For years, San Diego doctors have essentially written prescriptions for patients with disabilities to qualify for discounted Metropolitan Transit System fares. But MTS has declined to fulfill doctors’ recommendations hundreds of times in recent years, particularly for riders with mental health conditions.
Data obtained by Voice of San Diego after a public records request reveals MTS and the contractor it has directed to review applications have rejected more than 1,660 of the roughly 5,660 long-form applications MTS received in the last three years. Another third of applications submitted to MTS were deemed incomplete. The agency during roughly the same period processed nearly 20,000 applications submitted by seniors, riders with Americans with Disabilities Act placards and Medicare and Social Security income recipients who qualify with a short form that does not require a doctor’s sign-off.
A contingent of advocates, health care providers and MTS riders with disabilities have criticized the flood of denials and say they point to a broken system for doling out discounted fares and passes the agency is required to offer qualified riders with disabilities as a condition of federal funds it receives.
Regional clinic operator Family Health Centers of San Diego, homeless service provider Father Joe’s Villages, behavioral health nonprofit National Alliance on Mental Illness San Diego and county mental health workers have taken their concerns to MTS over the years. Some questioned why patients with mental health conditions so rarely receive discounted passes despite testimony from their doctors. Others described confusion about the form itself and the information MTS is seeking.
Family Health Centers has called multiple meetings with MTS, including in 2018 after the transit agency for a time stopped accepting applications from the lead physician at the nonprofit’s clinic at downtown Connections Housing after MTS said he failed to return calls inquiring about forms he had filled out.
“The actions of MTS lead to the providers changing their behavior and not applying as often because of the amount of work it takes and the frustration with the system,” said Anthony White, Family Health Center’s director of community and government relations. “This is particularly true for mental health issues, which most of our providers believe are never approved.”
The frustration over MTS’s review process coincided with the agency’s decision to dramatically ratchet up its enforcement  of fare evasion.
MTS has for years defended its policies even as it has made minor changes, maintaining that its requirements are consistent with Federal Transit Administration policies, which only mandate that agencies provide reduced fares to people whose disabilities require “special facilities or special planning or design to utilize mass transportation facilities and services as effectively as persons who are not so affected.”
MTS has long said its process is meant to protect taxpayers and ensure only those who qualify receive discounted passes. In June 2018, the agency farmed out the review process to contractor Medical Transportation Management, which also handles more in-depth eligibility assessments for MTS’s Access program  for riders whose disabilities make them unable to use the fixed-route transit system. MTS has said it expanded the Access contract without an additional charge to relieve its own employees and add more medical expertise to its process.
Federal policies give transit agencies like MTS discretion to decide exactly how to implement discounted fare programs. Indeed, nearby North County Transit District essentially only requires doctors to certify that their patients have a condition that qualifies them for a discounted pass, a lower bar than MTS.
After questions from VOSD about the agency’s policies and longstanding complaints about them, MTS CEO Sharon Cooney and board Chairman Nathan Fletcher wrote in separate statements last week that change is coming.
“MTS has always welcomed feedback on how we can better our processes, especially as they impact our riders,” Cooney wrote. “We are currently looking at our (Senior/Disabled/Medicare pass) eligibility requirements and are considering changes suggested by community advocates that will improve the way individuals with disabilities access our services.”
Fletcher, a county supervisor who has championed reforms  to the county’s behavioral health system, was more direct.
“We are changing the SDM policy to better serve our community,” Fletcher wrote in an email to VOSD.
He noted that the planned tweaks align with changes the agency’s new leaders have urged  to dial back enforcement and lessen the burden of MTS fare evasion tickets with a diversion program  set to begin next month.
Advocates say that for years, local health care providers filled out a simpler form to help patients with disabilities receive discounts now set at 68 percent for MTS passes and 50 percent for one-way bus and trolley fares. The discounts help patients, who are often low-income, afford bus and trolley rides to doctors’ appointments and social service providers – though MTS has emphasized in presentations about the program that income is not a factor in assessing eligibility.
MTS changed its vetting process in March 2011 after the agency reported a spike in the number of seniors and people with disabilities with reduced-fare passes. MTS’s concerns about fraud mirror those of advocates and authorities across the nation who have long decried abuses of resources such as ADA parking placards by people who are not disabled.
Alma Porley, a former counselor at the county’s El Cajon outpatient mental health clinic, said patients and doctors quickly recognized the change in 2011. Porley, who retired this spring, said MTS began informing applicants that their conditions didn’t qualify them for the discounted passes – and often denied patients multiple times, even after their psychiatrists provided additional information.
“People were rejected two or three times after the doctors sent back the information,” said Porley, who was baffled by MTS’s questioning of doctors’ recommendations.
Porley and others eventually learned that MTS was applying a stringent standard for patients to qualify. Doctors filling out the forms would need to explain how and why their patient needed special assistance or planning to use public transit, a requirement that has confused even doctors who treat many patients seeking discounts from MTS.
The latter standard stems from federal regulations  approved decades ago. An appendix  published years later clarifying those federal rules, which more cleanly describe mobility challenges, states mental illnesses are not considered a disability under the federal transit rules.
