With the 2015 passage of the federal Fixing America’s Surface Transportation (FAST) Act, the interagency Coordinating Council on Access and Mobility (CCAM) was codified into law, and it was tasked with developing a strategic plan to outline the roles and responsibilities of CCAM agencies and assess existing and emerging recommendations for laws and regulations to reduce barriers to transportation access. As part of its effort to learn about such barriers, CCAM held focus groups in 2018, with participants hailing from state and local agencies and stakeholders. The ten major lessons learned regarding barriers to local transportation coordination from these focus groups are shared below and for download here.
Takeaway 1: Limited Awareness
A lack of awareness of the Federal funding sources available for human service transportation, the policies that enable transportation coordination, and/or the community’s transportation options for targeted populations
Disability Services Stakeholders: Organizations are unaware of existing transportation options for people with disabilities
Centers for Independent Living (CILs), AAAs, and other disability service organizations refer clients to transportation services, but staff are frequently unaware of the full range of transportation options available for people with disabilities in their communities. This is typically the result of local, State, and Federal silos that prevent CILs and AAAs from learning about other organizations’ service offerings. Greater awareness of transportation options may enable referral staff to coordinate with these providers and direct clients to the most efficient options.
Veterans Transportation Stakeholders: VA stakeholders are not aware of all the transportation resources in their communities; ‘preventing’ them from coordinating to better serve Veterans
Many Veterans Affairs Medical Center (V AMC) mobility managers find it difficult to identify community transportation options for Veterans. As a result, it is challenging to identify opportunities for coordination with other community. organizations. According to focus group participants, improved awareness of all available transportation options would enable mobility managers to direct Veterans to the most cost-effective transportation service. This may help curtail costly Beneficiary Travel reimbursements.
Takeaway 2: Unengaged Stakeholders
Challenges associated with establishing and maintaining the organizational and community partnership necessary to pursue transportation coordination
Medicaid Nonemergency Medical Transportation (NEMT) Stakeholders: Some NEMT broker models may increase the fragmentation of the transportation system
NEMT providers reported that the broker model increases the fragmentation of transportation systems. They believe that in some instances the broker model transfers control of the transportation system from local organizations that understand the nuances of their community to larger organizations that standardize procedures across a broad spectrum of communities. Focus group participants noted that this standardization may force a one-size-fits-all approach, preventing them from pursuing innovative NEMT delivery models because they find it difficult to partner and collaborate with brokers.
Transit Stakeholders: Competition for resources hinders stakeholder engagement in transportation coordination efforts
Transit stakeholders compete for the same limited State and Federal funding, and many agencies fear they will lose funding if they coordinate with the competition. Additionally, some entities resist regional planning efforts because they are fearful that a coordinating body will have control over their program or beneficiaries. Some focus group participants found that regional transportation planning is too narrowly focused, only including transportation stakeholders, but failing to include important community organizations that provide medical, housing, employment, and other human services. Participants reported they are often unaware of other planning initiatives in their communities. As a result, other human service organizations may not consider transportation in early planning efforts, and transportation may become a barrier to access in the future.
Takeaway 3: Program Restrictions
Reporting obligations, eligibility criteria, trip purpose restrictions, and other program rules make it difficult to coordinate across different transportation programs.
Employment and Training Services Stakeholders: Focus group participants cited a variety of program requirements as barriers to coordination
Focus group participants perceived Federal agencies to have unrealistic expectations for how grantees report local match funding. Many organizations used match sources that vary in timing and amount from month to month. Organizations were reluctant to blend Federal funding streams because of the additional reporting complications. In addition, when more than one Federal program funds transportation, it can be difficult to determine if an individual meets each program’s eligibility criteria. Participants reported that the Department of Veterans Affairs (VA) programs have particularly specific eligibility requirements, further exacerbating this challenge. Some agencies avoid coordination with other agencies altogether out of fear of noncompliance with program regulations.
