Literature Review
Lack of Cost Allocation Methodology as a Barrier to Transportation Coordination
The Federal government has a long history of recognizing the need for coordination between governmentally funded public and human service transportation programs. As early as 1977, the General Accounting Office (GAO — later renamed as the Government Accountability Office) reported on the barriers to coordination between transportation agencies.1
The GAO revisited this subject in 1999 in a report that discusses the reasons for the persistent problem of fragmentation and duplication of service in public transit and human services transportation, despite consensus about the benefits of coordination.2 The report provides background on activities at the Federal level during the 1980s and 1990s within the Departments of Transportation and Health and Human Services. These activities included the formation of a Coordinating Council on Human Services Transportation in 1986 and its 1988 effort that identified 64 barriers to transportation coordination and issued a Federal response to each of them. These barriers included the lack of standardized accounting and reporting procedures used by human service providers that receive Federal transportation funding, with the DOT and HHS responding that they would continue to discuss the development of such standards for all transportation components of their programs.
The report documents efforts during the 1997 and 1998 DOT appropriations bills to address the need for state and regional planning to achieve transportation coordination objectives, including cost-sharing arrangements for HHS program clients transported by Americans with Disabilities (ADA) paratransit systems based on a uniform accounting system. Recommendations for Federal action include requiring the Coordinating Council to issue a strategic plan and an action plan, report annually on initiatives and accomplishments, and direct regional working groups to assess barriers to coordination at the local level.
In subsequent reports, the GAO continued to highlight the lack of a cost allocation methodology as a major barrier to coordination efforts. In 2003, the agency was asked to study the extent to which government agencies are currently providing transportation services to the transportation-disadvantaged (older adults, people with disabilities, and low-income individuals) and coordination of the provision of these services, including an update on actions taken by the Coordinating Council since the 1999 report. Research efforts identified 62 Federal programs that fund transportation services for populations that are transportation-disadvantaged.3 The report documents some successful coordination efforts undertaken at the local level around the U.S. and notes that the re-named Coordinating Council on Access and Mobility (CCAM) has adopted a strategic plan and sponsored some research and technical assistance activities to promote coordination. However, barriers to coordination persist, including a reluctance among human service agencies to coordinate due to fears of loss of control over vulnerable clients’ riding experience and the convenience of administering their own transportation.
The report documents that differing program requirements can impede coordination, including the lack of uniform data collection and reporting requirements among programs, which can make it difficult for agencies to determine their true transportation costs and the benefits that may be realized from coordination. One of the report’s recommendations is to harmonize requirements among Federal programs, such as providing more flexible regulatory language that would allow providers to serve additional client groups, creating consistent cost accounting methods, and adopting common safety standards.4 It was noted that the benefit from any change in standards or requirements would need to be balanced against continuing to properly meet client needs and sufficiently control funds distributed to grantees. It is also recommended in the report that the CCAM-member agencies develop guidance for grantees on cost-sharing arrangements for transporting common clientele.
A 2012 GAO report provides an update to the Federal government on transportation coordination since the publication of the 2003 report. The report includes a listing of CCAM activities since 2003, which included reports and policy statements, the United We Ride and Veterans Transportation and Community Living Initiative grant programs, and nationwide technical assistance programs. The report documents several key challenges in coordination efforts. These include a lack of activity at the leadership level of CCAM and the absence of key guidance documents for furthering agency coordination efforts, including a joint cost sharing policy that CCAM had committed to developing in its 2005 report to the President. This report noted that a major obstacle to sharing transportation resources has been the difficulty of reaching agreements at the local level about the appropriate allocation of costs to coordinating agencies.5
The report cites the concerns expressed by the Centers for Medicare & Medicaid Services (CMS) that the co-mingling of Federal program funds for transportation coordination could violate the Federal restriction against the use of Medicaid funds for purposes other than to deliver medical services to eligible beneficiaries.6 Similar concerns were expressed by the Veterans Administration (VA). While there have been many coordination activities at the State and local levels, local officials commented to the GAO that there is not sufficient Federal leadership and guidance on how to coordinate transportation services while following program requirements. The report’s concluding recommendations include the development of a cost-sharing policy endorsed by CCAM.
Soon after the 2012 report, the GAO issued a Statement for the Record that summarizes its reporting on transportation coordination.7 The Statement reaffirms the recommendation that CCAM develop a cost-sharing policy for Federally-funded transportation programs, noting that as of November 2013, this recommendation has remained open. The Statement also cites that the trend of states shifting Medicaid NEMT responsibilities to private managed care systems as a potential new barrier to Medicaid programs’ participation in State and local coordination efforts.