Transportation Disadvantaged Populations: Nonemergency Medical Transportation Not Well Coordinated, and Additional Federal Leadership Needed
Highlights
What GAO Found
Forty-two programs across six federal departments—Agriculture, Education, Health and Human Services (HHS), Housing and Urban Development, Transportation (DOT), and Veterans Affairs (VA)—can provide funding for nonemergency medical transportation (NEMT) service, although NEMT is not their primary mission. Twenty-one of these programs, including Medicaid, are administered or overseen by HHS. The type of funding provided by these programs varies, but includes capital investments (such as bus purchases) and reimbursements of transportation costs (e.g., bus passes). Total federal spending on NEMT is unknown because federal departments do not separately track spending for these services. In some cases data were not available or NEMT was incidental to a program's mission. However, one of the six departments (HHS) was able to provide estimates indicating that its spending totaled at least $1.3 billion in fiscal year 2012—most of this attributable to Medicaid.
Coordination of NEMT programs at the federal level is limited, and there is fragmentation, overlap, and potential for duplication across NEMT programs. The federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council)—chaired by the Secretary of DOT and tasked with promoting interagency cooperation and establishing mechanisms to minimize duplication and overlap of programs for the transportation disadvantaged—has taken some actions to improve coordination, such as developing a strategic plan. The strategic plan identified the council's goal, priorities, and objectives for 2011 to 2013. However, the council has provided limited leadership and has not issued key guidance documents that could promote coordination. For example, the council has not met since 2008 and has not finalized a cost-sharing policy that would allow agencies to identify and allocate costs among programs. GAO has previously found that agencies providing similar transportation services to similar client groups may lead to duplication and overlap when coordination does not occur. This review found instances of fragmentation, overlap, and the potential for duplication, although the extent could not be quantified.
State and local officials in the selected states GAO visited identified a variety of ways they facilitate coordination of NEMT. These include state coordinating bodies (two states GAO visited), regional coordinating bodies (two states GAO visited), local metropolitan planning organizations, and local transit agencies. Cost and ride sharing and one-call/one-click information centers were also used to coordinate NEMT services. However, GAO found two programs—Medicaid and VA NEMT programs—largely do not participate in coordination activities. Requirements to serve only eligible individuals and ensuring proper controls are in place to prevent improper payments and fraud are among the challenges to coordination for these programs. These important NEMT programs provide services to potentially over 90 million individuals and coordination without the Medicaid and VA programs increases the risk for potential overlap and duplication of services.
Why GAO Did This Study
Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. NEMT is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. GAO was asked to review the coordination of NEMT services. This report addresses (1) the federal programs that provide funding for NEMT services, (2) how federal agencies are coordinating NEMT services, and (3) how NEMT services are coordinated at the state and local levels and the challenges to coordination.
GAO analyzed a compendium of federal programs that provide assistance to the public; reviewed program information from the six departments that fund NEMT; interviewed officials of DOT, HHS, and VA; and interviewed state and local officials in five states, chosen based on a variety of considerations, including geographic diversity and existence of a coordinating body.
Recommendations
GAO recommends that the Secretary of Transportation, as chair of the Coordinating Council, should publish a new strategic plan, issue a cost-sharing policy, and address the challenges associated with coordinating Medicaid and VA NEMT programs with other federal NEMT programs. DOT concurred in part with developing a new strategic plan and issuing a cost-sharing policy, and it concurred with identifying challenges of coordinating NEMT, particularly with HHS agencies.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Transportation | To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and complete and publish a new or updated strategic plan that, among other things, clearly outlines a strategy for addressing NEMT and how it can be coordinated across federal agencies that fund NEMT service. | Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, federal efforts to coordinate transportation for the transportation disadvantaged population has rested with the federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council) made up of 11 federal agencies, including HHS and VA. Among other things, the council is tasked with promoting... interagency cooperation and establishing appropriate mechanisms to minimize duplication and overlap of federal programs so transportation-disadvantaged persons have better access to cost-effective transportation services. In December 2014, GAO reported that, while the Coordinating Council had taken some steps to increase transportation coordination, it exercised little leadership in this area, including NEMT. This included the absence of key guidance documents such as a current strategic plan. The previous plan had expired in 2013 and had not been updated. In addition, the goals and priorities in the previous plan did not specifically address NEMT. Instead, they focused things such as mobility and expanding the coordinated human-service-transportation infrastructure. GAO reported that by not updating or issuing a new strategic plan the Coordinating Council may have been missing an opportunity to identify and align goals and strategies for increased NEMT coordination with the benefits of coordination, such as increased program efficiency or reduced costs. Therefore, GAO recommended that the Coordinating Council complete and publish a new or updated strategic plan that, among other things, clearly outlined a strategy for addressing NEMT and how NEMT could be coordinated across federal agencies. In 2020, GAO confirmed that the Coordinating Council adopted a new strategic plan covering the fiscal year 2019 through 2022 period. This plan, among other things, established a goal of improving access to the community for members of the transportation disadvantaged population and an objective of reducing federal policy barriers to coordinated transportation. The council indicated these actions apply to NEMT as well as other coordinated transportation services. The Coordinating Council's new strategic plan responds to GAO's recommendation that the council issue a new plan. The plan also clearly outlines a strategy for addressing NEMT by focusing on ways to reduce policy barriers to coordinated transportation. With these actions, the Coordinating Council is in a much better position to identify issues surrounding coordination of NEMT across federal agencies and identifying ways to best achieve the benefits of coordination.
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| Department of Transportation | To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and finalize and issue a cost-sharing policy and clearly identify how it can be applied to programs under the purview of member agencies of the Coordinating Council that provide funding for NEMT. | Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, federal efforts to coordinate transportation for the transportation disadvantaged population, including NEMT, has rested with the federal Coordinating Council on Access and Mobility (Coordinating Council) made of 11 federal agencies, including HHS and VA. This council is tasked, among other things, with formulating and...
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| Department of Transportation | To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and using the on-going work of the Health, Wellness, and Transportation working group and other appropriate resources, (1) identify the challenges associated with coordinating Medicaid and VA NEMT programs with other federal programs that fund NEMT, (2) develop recommendations for how these challenges can be addressed while still maintaining program integrity and fraud prevention, and (3) report these recommendations to appropriate committees of Congress. To the extent feasible, the Coordinating Council should implement those recommendations that are within its legal authority. | Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, efforts to coordinate transportation for the transportation disadvantaged population across federal agencies has rested with the federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council), which is made up of 11 federal agencies, including the Departments of Health and Human Services...
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