution of Health Care Facilities According to VA’s Office of the Assistant Under Secretary for Health Policy and Planning, there were currently more than 1,600 VHA facilities in 2010. The types of medical facilities or sites that may affect veterans’ quality of life are Veterans Administration Medical Centers (VAMCs), community-based outpatient clinics (CBOCs), regional benefits offices, Veterans Integrated Service Networks (VISN) offices, veterans’ centers, and cemeteries. Key destinations for the purposes ofthis study include: 153 VA Medical Centers; 784 VA Community-Based Outpatient Clinics; 264 Veterans Centers; and57 VBA Regional Offices. 16 See http://www4.va.gov/healtheligibility/eligibility/ accessed November 11, 2010.

17Veterans may need to visit some or all of these facilities; some trips will need to be frequent. The VHA divides the United States into 21 health service regions known as Veterans IntegratedService Networks, or VISNs. Each of these networks is responsible for administering the health care services provided in their region; most regions include multiple states. The VISNs operate independently of each other and are not necessarily aware of the transportation practices employed in other regions. As seen in Table 1 and Figure 1, VISN headquarters are widely spread throughout the country and are not located in every state.Funds for VA Health Care Funding for health care for veterans has increased substantially in recent years. Appropriations for VA medical care increased from $29 billion in FY 2006 to $45.1 billion in FY 2010, an increase of55.5 percent. According to the House Committee on Veterans’ Affairs, “Currently, resource allocations are based on the number of veterans seen in the region in the previous years. Members were concerned that this process did not offer adequate flexibility to the changing demographics of today’s veterans or sufficient responsiveness to the wide range of health care needs. Because funding levels are dictated by those veterans that seek care rather than veterans that are eligible for care,veterans that are unable to access the system are not a part of the VA’s decision making process. Members raised concerns that some rural veterans are prevented from accessing VA health care because of the long distances they must travel, often in poor health. Additionally, low-income veterans may not have the means to access their entitled health care benefits and thus, are not counted.”1717 “House Committee Examines How Federal Dollars Get to Local Veterans for Health Care,” House Committee on Veterans’ Affairs, December 7, 2009, http://veterans.house.gov/news/PRArticle.aspx?NewsID=510 accessed January7, 2010.

18Table 1:VETERANS INTEGRATED SERVICE NETWORKS18VISN Name Location 1 VA New England Healthcare System Bedford, MA 2 VA Healthcare Network Upstate New York Albany, NY 3 VA NY/NJ Veterans Healthcare Network Bronx, NY 4 VA Stars & Stripes Healthcare Network Pittsburgh, PA 5 VA Capitol Health Care Network Linthicum, MD 6 VA Mid-Atlantic Health Care Network Durham, NC 7 VA Southeast Network Duluth, GA 8 VA Sunshine Healthcare Network Bay Pines, FL 9 VA Mid South Healthcare Network Nashville, TN 10 VA Healthcare System of Ohio Cincinnati, OH 11 Veterans In Partnership Ann Arbor, MI 12 The Great Lakes Health Care System Hines, IL 15 VA Heartland Network Kansas City, MO 16 South Central VA Health Care Network Jackson, MS 17 VA Heart of Texas Health Care Network Arlington, TX 18 VA Southwest Health Care Network Mesa, AZ 19 Rocky Mountain Network Glendale, CO 20 Northwest Network Portland, OR 21 Sierra Pacific Network Mare Island, CA 22 Desert Pacific Healthcare Network Long Beach, CA 23 VA Midwest Health Care Network Minneapolis, MN Lincoln, NE 18 Department of Veterans Affairs. (no dates). “Veterans Health Administration” http://www2.va.gov/directory/guide/division_flsh.asp?dnum=1. On January 23, 2002, the Department of Veterans Affairs (VA) announced the merger of VISN 13 and 14 into new VISN 23. This decision merged two health care networks that provided services to veterans in Iowa, Nebraska, Minnesota, South Dakota, North Dakota, and portions of western Illinois, western Wisconsin, and eastern Wyoming.

