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Table 2: ESTIMATED EXPENSES FOR KEY FEDERAL TRANSPORTATION PROGRAMS FY 2001 Estimated FY 2010 Program, Agency, and Department Transportation Transportation Expenses Expenses Medicaid (CMS/DHHS) $976,200,000 $2,044,000,000 Head Start (ACF/DHHS) $514,500,000 $1,000,000,000 Nonurbanized 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 $750,000,000 Autos/Adaptive Equipment for Veterans (VA/VBA) $33,639,000 $65,800,000 Sources: GAO 2003 report; 2010 estimates by Westat from total agency FY 2010 budgets. *Revised FY 2010 FTA Appropriations for grant programs. 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 made available 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 to Congress 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 26

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and accuracy of VA baseline model projections for health care expenditures for that fiscal year, and report 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 veterans who 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 employees in 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."33 Caregivers 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 veterans living in rural areas. Sec. 307 of the legislation is titled "Grants for Veterans Service Organizations for Transportation of Highly Rural Veterans." This section requires VA to create innovative grant programs 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. 27

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options 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 appropriated for each of fiscal years 2010 through 2014 is set at $3 million; the funding cap per innovative program is $50,000. Veterans Transportation Service 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. The 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 in Central Texas Veterans Health Care System (CTVHCS) at the Temple Texas site.34 CTVHCS is one of 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 of rideshare software and systems. 34For 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. 28

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The 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. 29