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Chapter 2 NATIONAL TRANSPORTATION POLICIES AND SERVICES FOR VETERANS To 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 services for 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 understand the overall VHA health care program. 15

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Eligibility Eligibility for VA health care is generally determined by a combination of factors including, among others, 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 benefits through three major operating units: the Veterans Health Administration (VHA), the Veterans Benefits 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 of this study include: 153 VA Medical Centers; 784 VA Community-Based Outpatient Clinics; 264 Veterans Centers; and 57 VBA Regional Offices. 16 See accessed November 11, 2010. 16

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Veterans 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 Integrated Service 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 of 55.5 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."17 17"House Committee Examines How Federal Dollars Get to Local Veterans for Health Care," House Committee on Veterans' Affairs, December 7, 2009, accessed January 7, 2010. 17

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Table 1: VETERANS INTEGRATED SERVICE NETWORKS18 VISN 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" 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. 18