19Figure 1: VETERANS INTEGRATED SERVICE NETWORKS[Source: Department of Veterans Affairs] The VA Medical Centers are independent operations administered by local directors who have great leeway over all operations, and especially over the transportation services available to veterans inthat VAMC service area. Local directors may or may not be aware of other travel options or best practices in veterans’ transportation services or in the broader field of coordinated community transportation. VA TRANSPORTATION: A BRIEF HISTORICAL OVERVIEW Congress enacted travel benefits in relation to VA health care for certain veterans in 1958. Since that time, VA has provided mileage reimbursement, special mode transport (ambulance, wheelchair van,etc.) and certain other modes of transport such as air travel to qualifying veterans and non-veterans: eligible veterans are those with VA-rated service-related conditions or low income. (See next

20section). Understanding that some veterans are not eligible for VA travel, and that travel is oftennoted as a barrier to care, the Disabled American Veterans (DAV) reports that they “then began organizing a national transportation network to find volunteer drivers to drive disabled veterans to their medical appointments because of the medical problems that this lack of access was creating.”19DAV’s transportation efforts began in 1987. Since then, DAV has donated 2,519 vehicles, transported more than 13 million veterans almost 500 million miles, and devoted more than 27 million volunteer hours in transporting veterans to VA medical facilities. The DAV VolunteerTransportation Network remains a key component of transportation services to veterans. TRANSPORTATION SERVICES THAT VHA PROVIDES FOR VETERANSThe Beneficiary Travel Program Conditions for EligibilityThe VA, through its Veterans Health Administration (VHA), provides health care benefits to eligible veterans that include outpatient medical services, hospital care, medicine, and supplies. Transportation costs can be considered part of outpatient and inpatient medical services. VHA’s Beneficiary Travel Office can authorize reimbursements to eligible beneficiaries for mileage costs, costs for special transportation modes, or, in certain circumstances, the costs of taxis or hired cars. These payments are specified in United States Code (USC), Payments or Allowances for Beneficiary Travel – 38 U.S.C. § 111 . (Appendix A, VHA’s Frequently Asked Questions concerning itsBeneficiary Travel Program, includes other references regarding payment procedures and conditionsfor eligibility.) Veterans Eligible for Beneficiary Travel PaymentsVeterans who are eligible for payments under VA’s Beneficiary Travel Program include:A veteran who travels to or from a VA facility or VA-authorized health care facility in connection with treatment or care for a Service Connected (SC) disability (regardless ofpercent of disability).19 Ibid.

21A veteran with a SC disability rated at 30 percent or more who travels to or from a VA facility or VA-authorized health care facility for examination, treatment, or care for any condition.A veteran who travels to a VA facility or VA-authorized health care facility for a scheduled compensation and pension (C&P) examination. A veteran receiving pension under 38 U.S.C. § 1521, who travels to or from a VA facility or VA-authorized health care facility for examination, treatment, or care. A veteran whose annual income (as determined under 38 U.S.C. § 1503) does not exceed the maximum annual rate of pension that the veteran would receive under 38 U.S.C.§ 1521as adjusted under 38 U.S.C. § 5312) if the veteran was eligible for pension and travels to or from a VA facility or VA authorized health care facility for examination, treatment, or care. In addition, certain veterans are eligible for certain kinds of emergency trips. Non-Veterans Eligible for Beneficiary TravelNon-veterans who are eligible for payments under VA’s Beneficiary Travel Program include: Allied Beneficiaries. For Allied Beneficiaries, as defined by 38 U.S.C. § 109, travel is subject to a reimbursement agreement by the government concerned. For information on the beneficiary travel eligibility of Allied Beneficiaries, see VHA Handbook 1601D.02.Attendants. Someone other than a VA employee, who is accompanying and assisting a veteran or beneficiary eligible for beneficiary travel payments, when such beneficiary is medically determined to require the presence of the attendant because of a physical or mental condition. Beneficiaries of Other Federal Agencies. Travel for beneficiaries of other federal agencies may be authorized travel incident to medical services rendered upon requests of those agencies, subject to a reimbursement agreement by those agencies. Other Persons. A member of a veteran’s immediate family, a veteran’s legal guardian, or a person in whose household the veteran certifies an intention to live, if such person is traveling for consultation, professional counseling, training, or mental health services concerning a veteran who is receiving care for a SC disability; or a member of a veteran’s immediate family, if the person is traveling for bereavement counseling

