Trauma and emergency care under the Affordable Care Act

In 2008, a tour bus carrying 53 people rolled down an embankment in Mexican Hat, UT, killing nine people and seriously injuring 35.¹ The first ambulance arrived on the scene one hour after the accident, and, in fact, some of the victims had to be transported to hospitals in county vans. The closest medical facility with a trauma center (Level IV) was located 117 miles away in Moab, and the nearest Level I trauma center was 190 miles away, in Arizona. Most of the victims were treated 75 miles away from the accident at a facility without a trauma center, and the rest were sent even farther away to various Level I and II trauma centers. Two victims died en route to medical facilities. Since this incident occurred in the four-corner area—a region of the U.S. consisting of the southwestern corner of Colorado, northwestern corner of New Mexico, northeastern corner of Arizona, and southeastern corner of Utah—counties in all of those states had to be alerted to the disaster. A Utah Department of Health report on the incident concluded that the preparation weaknesses resulted from decreases in grants and funding at state and local levels and a lack of focus on “inclusive, regionally coordinated prevention efforts.”¹

Trauma care and trauma systems have come under scrutiny in the wake of several natural disasters and man-made tragedies, such as the Mexican Hat incident, and most recently after the Boston Marathon bombings in 2013. However, the suffering and burden of mass-casualty events is staggering and merits consistent attention from policymakers at the federal and state levels, to ensure that the necessary systems are in place before they are needed—and not simply in times of tragedy.

Although the U.S. Congress scrutinized emergency room care during the health care reform debates, trauma care was, by and large, ignored initially. However, because of strong advocacy from the trauma community and the leadership of several legislators, trauma and emergency care systems eventually received the attention necessary to improve access and care for the injured patient.

The American College of Surgeons (ACS) played a leading role in securing language in the Affordable Care Act (ACA) of 2010 that pertains to patient access to day-to-day trauma care, surge capacity, and trauma research.² This article provides an update on the status of those provisions, highlights the major components related to trauma care and trauma systems in the ACA, and discusses the College’s ongoing efforts to secure funding for the authorized programs. We also address surge capacity issues in current systems.

The necessity of trauma systems

Unintentional injury is the leading cause of death in the U.S. for individuals one to 44 years of age and the fifth leading cause of death overall.³ In 2011, more than 182,000 people lost their lives to trauma, and 68 percent of these deaths were from unintentional injuries.⁴ More specifically, approximately 34,000 people lost their lives in motor vehicle accidents, and almost 27,000 to falls. In 2009, approximately 38.9 million people sought emergency medical attention for nonfatal injuries.⁵

Trauma adds significantly to the nation’s health care costs. Injuries cost the health care system $80 billion in 2000.⁶ The National Safety Council found that the total cost of unintentional injuries was $693.5 billion in 2009, including medical costs, lost wages, and productivity.⁵

Rapid assessment and treatment of severe traumatic injury can mean the difference between life and death. The type of facility where treatment is rendered has been shown to have a significant bearing on mortality as well. A study comparing outcomes for moderate to severe injuries at Level I trauma centers with hospitals lacking a trauma center showed that after adjustment for case mix, the risk of death one year after injury was 25 percent lower for patients treated at Level I trauma centers. The difference was greater for severe injuries than for moderate injuries.⁷

Unfortunately, though, approximately 17 percent of U.S. citizens live more than an hour’s drive from a Level I, II, or III trauma center.⁸ Rural populations and the poor residing in both urban and rural settings have less geographic access to trauma care. Furthermore, trauma centers have been closing at an unprecedented rate over the last three decades. Between 1990 and 2005, a total of 339 trauma centers—almost 30 percent of the 1,132 trauma centers in existence in 1990—closed their doors.⁹ By 2007, 24 percent of the U.S. population had to travel farther to reach a trauma center than in 2001.¹⁰ Closures have been attributed to the high cost of trauma care and low rates of reimbursement.

Trauma systems have fared no better. A 2009 survey of ACS state society chairs revealed that only two-thirds of all states had a trauma system, even at the most basic level, and most did not have adequate funding to maintain those systems.¹¹

The development of well-organized, collaborative, and regionalized trauma systems has featured prominently in the College’s efforts to improve quality of care. ACS Past-President A. Brent Eastman, MD, FACS, a general, vascular, and trauma surgeon who was Vice-Chair of the Board of Regents at the time, focused his remarks during the 2009 Scudder Oration on “the development of inclusive trauma for every citizen and traveler, in every state and province, wherever the dart lands.”¹¹ (The Scudder Oration is presented annually at the ACS Clinical Congress.) According to the Health Resources and Services Administration’s (HRSA) definition, ideal trauma systems encompass prevention, triage, treatment, and rehabilitation at a statewide level, with the goal of reducing trauma morbidity and mortality and with data collection and analysis to demonstrate effectiveness of the program.¹² These systems have demonstrable benefits.

