Senator Eliot Shapleigh - El Paso, Texas

A hospital's emergency room is like a swelling river that carries whatever water its tributaries dump into it. As each tributary's flow increases, the river bears the burden until the riverbanks eventually flood.

Texas trauma centers and emergency rooms are overflowing, and it's time to take action to contain the flood. Among the tributaries: growing population, increasing number of uninsured residents, unabated illegal immigration and persistent misuse of these facilities for primary care.

Texas' population grew 18.5 percent while ER visits increased more than 30 percent in 1997-2005, according to a Texas Hospital Association survey. Because hospital beds grew just 4.3 percent during that period, ER hallways increasingly serve as bullpens for patients waiting for a vacancy elsewhere in the facility.

Trauma centers are a subset of ERs, with specialized resources and specially trained personnel to handle accident or assault victims. Paramedics are trained to determine whether injury victims should be delivered to a local ER or a trauma center. If you have a broken leg or broken rib, you're headed to an ER. If you have multiple fractures or a punctured lung, you are destined for a trauma center.

The long-running television show ER should really be called TC because it captures the split-second urgency of a Level I trauma center.

There are four levels of trauma centers, with Level I being the best equipped and Level II not far behind. Tarrant County's trauma centers -- John Peter Smith and Harris Methodist Fort Worth -- are Level II regional centers that serve 23 counties.

The THA survey reported that all of the state's Level I and II centers were at or above capacity. But it's not because of the trauma victims -- it's because of everyone else.

Only about 25 percent of the trauma-center patients are trauma victims. Many of the rest belong elsewhere, but they end up in the wrong place because of the federal Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986. The law requires trauma centers to treat any patient, regardless of citizenship or ability to pay.

The highest-level trauma centers generally are located in densely populated urban areas with high levels of uninsured patients with no primary care home. The saturation of trauma center resources by people seeking non-emergency care endangers lives, pure and simple.

The flooded banks are inevitable.

ER diversion -- meaning that facilities will not accept trauma cases at certain peak times when their load already exceeds capacity -- has become commonplace across the U.S., and especially in Texas. That costs precious time, inevitably increasing mortality.

A companion to the ER capacity problem is staffing shortages, exacerbated by the difficult working conditions and lack of adequate resources.

Several research studies have established that the uninsured -- and Texas is No. 1 in the nation in the percentage of its population in this category -- are disproportionate ER users.

Last year, the American College of Emergency Physicians graded each state on emergency medicine. Texas received mostly D's because it ranked near the bottom of the nation in several categories: state spending on hospital care; board-certified emergency physicians; registered nurses; and percentage of population with access to advanced-life-support ambulance services.

A 2000 study of four major Texas trauma hospitals -- Parkland in Dallas, Brackenridge in Austin, and Ben Taub and Memorial Hermann in Houston -- found that 42 to 57 percent of ER visits were non-emergency and treatable in a primary care setting. Two-thirds of those were uninsured or Medicaid patients, who have little or no capacity to pay.

All trauma centers and most ERs drain valuable hospital resources and make them less competitive with more lucrative specialty hospitals that do not have to carry these fixed costs.

Texas healthcare policy and tradition are complicit in all of this. The state has been reluctant to expand the insurance safety net to cover more low-income residents and only recently has agreed to increase Medicaid reimbursement under threat of legal sanctions. Funding for indigent care has been forced down to the county level through property taxes paid to hospital districts, and public hospitals are expected to pick up the slack.

The model falters, however, when county hospitals are compelled to accept out-of-county trauma patients who don't pay into the system.

For example, because Parkland is a Level I trauma center, about 10 percent of its trauma patients are not Dallas County residents. County taxpayers are understandably miffed about this. There has been talk of establishing a regional hospital district to address this, but the politics are too fractious for an imminent solution.

THA estimates the annual ER uncompensated tab to be about $200 million in Texas. Who pays for that? The standard practice in healthcare has been to shift the costs to those who are able to pay through higher hospital charges and health insurance premiums.

In 2003, the Texas Legislature started an ingenuous effort to help our trauma centers by creating a new sin tax called the Driver Responsibility Program (DRP). Drivers cited for various violations are required to pay surcharges on their fines, including those for such things as failure to maintain insurance or driving with an invalid license. The biggest hit is $1,000 for the first DWI conviction and $1,500 for the second. The money is intended to be split evenly between trauma centers and the state's highway funds.

The tax makes sense. The No. 1 cause of trauma is traffic accidents, with the cost of care averaging about $50,000 per patient. Texas has consistently led the nation in DWIs and alcohol-related crashes and is among the top three states in traffic deaths.

Unfortunately, the state is having trouble collecting the DRP funds. According to a Department of Public Safety report, less than a third of the $478.4 million generated by the program has been collected. The Senate recently passed legislation authorizing the use of collection agencies and creation of an installment-payment program to boost penalty recovery.

More significantly, the Legislature has not released $82 million in DRP funds for the past two fiscal years, consistent with the state government's misguided tradition of diverting or withholding designated funds.

The House Appropriations Committee passed an amendment in March fully funding trauma centers to the tune of $98 million annually for the next two years, but it remains to be seen whether the appropriation survives the House-Senate conference committee legislative cement mixer in the session's final hours.

Lillie Biggins, Harris Methodist Fort Worth vice president of operations, said the extra funding would allow the facility to acquire needed trauma technology and fill its specialized surgery vacancies.

"We need [financial] help, and we need it quickly," she said.

Ron Stutes, JPS Health Network chief operating officer, said the additional DRP funding would help offset the costs of its new trauma care tower, scheduled to open in January 2008.

Strengthening local trauma assets with designated funding is a no-brainer. Lives hang in the balance.