22relating to the death of the veteran in the active military, naval, or air service in the line of duty and under circumstances not due to the Veteran’s own misconduct.20Special Mode TransportationVeterans qualify for Special Mode Transportation (ambulance, wheelchair van, “and other modes which are specifically designed to transport certain disabled individuals”21) when: 1. VA determines that their medical condition requires an ambulance or a specially equipped van, and2. They meet one of the eligibility criteria for veterans described above, and3. The travel is preauthorized (authorization is not required for emergencies if a delay would be hazardous to life or health).22Veterans must meet all three of these criteria unless they are OIF or OEF veterans, and then they need only meet one of the criteria to be administratively eligible for transport at VA expense. This includes meeting the basic criteria, as well as being “unable to defray the expenses of travel” asdefined in 38 CFR 70.10 (c). . . Once administrative eligibility is established, a VA clinician must then determine that a special mode of transportation is medically required to transport the veteran for VA health care. Unless one of the forms of special mode of transportation is required and documented as such, this method of transportation is inappropriate.”23Means of TransportationThe VA will, under certain circumstances, reimburse individual veterans for their medical travelunder regulations for the Beneficiary Travel program. In addition, travel offices at VAMCs may provide their own transportation services, may contract directly with transportation providers for trips to VAMCs, or may work with volunteer networks to provide transportation for veterans20 July 21, 2010 VHA HANDBOOK 1601B.05, http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2275 accessed November 9, 2010.21 Department of Veterans Affairs. (no dates). “Beneficiary Travel Frequently AskedQuestions” http://www4.va.gov/healtheligibility/Library/FAQs/BeneTravelFAQ.asp , accessed December 9, 2009. 22 Department of Veterans Affairs. (no dates). “VA Health Care Eligibility Enrollment: Special and Limited Benefits” http://www4.va.gov/healtheligibility/coveredservices/SpecialBenefits.asp#Auto , accessed May 5, 2010. 23 Department of Veterans Affairs. (no dates). “Beneficiary Travel Frequently AskedQuestions” http://www4.va.gov/healtheligibility/Library/FAQs/BeneTravelFAQ.asp , accessed December 9, 2009.

23seeking health care. The ways that VA is involved in assisting a veteran with his or her trips for medical care are as follows: Individual veterans provide their own travel and are reimbursed. o The current rate is 41.5 cents per mile. o The Beneficiary Travel deductible amounts are:– $3.00 per one-way trip – $6.00 per round trip, or– $18.00 per calendar month or six one-way trips (three round trips), whichever occurs first, for travel to all VA facilities. – Some trips are exempt from the deductible amount, including trips made by veterans who require a special mode of transportation and travel in relation to a VA compensation and pension examination.Transportation services are provided directly by VA Medical Centers. Transportation services are provided by contractors to VA Medical Centers. Transportation is provided by volunteer organizations working with VA Medical Centers.Title 38 United States Code (U.S.C.) 111 and 38 Code of Federal Regulations (C.F.R.) 70.1 – 70.50 are the authorities for Beneficiary Travel. Regulations that currently apply to VHA beneficiary travel were published in the Federal Register on July 29, 2008. The Regulations are currently under revision due to several recent legislative and policy changes; these revised are expected to be published in 2011.Trips to access to medical care are the only travel needs supported by VHA Beneficiary Travel funding. (Travel for compensation and pension examinations is considered to be allowable under the Beneficiary Travel program.) Trip purposes such as shopping, recreation, personal business, and other nonmedical or noneducational trips are not supported by VA, even though such trips may have a profound impact on an individual veteran’s quality of life.