A retrospective study of trauma-related deaths in Montana before and after the implementation of a voluntary statewide trauma system showed a significant decrease in the preventable death rate (PDR), from 13 percent before the implementation of a trauma system to 8 percent one year after the system was put in place.¹³

Surge capacity response

Surge capacity response is a crucial element of any trauma system. In 2008, the U.S. House Committee on Oversight and Government Reform published a report on surge capacity at Level I trauma centers in seven major cities.¹⁴ This effort was undertaken in response to a 2004 train bombing in Madrid, Spain—which resulted in 177 fatalities and more than 2,000 injuries—to determine whether U.S. hospitals had the capacity to respond to a similar level of casualties. This report showed severe emergency department overcrowding, with each city having fewer available treatment spaces in all of their Level I trauma centers combined than a single hospital in Madrid. Multiple hospitals were on diversion, and more than half were operating above capacity. The average institution could accommodate fewer than 25 percent of the patients admitted to a single Madrid hospital.¹⁵ The Centers for Disease Control and Prevention (CDC) estimates that federal support for mass-casualty disasters is unlikely to be issued in less than 72 hours—far too late to benefit severely injured patients.¹⁶ State-level surge capacity is, therefore, a critical component of disaster response.

Trauma-related provisions in the ACA

The ACS worked closely with other specialty organizations and legislators to secure language in the ACA that would support efforts to improve access to quality trauma care. More specifically, the College lobbied for reauthorization of the Trauma Care Systems Planning and Development (TCSP) and the National Trauma Center Stabilization (NTCS) Acts, as well as new language related to the regionalization of emergency care, trauma service availability grants, and pediatric emergency care.

The TCSP Act

The TCSP Act was enacted in 1990 (Title XII of the Public Health Service (PHS) Act, 1211-1232) in response to a 1986 General Accounting Office (GAO) report, which indicated that severely injured individuals in most areas of the U.S. did not have access to trauma systems.^17,18 Since 1990, the TCSP has provided $31.4 million to help states and U.S. territories develop and implement statewide trauma care systems. However, the act went unfunded in 2006 and 2007.¹⁹ In 2007, former President George W. Bush signed legislation resurrecting the TCSP and authorized $46 million through fiscal year (FY) 2012, under the auspices of HRSA.²⁰ This law established a program to develop research and training projects to improve trauma care, improve the availability and quality of trauma care in rural areas, and create a new grant program for states to broaden access and communication using national standards and protocols. However, securing appropriations for the program proved difficult.

The ACS worked with members of Congress to ensure reauthorization of the program in health care reform legislation. These efforts came to fruition in the Senate version of the ACA. Section 3504 of the law reauthorized the program through 2014.²¹ The program also was moved from HRSA to the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the recommendation of the Office of Management and Budget (OMB), the U.S. Department of Health and Human Services (HHS), and ASPR, with support from the trauma community, which believed it might be easier to secure funding through the Office of the ASPR. Authorization for the program was set at $12 million per year. The funds have yet to be appropriated; however, ACS has continued to advocate for appropriations for the program, along with champions of the legislation, Reps. Gene Green (D-TX) and Michael Burgess, MD (R-TX), and Sens. Patty Murray (D-WA) and Jack Reed (D-RI).

Regionalization of Emergency Care Pilot Program

Section 3504 of the ACA also includes new legislation (Title XII of the PHS Act, 1201-1204), which authorizes $12 million annually through 2014 for no fewer than four multi-year “pilot projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems.” These projects, run under the auspices of the ASPR, would be designed by state or private entities to do the following:

• Coordinate public health, safety, and emergency services and trauma centers
• Establish a communications system to direct patients to the most appropriate medical facility
• Track pre-hospital and hospital resources in real time
• Include a data management system for pre-hospital, hospital, and inter-facility destination decisions and outcomes
• Submit data to the ACS National Trauma Data Bank^®, National Emergency Medical Services Information System, and appropriate federal and state registries

There is a required level of non-federal matching, and the reports must be publicly available.

The National Trauma Center Stabilization Act

Trauma centers across the country have been facing downgrades and closures due to uncompensated care, workforce shortages, liability costs, and outlays to support the infrastructure. The NTCS Act was introduced in the U.S. Senate in 2007 as an amendment to Title XII of the Public Health Service (PHS) Act to support trauma centers with a high pool of uncompensated care for part or the entire amount of the uncompensated care costs.²² The level of compensation was tiered based on the proportion of uncompensated care provided by the center. The amount authorized annually in this bill through 2014 was $100 million, but it was never appropriated. ACA Section 3505 included two trauma grant programs under HRSA, the reauthorized Trauma Care Center Grants (Title XII of the PHS Act, 1241-1246) and a new program called the Trauma Service Availability Grants (Title XII of the PHS Act, 1281-1282).²³ These programs were championed by Sens. Murray and Johnny Isakson (R-GA), Representative Burgess, and former Representative Edolphus Towns (D-NY).

