State legislatures regularly address issues related to the provision of trauma care and injury prevention. The U.S. Congress has also historically played a role in trauma system development and funding, but federal lawmakers recently have experienced difficulty passing system development legislation and appropriating money for trauma, leaving it to state legislatures to identify funding sources and to design and implement their own trauma systems.
The American College of Surgeons (ACS) actively monitors state legislative activity. In 2015, for example, ACS State Affairs staff has reviewed approximately 200 pieces of trauma-related legislation. Most of these bills pertained to injury prevention efforts, but some were related to trauma system development and funding. In addition, the American Medical Association’s (AMA) House of Delegates (HOD), which includes an ACS delegation, took a close look at trauma prevention during its annual meeting in June. A number of resolutions were put forth calling for the AMA to weigh in on injury prevention policy.
This article examines the trauma-related issues considered in state legislatures and by the AMA HOD over the last year.
State legislatures debated a significant amount of legislation aimed at injury prevention in 2015, including laws pertaining to distracted driving, motorcycle helmet use, gun control, and vulnerable users of roadways.
The most ubiquitous type of injury prevention legislation recently considered in the state legislatures seeks to discourage distracted driving. Most states restrict the use of cell phones and other handheld devices while driving. In all, 14 states (California, Connecticut, Delaware, Hawaii, Illinois, Maryland, Nevada, New Hampshire, New Jersey, New York, Oregon, Vermont, Washington, and West Virginia), and the District of Columbia and Puerto Rico, have prohibited drivers from using handheld devices; however, most states have specifically banned texting while driving with either a primary or secondary enforcement mechanism. A primary enforcement mechanism means that an officer can ticket the driver for the offense without any other traffic violation taking place, whereas a secondary enforcement mechanism means an officer can only issue a ticket if a driver has been pulled over for another violation, such as driving erratically. Only two states, Montana and Arizona, allow texting while driving. This year, the lawmakers at the state level considered legislation that would update current distracted driving statutes to address advances in technology. Utah is one of the few states that attempted to weaken its law by altering its ban on texting while driving to allow one-button dialing on cell phones with voice commands and similar one-button commands for music or other apps. However, that legislation failed to advance.
Motorcycle helmet mandates
In a number of states, legislators attempted but ultimately failed to change current laws related to mandatory helmet use. In Iowa, H.F. 267 would have mandated that motorcycle operators and passengers wear a safety helmet. In New Mexico, two bills were introduced that would have placed new requirements on motorcycle operators. One bill, S.B. 327, would have implemented a universal helmet requirement. The other bill, S.B. 308, would have instituted a helmet requirement, although under the proposed law operators would have been permitted to ride helmetless if they were older than 18 years of age and if they had purchased a validating sticker for $692. The fees collected would have gone to the Trauma System Fund, the Brain Injury Services Fund, and the Fatal-Injury Diagnosis and Reporting Fund. Similar legislation, S.B. 356, was introduced in West Virginia. This bill would have provided an exemption from wearing helmets for operators who meet certain safety requirements and have at least $10,000 in medical coverage, including coverage for motorcycle accidents.
In Tennessee, separate pieces of legislation were considered that would loosen helmet restrictions. S.B. 925/H.B. 700 would have exempted motorcycle drivers and passengers older than 21 years of age from the helmet requirement if those individuals were covered by health or medical insurance other than the state-funded TennCare program. This legislation advanced through the committee process but ultimately failed to pass. It will, however, carry over to next year’s legislative session. Another bill of a much more limited scope, S.B. 469, was signed into law in Tennessee. This new law allows for a helmet wearing exemption for persons riding in a funeral procession, memorial ride under a police escort, or body escort.
Nebraska bill L.B. 31 would have repealed the state’s mandatory helmet law completely, and in Washington, S.B. 5198 would have removed the mandatory helmet requirement for individuals older than age 18. Both bills received public hearings, but neither advanced further.