24The Automobile Assistance Program The Veterans Benefits Administration administers the Automobiles and Adaptive Equipment for Certain Disabled Veterans and Members of the Armed Forces program,24 which offers a one-time payment of not more than $11,000 toward the purchase of an automobile or other vehicle. VA paysfor adaptive equipment and for repair, replacement, or reinstallation required because of disability. A veteran may qualify for automobile assistance for this VA benefit if he or she has: A service connected loss or permanent loss of use of one or both hands or feet; or A permanent impairment of vision of both eyes to a certain degree; or Entitlement to compensation for ankylosis (immobility) of one or both knees or one ofboth hips.25VA TRANSPORTATION EXPENDITURES In 2003, the Government Accountability Office (GAO; then known as the General AccountingOffice) reported FY 2001 expenditures for transportation of disadvantaged persons by the VA of$126,594,591 through the Veterans Medical Care Benefits program and $33,639,000 through the Autos and Adaptive Equipment for Certain Disabled Veterans Program.26 According to an unpublished report from CTAA, the Department of Veterans Affairs spent $170 million in FY 2004 to reimburse veterans for travel to and from VA facilities to receive medical care.27“. . . the VA is committed to providing services to veterans meeting certain eligibility criteria.This service, called “Beneficiary Travel”, is funded through the Veterans Health Administration (VHA) as part of the medical care budget and is contained in the budget line item “Miscellaneous Benefits and Services”. The funding is separate from the Veteran’s Benefits Administration (VBA) that funds disability compensation and pension benefits. 24 The authorization for this program is found in Title 38 Unites States Code Chapter 39; implementing regulations are found in Title 38 CFR 17.155 – 17.159.25 Department of Veterans Affairs. (no dates). “VA Health Care Eligibility and Enrollment: Special and LimitedBenefits” http://www4.va.gov/healtheligibility/coveredservices/SpecialBenefits.asp#Auto , accessed May 5,2010.26 United States General Accounting Office, Transportation Disadvantaged Populations: Some Coordination Efforts Among Programs Providing Transportation Services, but Obstacles Persist, Washington, DC, June 2003, GAO-03-697.27 John Lasfargues, “Evaluation of Existing Capacity and Unmet Need for Medical Transportation with the Veteran Population,” draft report prepared for the Community Transportation Association of America, Washington, DC, March 2005, p. 1.

25However, eligibility for medical care benefits is determined by a complex rating system that is administered by VBA.”28VA provides funds for travel to approved medical services related to health conditions and travel for compensation and pension eligibility examinations. (The next section provides more precise details concerning eligibility for these services.) “The transportation that is provided for veterans is either provided through a contract with an outside source or left to the veteran to arrange and then bereimbursed. The program is administered at the local level and left to the individual hospital networkto determine how this service will be provided. In all cases except in cases of medical emergency, the veteran must receive authorization from his attending physician stating that the treatment or service is medically necessary.”29From 2005 to 2010, VHA’s transportation expenses increased dramatically. VHA Beneficiary Travel expenses for FY 2009 were $629 million, which was a 69 percent increase over the FY 2008 figure of $373 million. In FY 2010, costs increased to $745 million. (Note that these figures do notinclude expenses for VBA’s Automobile Assistance program.) This rapid cost increase stems froman increased number of veterans claiming travel reimbursement, increased numbers of claims per veteran, and the congressionally mandated changes in travel reimbursement costs and decreased deductible requirements. For many years, the beneficiary travel mileage reimbursement rate that veterans could claim for eligible trips for medical and other approved trips was 11 cents per mile. That rate was changed to 28.5 cents per mile effective February 1, 2008; VA’s Secretary raised the beneficiary travel reimbursement rate to 41.5 cents per mile on November 17, 2008. VA’s December 2009 report to Congress reported that “Since the November 2008 rate change, VA hasexperienced [an] approximate increase of 76 percent in the number of mileage claims, and [a] 30 percent increase in the number of veterans claiming travel reimbursements.”30This new level of expenditure makes VHA’s Beneficiary Travel program one of the most highly funded transportation programs for persons with special needs. As shown in Table 2, VHA’s expenses exceed all but the two largest transportation programs for individuals with special travel needs: Medicaid and Head Start.28 Ibid. 29 Ibid, p. 3. 30 Department of Veterans Affairs, “Report to Congress: PL 110-387, Section 401: Veterans Beneficiary Travel Program,” December, 2009.