The Trauma Care Center Grants include three awards: uncompensated care awards, core mission awards, and emergency awards. The uncompensated care awards provide tiered funding based on the proportion of uncompensated care delivered or Medicaid patients served. This program would provide critical funding to centers that are at risk of closing due to high levels of uncompensated care and/or Medicaid patients. The Core Mission Grants support such activities as education and outreach, patient stabilization and transfer, and coordination with local and regional systems. The Emergency Grants provide relief to centers at imminent risk of closing or in areas that have experienced natural disasters. The legislation specifically requires the centers seeking funds to be verified by the ACS or designated as such by an equivalent state or local authority. The legislation also supports ACS guidelines for trauma care registries. It authorizes $100 million for the first year and “such sums as may be necessary” through FY 2015. These funds had not been appropriated at press time.

The Trauma Service Availability Grants provide funding to states for trauma centers that serve as safety nets as per the criteria described for the Trauma Care Center Grants. These grants provide funds to support physician compensation, address overcrowding, increase access in underserved areas, and enhance surge capacity and collaboration among centers. This program is authorized at $100 million annually through FY 2015. The funds had not been appropriated at press time.

Program	Authorization (end year)
Trauma Care Systems Planning and Development Act	2014
Regionalization of Emergency Care Pilot Program	2014
The National Trauma Center Stabilization Act	2015

ACS efforts to secure appropriations

Despite authorization in the ACA, it has been difficult to secure appropriations for these trauma programs. Legislators intent on repealing the ACA are unwilling to allocate funds even for programs that were established before the ACA was enacted. The ACS has made sustained efforts to secure appropriations for these programs through HHS and Congress. The College, along with other specialty organizations, sent a letter to and met with ASPR Nicole Lurie, MD, and HRSA Administrator Mary Wakefield, PhD, RN, requesting that the administration include funding in the President’s FY 2013 budget for these programs.²⁴

The ACS drafted sign-on letters in 2012 to the House and the Senate Committee of Appropriations Subcommittees on Labor, HHS, and Education requesting $28 million in appropriations for these programs for FY 2013.²⁵ Signatories included Representatives Green and Burgess. The ACS also drafted a sign-on letter that Senators Reed and Murray sent to HHS Secretary Kathleen Sebelius requesting funding for these programs.²⁶ In addition, the ACS and other trauma champions have met frequently with HRSA, ASPR, congressional aides, the White House staff, and the OMB to advocate for these programs. The ACS Leadership & Advocacy Summit and the ACS Committee on Trauma (COT) advocacy agendas also are geared toward discussion of trauma-related issues with representatives in Congress.

Pediatric research

The ACS has long advocated for emergency and trauma care for children. ACS Division of Advocacy and Health Policy staff assisted in drafting new language in Section 3504 of the ACA, which amends Title IV of the PHS Act (Part H, Sec 498D), and addresses pediatric emergencies.²¹ The law authorizes pediatric emergency medical research to be carried out under the auspices of the ASPR based on the recommendations of the Institute of Medicine (IOM). Authorized for “such sums as may be necessary” through 2014, federal agencies such as the National Institutes of Health, CDC, HRSA, and others, would collaborate on pediatric emergency medicine and medical care systems.

The ACS also has supported funding for the Wakefield Emergency Medical Services for Children (EMSC) program, which awards grants to states and medical schools to expand and improve trauma and critical care emergency services for children.²⁷ ACA Section 5603 reauthorizes the program through 2015, with annual authorizations between $25 million and $30 million.²⁸ The ACS supports this program annually, signing on to letters to the House and Senate appropriators requesting full funding. Congress allocated $21 million to the program for FY 2013—a victory in the prevailing fiscal environment.

Surge capacity and preparedness

The ACS is very mindful of the gaps in the nation’s trauma and emergency care systems and the problems they create in the event of a natural or man-made disaster. In 2012, House Energy and Commerce Committee Chair Fred Upton (R-MI) and Ranking Member Henry Waxman (D-CA) submitted a letter to the Government Accountability Office requesting an assessment of the surge capacity within the health care systems, their ability to handle mass casualties, the impact of federal grant programs on preparedness, and gaps in data collection related to the adequacy of these systems.²⁹ Additionally, the ACS-drafted letter to HHS Secretary Sebelius included a request to address the current surge capacity and preparedness in hospitals in the event of a catastrophe, and HHS efforts to ensure preparation for mass-casualty scenarios apart from bioterrorism.²⁶ The Secretary responded that the ASPR Hospital Preparedness Program provided $350 million in 2012 to states to strengthen their ability to respond to mass-casualty events; however, it is unclear whether these funds were disbursed for states to use in the development of trauma systems.