Still, the appendix notes that the FTA “encourages applicants to provide the broadest possible coverage in defining eligible handicaps, including mental illness.”
MTS spokesman Rob Schupp said MTS has made reasonable efforts to try to provide that coverage by requiring doctors treating patients with mental health conditions to describe how they need special planning or assistance to use transit.
“Many times, a doctor’s explanation does not sufficiently describe how the mental illness makes transit more difficult to use,” Schupp wrote in an email to VOSD.
Dr. Jeffrey Norris, chief medical officer at Father Joe’s Villages, said he has struggled to describe patients’ disabilities and how they are affected by them in the single line MTS provides on its form to provide those details. Norris said he has written around the margins of the form after patients’ initial applications were rejected, hoping the additional details will suffice and fearing that MTS will not accept an attached letter.
“What they’re looking for is not always clear,” said Norris, whose agency raised that concern directly with MTS a few years ago.
(MTS told VOSD that it accepts attached doctors’ letters though it does not say so on its form.)
Heather Petersen of NAMI San Diego, who serves as program director of a county-funded recovery program affiliated with the county’s Midway psychiatric hospital, said her agency has also found many doctors are confused about the form and can inadvertently leave required sections blank, among other issues.
“The form is not simple,” Petersen said.
Family Health Centers officials told VOSD they have come away from discussions with MTS about the form and its policies thinking that MTS decisions to reject applications from the nonprofit’s downtown clinic located at a homeless service center reflected the agency’s intent to keep its homeless patients from accessing reduced fares, a premise MTS rejects.
“MTS processes are the same regardless of (the) applicant,” Schupp wrote. “We hold all of our riders and all applicants for discounted fares in high regard.”
Ann Menasche, a San Diego-based attorney with Disability Rights California, also believes the confusion around MTS’s form and who can qualify for a discounted fare has been intentional.
“It’s kind of a game,” Menasche said. “They have law on their side in the sense they can have this restriction, and then they make it difficult for the doctors to understand what they need to do to get the benefit.”
Menasche has successfully advocated for a handful for clients who were initially denied disabled passes from MTS. Menasche said all had conditions that should have qualified them before she got involved.
Menasche thinks MTS should significantly simplify and clarify its process for patients whose busy doctors now may be unclear that they need to describe on the form that a patient may need to take extra steps to plan their trolley routes to lessen anxiety or grapple with other conditions.
Amanda Garcia, 36, agrees.
Garcia, who has been diagnosed with post-traumatic stress disorder, anxiety and depression, learned earlier this year that MTS denied her application for a discounted fare.
A January letter from MTS and its contractor Medical Transportation Management informed Garcia that her application “did not indicate a qualifying disability or transit-impairing requiring special facilities planning or design” and explained that that the medication she relies on also made her ineligible.
“Condition(s) that are controlled through medication(s) do not qualify under MTS’s guidelines,” the letter read.
Garcia, whose family has since helped her get a car so she can get around without transit, wasn’t surprised by the denial. She said a county psychiatrist had warned her that MTS rejects many applications. She argued MTS should not deny her or others with mental health conditions that can have ramifications as dramatic as physical disabilities.
“Do I have to go through something debilitating for them to see that I would have needed that reduced fare each month?” Garcia said. “How bad does my mental disability have to be to take advantage of resources that are allotted for people like me?”
MTS defended its decision to not to grant fare discounts to people whose conditions can be significantly aided with medication.
“If medication eliminates the need for special planning, design or facilities, the individual is determined not to be eligible,” Schupp wrote.
Two experts told VOSD they found MTS’s conclusion troubling.
Debbie Plotnick, vice president for mental health and systems advocacy for Washington D.C.-based Mental Health America, likened it to declaring that a person with mobility issues who has gotten a wheelchair no longer has mobility challenges.
“Having medication or having an aid or having something that helps you with that condition does not mean you do not have the condition or do not need the help,” Plotnick said. “That’s out and out discrimination against people with mental health conditions.”
Jennifer Mathis, director of policy and legal advocacy of the D.C.-based Bazelon Center for Mental Health Law, drew a similar conclusion.
“It makes very little sense,” Mathis said. “It assumes that people are always taking medication and it affects them exactly the same way all the time, which is clearly not true with psychiatric medications.”
Mathis and Plotnick also agreed that MTS seemed to be applying overly burdensome standards for San Diegans with disabilities to meet to receive discounted fares.
“This is another barrier that gets thrown up in people’s way, hoping they’ll go away,” Plotnick said.
At least a few riders have gone elsewhere – to get approved.
Homeless advocate John Brady and Mark Sheetz, who is now staying at the Convention Center shelter, each pursued a discount from NCTD after being denied by MTS.
Sheetz, who has anxiety and depression and sustained head injuries after being struck in two past car accidents, said he was worried three years ago after MTS at least twice rejected applications signed by his psychiatrist.
“I just thought it was extremely odd to, say the least – just a way to mess with the homeless and those that need the discount,” Sheetz said.
Sheetz, 57, was worried. He couldn’t afford a $72 monthly MTS pass.
Brady, who had successfully used NCTD’s less complicated process a couple years earlier, drove Sheetz to North County to help him turn in his disabled pass form.
NCTD approved Sheetz’s application.