26Table 2:ESTIMATED EXPENSES FOR KEY FEDERAL TRANSPORTATION PROGRAMSProgram, Agency, and Department FY 2001 TransportationExpensesEstimated FY 2010 TransportationExpensesMedicaid (CMS/DHHS) $976,200,000 $2,044,000,000Head Start (ACF/DHHS) $514,500,000 $1,000,000,000Nonurbanized Area Program, S. 5311 (FTA/DOT) $203,200,000 $438,159,210*Elderly and Disabled Program, S. 5310 (FTA/DOT) $174,982,628 $133,825,717*Temp. Assistance for Needy Families (ACF, DHHS) $160,462,214 $200,000,000 Veterans Medical Care Benefits (VA/VHA) $126,594,591 $750,000,000â€Autos/Adaptive Equipment for Veterans (VA/VBA) $33,639,000 $65,800,000â€Sources: GAO 2003 report; 2010 estimates by Westat from total agency FY 2010 budgets. *Revised FY 2010 FTA Appropriations for grant programs. â€Data provided by VA, Department of Veterans Affairs, 2010. RECENT LEGISLATION AND ACTIVITIES The Veterans Health Care Budget Reform and Transparency Act of 2009 The Veterans Health Care Budget Reform and Transparency Act of 2009 became Public Law No: 111-81 in October 2009. That law amended Title 38 of the United States Code to provide advance appropriations authority for certain accounts of the Department of Veterans Affairs. The law directs the President to include estimates of appropriations for the following accounts:1. Medical services; 2. Medical support and compliance; and 3. Medical facilities. The law requires, beginning with FY 2011, discretionary new budget authority to: (1) be madeavailable for that fiscal year and (2) include, for each such account, advance discretionary new budget authority that first becomes available for the first fiscal year after the budget year. Other provisions include (a) the requirement that the Secretary of the Veterans Affairs report annually toCongress on the sufficiency of VA resources for the forthcoming fiscal year with respect to the provision of medical care and (b) the requirement that the Comptroller General study the adequacy

