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population living in rural areas. This number supports the conclusion that veterans are now more highly concentrated in rural areas, where transportation services may be limited and health care opportunities only available at long distances away. Rates of Physical and Mental Injuries Appear to Be Rising For every fatality in Iraq, there are 16 wounded or injured soldiers; in Vietnam the ratio was 2.6 injuries for every fatality. Nearly 2,000 Iraq and Afghanistan veterans have returned with traumatic brain injuries (TBI). The suicide rate among veterans is now the highest since the U.S. Army began keeping records in 1980. Records indicate more than 1,000 veterans attempt suicide every month. 10 Although most service members return from Iraq and Afghanistan without physical injuries, many return with symptoms of post traumatic stress disorder (PTSD) or depression. Recent data from a 2008 RAND study estimated that 18.5 percent of returned troops (about 300,000 of Operation Iraqi Freedom [OIF] and Operation Enduring Freedom [OEF] veterans) met criteria on a structured survey assessing probable PTSD or depression.11 Another study reported that 25 percent of OIF and OEF veterans were diagnosed with significant mental health problems.12 These statistics suggest an increased need for medical services and the travel associated with receiving those services. MOBILITY CHALLENGES FACING VETERANS This report and other reports have identified problems and concerns with transportation services now provided to veterans. The kinds of problems that have been observed include the following: Veterans report problems accessing VA medical services and other necessary destinations. 10 Veterans Transportation: How It Works and How You Can Help, CTAA presentation quoting 2008 VA statistics. 11 T. Tanielian and L. Jaycox, eds., Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, 2008, http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf (accessed January 18, 2010). 12K.H. Seal, et al., "Bringing the War Back Home: Mental Health Disorders Among 103,788 US Veterans Returning From Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities," Archives of Internal Medicine, Vol. 167, No. 5, March 12, 2007: 476-482. 12

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The need for veterans' transportation is growing rapidly due to an increase in injuries. With annual VHA Beneficiary Travel expenses in excess of $750 million in FY 2010 and increasing rapidly, cost-effectiveness of transportation services is a growing concern. Rural areas offer special transportation challenges for transportation services serving veterans. 40 percent of veterans live in rural areas. The younger veterans who served in Iraq and Afghanistan are more likely than other veterans to live in rural areas. o Some veterans living in rural areas may need to travel extremely long distances to receive medical care and the other services for which they are eligible. Some states have extremely limited numbers of major VA facilities, meaning that veterans in some communities need to travel long distances for their care. VA does have the authority to contract for non-VA care when VA facilities (a) are not capable of furnishing economical care or services because of geographical inaccessibility or (b) are not capable of providing the required care or services. Limited public resources in some communities or eligibility issues with some veterans are factors that may also add to the need for long-distance travel. o Some kinds of specialized medical care are offered at very few of the 153 VA Medical Centers around the country; receiving such care may require extremely long trips. (For example, Kansas has major VA medical facilities only in Wichita, Topeka, and Leavenworth, meaning that a veteran in far western Kansas would need to travel long distances--more than 250 miles one way--for his or her specialized health care. The trip from Williston in the northwest corner of North Dakota to the one VA hospital in the state in Fargo requires a one-way journey of 395 miles.) o Veterans living in rural areas are reported to be in poorer health than veterans living in urban areas.13 Veterans who miss medical appointments exhibit higher rates of depression, poor healthcare access, socialization problems, and suicide. There is a huge and growing need for transporting aging and younger traumatic brain injured veterans. According to some sources, veterans' transportation services are frequently not coordinated with existing community and public transportation services at this time, with the result that neither the veterans' transportation services nor existing community transportation services operate as cost-effectively as they might. 13 Community Transportation, Summer/Fall 2009, 27:4, p. 11. 13

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Some of the volunteer-based services (such as those provided by Disabled American Veterans (DAV)) are struggling to obtain or maintain a sufficient number of volunteers. Most transportation services for veterans operated by volunteer drivers do not operate vehicles accessible to veterans in wheelchairs. Some of the current transportation services are characterized by excessive wait times for trips or for appointments for trips. As veterans' transportation services tend to be administered locally, local administrators may not be aware of other travel options or best practices in veterans' transportation services. With decentralized decisionmaking for transportation services for veterans, these services exhibit a lack of uniformity and consistency. While there are no comprehensive statistics concerning how many veterans experience the specific kinds of transportation challenges listed above, the 2001 National Survey of Veterans does state that the fourth most prevalent reason for not using VA health care services, reported by 18.0 percent of 19,978,000 veterans who had not used VA health care in the past year (about 3,596,000 veterans), was that "VA care is not convenient." Of the 16,396,700 veterans who reported never using VA health care, the fifth most prevalent reason, cited by 13.3 percent (about 2,180,800 veterans), was that "VA care is not convenient."14 The 2009 National Survey of Veterans asked why veterans did not use VA health care ever and in the past 6 months, respectively. Response categories included "VA health care is difficult to access (parking, distance, appointment availability)." Results from the 2009 survey were not available when this report was written but, when available, these data should help illuminate the dimensions of access problems to medical care. A VA study on veterans with traumatic brain injury (TBI) reported that 48 percent of the patients indicated that there were few resources in their communities for brain injury treatments and that 38 percent reported that transportation was a major problem. This figure is more than twice as large as the 17 percent who reported that not having enough money to pay for medical, rehabilitation, and injury-related services was a major problem.15 142001 National Survey of Veterans (NSV), Department of Veterans Affairs, Washington, DC. Tables 6-16 and 6-17 (no date) http://www1.va.gov/vetdata/docs/NSV%20Final%20Report.pdf, accessed February 23, 2010. 15 Community Transportation, Summer/Fall 2009, 27:4, p. 11. 14