Physical and Behavioral Health Services Stakeholders: Reporting requirements create a challenge for coordination
Even when stakeholders identify funding sources, complying with their various reporting requirements is difficult. States and providers struggle to interpret and follow the rules and regulations across different Federal and State funding sources. This complexity disincentivizes coordination because grantees are reluctant to combine funding sources, either internally or through partnerships with other organizations. One participant from a State rural health office noted that the volume of Centers for Medicare and Medicaid Services (CMS) rules and regulations presents a particular challenge. “Even if we wanted to coordinate, we can’t interpret all the rules.”
Veterans Transportation Stakeholders: Program eligibility requirements restrict coordination of Veterans transportation, leading to underutilization of VA resources
In addition to the eligibility challenges described in the-general transportation issues above – which restrict certain Veterans from accessing VA-funded transportation – eligibility requirements also create a barrier to coordination with other Federal funding sources. Specific eligibility requirements determine who can ride on a (Veterans Transportation Service) VTS vehicle. Participants reported that these restrictions prevent V AMC mobility managers from grouping trips. Though a VTS vehicle may transport multiple beneficiaries on the same trip, the vehicle cannot transport non-eligible individuals on a fee-for-service basis, even when there are open seats in the vehicle. These restrictions result in underutilization of resources and the missed opportunity of potential revenue for VTS programs.
Takeaway 4: Insufficient Incentives
A lack of incentives or financial motivation for human service providers to pursue transportation coordination initiatives
Aging Services Stakeholders: There are no incentives for the aging network to coordinate transportation
Aging Services stakeholders reported that the Federal Transit Administration (FTA) and the Administration for Community Living (ACL) do not provide incentives for funding recipients to coordinate transportation services for older adults. They indicated that their organizations would be more motivated to pursue coordination partnerships if FTA and ACL included incentives in grant announcements.
Housing Services Stakeholders: The Department of Housing and Urban Development (HUD) grantees do not participate in coordinated planning
Housing stakeholders noted that they do not participate in coordinated transportation planning. Similarly, transportation providers and stakeholders are not required to participate in the consolidated planning process required of Community Development Block Grant (CDBG) grantees. Community planning is siloed and not well coordinated, which reduces opportunities for transportation coordination and increases the likelihood of duplication and fragmentation of services.
Takeaway 5: Limited Federal Guidance
An absence of the Federal guidance that States and local communities need to coordinate transportation in compliance with Federal law
NEMT Stakeholders: State and local stakeholders lack necessary cost-sharing guidance from the Federal government
Focus group participants explained that a cost-allocation model would allow transportation providers to serve beneficiaries of multiple programs in a single trip. It may also enable NEMT providers to more efficiently arrange multiple transportation services for beneficiaries that are eligible for multiple transportation benefits. However, State Medicaid Agencies (SMAs), NEMT brokers, and NEMT providers alike, cited a lack of guidance from CMS as a significant barrier to cost allocation. Focus group participants reported that they are unlikely to explore innovative coordination models because the Federal government has not issued sufficient official guidance on acceptable cost-sharing arrangements, cost-allocation procedures, or partnerships with transportation network companies (TNC). Many stakeholders expressed interest in cost-allocation models but noted the lack of guidance as the primary barrier to deploying such models.
Transit Stakeholders: A lack of Federal guidance impedes coordination partnerships, according to transit stakeholders
Without explicit guidance and approval from Federal oversight agencies, many State and local stakeholders hesitate to commit to new or innovative transportation models. For example, a State department of transportation participated in State work groups to develop a cost-sharing model agreed upon by all stakeholders. However, when the State Medicaid agency (SMA) asked CMS to approve the arrangement, CMS declined to comment, and the state abandoned the cost-sharing model. Transit stakeholders reported that, without guidance from the CCMA, it is difficult to foster an environment of coordination.
Takeaway 6: Jurisdictional Boundaries
City, county or other regional lines that define and organization’s service area and prevent that organization from coordinating with other entities beyond the service area
Housing Services Stakeholders: CDBG grantees can only use funds to provide services in designated areas
HUD permits CDBG grantees to distribute funding only to eligible geographic areas as designated by HUD. Eligible areas are primarily residential, and at least 51 percent of the residents are low- and moderate-income persons. This regulation prevents CDBG grantees and sub-recipients from coordinating transportation services with other organizations within the grantee’s service area but outside the boundaries determined by HUD.