Implications of losing authorization

The lack of regionalized trauma systems was considered a major weakness in the preparation for and response to the 2008 Mexican Hat mass-casualty incident. An IOM workshop assessed this event, as well as a flood disaster in Arkansas in 2010 resulting in 20 fatalities. Based on this assessment, the IOM  concluded that there was a need for availability of regionalized trauma centers, a multistate response system, the ability to track patients, and enhanced communications to overcome the challenges of emergency care, particularly regarding events of this nature.¹ A recent article published in the Journal of the American Medical Association cites preparedness, including drills, command training, and communication improvements, as some of the factors contributing to the successful response to the Boston Marathon bombings in 2013.³⁰ The trauma programs in the ACA are geared toward addressing these shortfalls where they exist.

Unfortunately, these programs are in danger of losing authorization in the coming years. Some members of Congress view programs that have been unfunded during a period of authorization as nonessential and are unlikely to reauthorize them. Failure to reauthorize these programs would be a wasted opportunity to strengthen and improve trauma care and trauma systems nationwide. The table on this page outlines the years for which authorization for each of the trauma programs described will expire. The lack of appropriations has prevented these programs from being used and proving their value with data and success stories in recent years. The current level of bipartisan bickering is also an obstacle to reauthorization of these programs.

The ACS and other members of the trauma community will continue to lobby for appropriations for the programs in their last year and for their reauthorization. In Washington, DC, the goal is to achieve consensus among representatives on both sides of the ACA debate regarding the value of these programs. Hearing from constituents has the greatest effect on policymakers, and ACS Fellows can make an impact by delivering messages supporting these programs to their elected officials.

A new effort is also under way to provide local stories highlighting the necessity of trauma systems to representatives. For example, various stakeholders in Texas have decided to undergo an ACS COT-led region-by-region review of its trauma systems and capacity. The results from this review, particularly any major shortfalls, will be presented to policymakers at both the state and federal levels. It is anticipated that by updating elected officials on the status of trauma in their districts and educating them on the programs that exist to address shortfalls, trauma care will gain a new group of champions who will advocate for the reauthorization and funding of these programs. Currently, Texas has two strong champions of trauma care—Representatives Burgess and Green. The ACS is working closely with these legislators to increase support of these programs. If the Texas model proves effective, this effort could be replicated in other states.

There are drawbacks to this region-by-region review strategy. It is time-consuming, the results are unpredictable, and it requires grassroots involvement and advocacy from local surgeons, hospitals, emergency medical services, and patients. However, this type of concerted effort may be the best chance to obtain critical funding for trauma centers and to develop statewide trauma systems to ensure that every individual in the country has access to appropriate and timely trauma care.

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References

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18. Trauma Care Systems Planning and Development Act of 1990. H.R. 1602 (101st). Available at: https://www.govtrack.us/congress/bills/101/hr1602/text. Accessed January 5, 2014.
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23. Patient Protection and Affordable Care Act. § 3505. 2010. Available at: http://en.wikisource.org/wiki/Patient_Protection_and_Affordable_Care_Act/Title_III/Subtitle_F. Accessed January 5, 2014.
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25. Members of U.S. Congress. Letter to Dennis Rehberg, Chairman, Subcommittee on Labor, Health and Human Services and Education, Committee on Appropriations, and Rosa DeLauro, ranking member, Subcommittee on Labor, Health and Human Services and Education, Committee on Appropriations. March 2012. Available at: http://www.facs.org/ahp/trauma/trauma031912.pdf. Accessed February 25, 2014.
26. Reed J, Murray P. Letter to Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services. April 2012. Available at: https://media.gractions.com/C91C8991062AAE070AEA00309C178DDE1D72FBA6/56dc3296-31ae-440b-b8df-af6078e3d99c.pdf. Accessed February 25, 2014.
27. American College of Surgeons. Letter to Dennis Rehberg, Chairman, Subcommittee on Labor, Health and Human Services and Education, Committee on Appropriations, and Rosa DeLauro, ranking member, Subcommittee on Labor, Health and Human Services and Education, Committee on Appropriations. March 2012. http://www.facs.org/ahp/trauma/emsc032012.pdf. Accessed February 25, 2014.
28. Patient Protection and Affordable Care Act. § 5603. 2010. Available at: http://en.wikisource.org/wiki/Patient_Protection_and_Affordable_Care_Act/Title_V. Accessed January 5, 2014.
29. Upton F, Waxman H. Letter to the Honorable Gene L. Dodaro, Comptroller General of the U.S. Government Accountability Office. January 17, 2012. Available at: http://www.facs.org/ahp/trauma/gao-trauma0312.pdf. Accessed January 5, 2014.
30. Walls RM, Zinner MJ. The Boston Marathon response: Why did it work so well? JAMA. 2013;309(23):2441-2442.