Gun control continues to be a hot topic in the state legislatures. Dozens of bills were considered on issues ranging from private sale background checks to permit-less concealed carry of guns. Kansas, Maine, and Mississippi all passed bills allowing for concealed guns to be carried in public without a permit. Nevada passed a bill (S.B. 175) that expands the state’s stand-your-ground statute, which protects individuals who decide not to retreat when defending a motor vehicle and recognizes out-of-state conceal and carry permits. H.B. 2014 was signed into law in Oklahoma, which allows a school district to permit school personnel to carry loaded firearms on the grounds of public elementary and secondary schools if they obtain reserve officer certification, and in Georgia, school districts are now prohibited from regulating gun possession on school grounds as mandated by H.B. 492. Texas will now allow concealed carry permit holders to carry loaded firearms openly in public as well as allowing permit holders to carry firearms on college and university campuses with some regulation permitted by local school officials.
Oregon enacted S.B. 941, which requires background checks on unlicensed gun purchasers in the state. In Nevada, S.B. 240 was signed into law, prohibiting mentally ill convicts from owning a gun. The law also removes Nevada’s $35 fee for background checks for private gun sales, criminalizes the practice of buying a gun for another person, and strengthens reporting requirements on criminal history and mental illness. Also in Nevada, S.B. 175, mentioned previously, prohibits individuals convicted of a domestic violence misdemeanor from owning or possessing a firearm. Alabama, Delaware, Louisiana, Oregon, South Carolina, and Washington State all passed legislation making it more difficult for individuals charged with domestic violence to possess firearms.
Safe travels for vulnerable users
An emerging issue in the state legislatures in recent years has focused on improving safety for so-called vulnerable users on roadways. Vulnerable users are typically defined as pedestrians or individuals using bicycles, skateboards, roller skates, inline skates, and other nonmotorized modes of transportation. These bills differ by state but usually require increased penalties when a vulnerable user is injured or killed by a motor vehicle. These penalties include increased fines, license suspension, community service, or mandatory traffic courses. A total of 12 states (Colorado, Delaware, Hawaii, Illinois, Louisiana, Maryland, Mississippi, Nevada, New York, Oregon, Tennessee, and Washington) have already adopted some sort of vulnerable user protections. An additional eight states (Arizona, Delaware, Florida, Maine, Massachusetts, New Hampshire, Utah, and Vermont) considered bills this year, but only Utah enacted legislation.
Trauma system funding and development
Minimal activity in the state legislatures pertained to trauma system development and funding, as most state budgets are still recovering from the recession and some are still facing budget deficits. In addition, many states have trauma systems in place with at least some available funding. Nonetheless, a few state legislatures did consider changes to their trauma systems or are trying to identify new funding sources. State lawmakers took unique approaches to reforming these systems, especially with respect to establishing funding.
In Texas, legislation to repeal the Driver Responsibility Program, which provides funding for the state trauma system, did not pass this session. S.B. 93 received unexpected support in the legislature and was passed by the Senate, but the House did not act before the session ended. The Driver Responsibility Program imposes surcharges on drivers who receive citations for traffic violations. As originally written, S.B. 93 would have repealed the Driver Responsibility Program entirely, but the amended bill left the program intact. The amended legislation, however, also removed a provision that would suspend the driver’s licenses of those individuals who fail to pay the fine. License suspension is the main enforcement mechanism for the program; if eliminated, it would have led to a significant decrease in funding for trauma care in the state. The ACS actively opposed the bill and will continue to counter efforts to cut trauma funding when the Texas legislature reconvenes in 2017.
Legislation was introduced in Nevada that would have required the Department of Health and Human Services to develop a standardized system for the collection of information for the state trauma registry. The bill, S.B. 189, also would have created the Fund for the State Trauma Registry, which would have required automobile and home insurers to charge an annual $1 fee to fund the development of this system. The bill did not make it out of committee.
In Ohio, H.B. 261 was introduced to create a new Ohio Trauma Board and to make other changes to its trauma system. The Ohio Trauma Board, which would be administered within the Ohio Department of Health, would comprise 19 members appointed by the Governor, the Speaker of the House, and the President of the Senate. The board would be responsible for operating the state trauma registry, seeking and distributing grants, and developing a statewide system for improving the quality of trauma and rehabilitative care. At least three of the Ohio Trauma Board members would be trauma surgeons. The Ohio Chapter of the ACS would be required to submit nominations for two of the positions.
