Increasing financial strains are pushing Level I and II trauma centers to the point of breaking, according to a recent article on Grady Memorial Hospital— the only Level I trauma center serving Northern Georgia, which loses over $40 million a year on trauma care. The problem is simple: the trauma services rendered to the uninsured are uncompensated, and the revenue generated from treating the insured is not enough to cover the deficit. The solution is clear: we must cover all Americans to financially stabilize our trauma care services in this country.

In 2004, over 112,000 Americans died from unintentional injuries—such as car crashes and falls—and another 17,357 were victims of homicide. A 2003 survey in JAMA of trauma centers in the U.S. found that only 453 hospitals or about 10 percent of all hospitals were classified as a Level I or Level II trauma center and thus qualified to treat these life-threatening injuries on a 24/7 basis. While many hospitals carry designations that qualify them to treat patients with lesser injuries—such as broken legs and concussions—the Level I and II hospitals are a key community resource, and thus their peril warrants our serious concern.

Emergency care in the US is governed by the Emergency Medical Treatment and Active Labor Act (EMTALA). This legislation requires hospitals and doctors to treat patients judged to have a life threatening emergency, regardless of their ability to pay. Practically and ethically it could hardly be any other way. We all look alike covered in blood on a stretcher.

EMTALA means that trauma hospitals admit and treat all members of their community. In communities with a high percentage of uninsured, trauma hospitals lose money because the revenues from treatment of insured patients are not enough to offset the losses from the care of uninsured patients and the hospitals become financially unstable.

The predominant means of stabilizing the trauma system in states with a high percentage of uninsured is to provide dedicated funding for trauma care, as Georgia is now considering including $10 fee on auto registrations that would generate about $74 million a year. The financing of trauma care is complicated by the fact that about 20 percent of Level I and II trauma centers are public hospitals, and often are also academic teaching hospitals such as Grady Memorial Hospital.

Over the last decade, federal funds that supplement local funding of public hospitals have progressively declined. The budget submitted by President George W. Bush proposes to cut $25 billion in "disproportionate share" payments to hospitals serving predominantly poor patients and cut $23 billion more to teaching hospitals. These hospitals are already losing money, yet required by law (and a sense of what's right) to treat uninsured patients.

As long as there are 47 million uninsured in the United States, maintaining a stable trauma system will be a constant struggle. Coverage for all Americans is ultimately the only means of stablizing the financial staus of key emergency hospitals in the U.S. and thus stabilizing the system of emergency care.