Transit Stakeholders: Jurisdictional boundaries impede coordination among transit agencies and between transit and other human service organizations
City and county governments often plan and operate transportation systems at the local level, resulting in fragmented services within a single state. In many cases, these local governments do not permit transit agencies to provide service outside their jurisdiction, preventing coordination with other transportation systems. In addition, jurisdictional boundaries prevent many transit providers from coordinating with V AM Cs, specialty care providers, or other health care providers that are located across jurisdictional lines, even when these facilities are the nearest care provider in the region.
Takeaway 7: Administrative Burden
The accounting obligations, logistical responsibilities, implementation work, and other administrative tasks that consume an excessive amount of time and resources
Aging Services Stakeholders: Coordination involves a significant administrative burden
Aging services stakeholders indicated that they are unwilling to coordinate because the administrative burden associated with coordination is too cumbersome. It is difficult to understand the various Federal regulations, and it is challenging to comply with the varying reporting requirements involved when coordinating across multiple Federal funding streams.
NEMT Stakeholders: Brokers may exacerbate existing Medicaid NEMT scheduling difficulties
NEMT providers reported that their brokers guarantee specific pickup and drop-off times for beneficiaries, but do so before confirming availability with the providers. They also reported that brokers frequently send inaccurate or incomplete referral data to providers, who cannot efficiently schedule the trip without complete information. These scheduling and communication challenges prevent providers from grouping and coordinating trips.
Takeaway 8: Insufficient Data
A lack of the data that States and local communities need to increase the transparency of transportation spending, demonstrate the utility of transportation coordination, and allocate the costs of coordinated transportation equitably
Employment and Training Services Stakeholders: Sharing data across services is a challenge
Due to privacy concerns and incompatibility of data systems, it is difficult for employment and training service providers to share data with other organizations that serve the same individuals. Participants reported that they need a unified data system across sectors so they can holistically track the services an individual receives and follow their employment progress.
Physical and Behavioral Health Services Stakeholders: States and providers need guidance on transportation data collection
Participants believe that transportation data would facilitate coordination, but they reported that the Federal government provides limited guidance and incentives for data collection. Despite an increased emphasis on social determinants of health, the Health Resources and Services Administration (HRSA) does not require Federal Qualified Health Centers (FQHCs) to report transportation data, and an FQHC was not aware that HRSA’s Uniform Data System includes fields for transportation-related data. As one participant reported, in order to measure social determinants of health, providers need defined indicators.
Takeaway 9: Cost-Sharing Concerns
Apprehension about sharing the costs of coordinated transportation across participating stakeholders in a way that is equitable and proportionate to the services received
Transit Stakeholders: Human service organizations often do not pay the fully allocated cost of transit trips for their beneficiaries
Transit stakeholders reported that human service providers direct their beneficiaries to use transit to access human services, but the providers do not pay the fully allocated cost of the trip. This is known as “ride dumping.” The Americans with Disabilities Act (ADA) paratransit services cannot deny service to eligible individuals and cannot ask about trip purpose, so many human service organizations direct their beneficiaries to ADA paratransit rather than pay for transportation themselves. Transit stakeholders believe this is an unfair distribution of costs. Medicaid agencies are prohibited from paying more than the general public fare for fixed route transit services and the state human service agency rate. Typically, neither the general public fare nor the State human service agency rate represents the full cost of the trip to the transit provider. As a result, many transit providers argue that transit funds are subsidizing Medicaid NEMT, increasing transit costs. This results in misconceptions about the true cost of Medicaid NEMT to the Federal government.
Takeaway 10: Inaccessible Systems
Transportation vehicles and facilities that funding recipients cannot use for some coordination activities because they are inaccessible to people with functional limitations
Disability Services Stakeholders: The inaccessibility of some transportation options inhibits coordination partnerships
People with disabilities have difficulty accessing many types of transportation services, including ADA paratransit and Medicaid NEMT. This prevents CILs and other disability organizations from pursuing coordinated partnerships with transportation programs that use vehicles that are not fully accessible.