In addition, H.B. 261 also would add new designation standards, such as participation in statewide and regional injury prevention activities and submission of more timely data to the registry. Furthermore, the bill would require the Department of Health to hire an executive director and chief medical director. The ACS would still verify trauma centers, but additional standards would be added for centers to gain verification. Currently, the trauma system in Ohio is funded solely through fees assessed on trauma hospitals, and this legislation does not address that issue. One suggested means of addressing the funding situation would require hospitals to contribute at least some of the revenue needed to make the proposed changes in the legislation. Ohio’s original trauma law was passed in 2000.
A bill introduced this year in Indiana would have provided some funding for the statewide trauma system. Although funds have been authorized for the trauma system through the Spinal Cord and Brain Injury Fund that became effective through legislation passed eight years ago, no actual funding is provided for trauma system development and infrastructure support. The bill introduced this year, H.B. 1404, would have used speed cameras to identify drivers speeding through construction or school zones or illegally passing a school bus and would have imposed a fine with a ticket sent through the mail. Half of the funds received from these fines would have been directed to the Spinal Cord and Brain Injury Fund, specifically for use in developing a statewide trauma hospital network. The bill failed in the Committee on Roads and Transportation.
In addition, significant behind-the-scenes work is occurring in some states to gain support for trauma system development. As a result, increased legislative activity is expected to occur next year.
AMA HOD activities
In the course of its annual meetings, the AMA HOD typically considers a number of resolutions pertaining to trauma care. This year’s meeting was no exception. Reference Committee D, which considers resolutions focused on public health, reviewed a number of resolutions centered on injury prevention.
One of the more hotly debated resolutions centered on mandatory protective headgear/helmets for female lacrosse players in order to prevent concussions. U.S. Lacrosse, the national governing body of the sport, currently opposes mandatory helmet use for female players but is debating whether to change policy. Some delegates argued that the AMA should wait until U.S. Lacrosse has ruled before getting involved. After hearing significant testimony in favor of the resolution, the AMA adopted the new policy and will advocate for protective headgear for female lacrosse players.
In another effort to prevent youth concussions, the AMA adopted a policy to promote requirements for youth sports participants who are suspected of having a concussion. Specifically, these requirements mandate the suspension of these athletes from all forms of the activity until written approval is provided by a physician or designated member of the care team.
The AMA also regularly considers resolutions dealing with gun safety. At this year’s meeting, the House of Delegates adopted a resolution directing the AMA to encourage toy gun manufacturers to take additional steps to further differentiate toy guns from real guns. Currently, makers of toy guns add an orange tip to their products to distinguish them from actual weapons. The resolution that was adopted was amended from its original version, which would have required the AMA to support legislation strengthening current laws on the manufacturing of toy guns.
Another resolution that garnered some attention dealt with the use of restraint systems for children on commercial airline flights. There was mixed testimony on the resolution, which recognized the need to keep children safe on flights but acknowledged the logistical challenges. The delegates adopted a policy, which calls on the AMA to support the use of restraint systems for children on flights and for public education about the use of the devices. The resolution also recommends that the AMA work with relevant federal and international agencies to establish criteria for appropriate child restraint systems.
The AMA also considered and adopted an amendment to its current policy on distracted driving. The amendment added in language about the dangers of using headphones/earbuds while driving and while partaking in outdoor activities such as biking, jogging, rollerblading, walking, and skateboarding. The amendment directs the AMA to support education about these dangers, as well as the addition of warning labels indicating the dangers of using handheld devices with headphones/earbuds. The ACS supported the resolutions on increasing toy gun safety, concussion and youth sports, and mandating support of protective headgear in lacrosse.
ACS staff members work closely with the Committee on Trauma to review trauma-related policies and to take a position on them as appropriate. The College also builds relationships with individual members and State Chairs of the Committee on Trauma to ensure proper coordination of state legislative advocacy.
If you have questions or would like more information about the ACS state legislative activities, contact Tara Leystra Ackerman or Justin Rosen, State Affairs Associates, at firstname.lastname@example.org. If you have any questions or would like more information regarding the work of the ACS delegation to the AMA HOD, contact Jon Sutton, Manager, State Affairs, at email@example.com or 202-672-1526.