27and accuracy of VA baseline model projections for health care expenditures for that fiscal year, andreport study results, during 2011 through 2013, to the congressional veterans, appropriations, and budget committees. Because of these provisions, VA is now making regular reports to Congress on the costs of the Beneficiary Travel program.31 The full text of this legislation is available at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ081.111. Rural Veterans Health Care Improvement Act of 2009 In 2009, members of both the U.S. Senate and the House of Representatives introduced legislation (Senate Bill 658 H.R. 2879) for several purposes, including that of improving health care for veteranswho live in rural areas.32 Also introduced in previous sessions of Congress, but not passed in either the Senate or the House, the bill proposed payment of travel expenses for veterans receiving treatment at Department of Veterans Affairs (VA) facilities at the rate provided to federal employeesin connection with the performance of official duties. The bills also included provisions that VA “(1) establish and operate at least one and up to five centers of excellence for rural health research, education, and clinical activities; (2) establish a grant program to provide innovative transportation options to veterans in remote rural areas; (3) carry out demonstration projects to examine alternatives for expanding care for veterans in rural areas; and (4) report annually to Congress on matters related to VA care for veterans residing in rural areas.”33Caregivers and Veterans Omnibus Health Services Act of 2010 The Caregivers and Veterans Omnibus Health Services Act of 2010 became Public Law No: 111-163 on May 5, 2010. Among other items, this bill is intended to improve health care for veteransliving in rural areas. Sec. 307 of the legislation is titled “Grants for Veterans Service Organizationsfor Transportation of Highly Rural Veterans.” This section requires VA to create innovative grantprograms for state veterans’ agencies or veterans’ service organizations (VSOs) to provide mobility 31 For example, see Department of Veterans Affairs, “Report to Congress: PL 110-387, Section 401: Veterans Beneficiary Travel Program,” December, 2009. 32 GovTrack (2010) “S. 658: Rural Veterans Health Care Improvement Act of 2009” http://www.govtrack.us/congress/bill.xpd?bill=s111-658, accessed May 18, 2010. 33 GovTrack (2010) “S. 1146: Rural Veterans Health Care Improvement Act of 2007” http://www.govtrack.us/congress/bill.xpd?bill=s110-1146&tab=summary, accessed January 19, 2010.

28options for veteran residents in highly rural areas, which are defined as areas consisting of a county or counties having a population of less than seven persons per square mile. Funding appropriatedfor each of fiscal years 2010 through 2014 is set at $3 million; the funding cap per innovative program is $50,000. Veterans Transportation ServiceThe newly created Veterans Transportation Service (VTS) is one of the T21 initiatives. With more than $16 million in VA funding, VTS seeks to implement pilot projects that will demonstrate innovations in overcoming barriers to VHA access, especially for veterans who are visually impaired, elderly, or immobilized due to disease or disability, as well as those living in rural and highly rural areas. VTS will increase VHA transportation resources at the facility level, but will also focus on improving the efficiency of existing transportation resources through use of 21st Century technology, including ridesharing software and GPS units. On September 17, 2010, VTS offered its first official ride to a Veteran. The first ride occurred inCentral Texas Veterans Health Care System (CTVHCS) at the Temple Texas site.34 CTVHCS is oneof four initial pilot sites for the program; the other three sites are Ann Arbor, Michigan; Muskogee,Oklahoma; and Salt Lake City, Utah.VTS plans to expand the four pilot sites funded in FY 2010 with an additional 22 new sites in the first half of the 2011 Fiscal Year, and then fund up to 20 additional sites by the end of the year. The new sites are expected to benefit from lessons learned by the original four sites as well as work done by the national program office. These efforts are planned to include a streamlined approach to vehicle acquisition, the development of a VTS specific customer service video, and the acquisition ofrideshare software and systems. 34 For further details of activities at this site, see “Central Texas Veterans Health Care System: Veterans Transportation Services,” http://www.centraltexas.va.gov/news/veterans_transportation_Services.asp, accessed November 16, 2010. In 2010, the VA initiated a series of initiatives designed to improve Veteran care and the functioning of VA as a whole. This effort, known as T21, stands for 23 (originally 21) initiatives designed to transform VA’s system of delivering services to veterans. For VHA, T21’s impact will involve a transition to what is being called Universal Health Care Services. One of the major areas under this program is access to services.

29The rideshare software and systems are comprised of ride routing/scheduling software and other integrated technologies intended to enhance operational efficiency and ensure positive experiences for veterans. The other technologies include GPS device integration, automated vehicle routing, electronic manifest updating, dispatch/driver communications, an interface for transportation coordinators and stations, automated passenger notifications, information storage and updating, and reporting.Coordinating Council Attention At the end of May 2010, the FTA announced that the Coordinating Council on Access and Mobility had adopted improving the mobility of veterans as one of its four major priorities for the forthcom-ing year. This action is intended to focus the attention of the Departments of Transportation and Health and Human Services, as well as the Department ofVeterans Affairs and other federal depart-ments, on improvements to the mobility of veterans.

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