Advancing Trauma Systems in the United States: Bridging Disparities Through State‐Level Legislation and a Health Systems Approach
本文评述美国创伤系统的不足，提出通过州级立法和卫生系统方法减少城乡及人群间的创伤护理差距，改善分诊、劳动力、数据整合和康复连续性。
Traumatic injury is a leading cause of death and disability across all age groups in the United States, yet major gaps persist in the provision and coordination of trauma care [1]. The National Safety Council estimates an economic burden of US $1.3 trillion per year in direct medical costs, work-loss, and quality-of-life decrements, while CDC modeling places the broader societal cost of injury at US $4.2 trillion [2, 3]. Survival after severe injury can depend on where the patient is located. County-level analyses show the risk of prehospital trauma death is 25% higher in small fringe-metropolitan counties and 69% higher in rural non-core counties than in large metropolitan cores [4], and trauma patients from rural communities are 14% more likely to die from their injuries compared to urban residents [5]. Rural communities already face recorded disparities in access to care and poorer health outcomes; for example, the natural-cause mortality (NCM), defined as stemming from disease-related deaths, for the working age population (25–54 years) in rural areas is 43% higher than their urban/metropolitan counterparts [6]. National estimates indicate that under-triage remains widespread: almost one-half of trauma patients who ultimately die in the emergency department arrive at non-trauma centers, including 86% of rural cases and 36% of urban cases, showcasing some of the stark geographic gaps in access to definitive care [7]. Contemporary registry data corroborate the problem, showing that one in five injured patients whose injuries truly warrant a full trauma team activation still only receive a limited response, with under-triage rates differing across trauma center levels and patient demographics [8]. Nearly 20 years since trauma centers were established as the best source of care for critically injured patients [9], and 10 years after the National Academies of Science, Engineering, and Medicine called for a robust national trauma system, disparities in trauma outcomes continue to plague many states and vulnerable populations [10]. These disparities are exacerbated by uneven legislation, variable funding for local emergency medical services (EMS), and persistently high rates of under- and over-triage [11, 12]. A health systems approach, combined with responsive legislation at all levels of government, is essential to address these deficiencies. State-level legislation, in particular, has the potential to play an important role in complementing federal legislation, especially at times when federal priorities may be structurally misaligned with the needs of different regions. In this commentary, we (i) synthesize where US trauma systems underperform, (ii) situate those gaps against international experience and US trends, and (iii) propose concrete, state-led legislative levers, paired with federal catalysts and public reporting, to reduce under- and over-triage, strengthen the EMS workforce, integrate data, and extend the trauma continuum into rehabilitation. Many states now enshrine trauma center designation in statute, but the substance of those statutes diverges sharply (Table 1). While some define levels of care by American College of Surgeons verification criteria, others designate using seemingly arbitrarily defined levels or leave designation to individual hospitals. Thirty-two states provide no funding to designated trauma hospitals for readiness or uncompensated care costs [13]. In states where fiscal support is weak, the predictable result is a patchwork of trauma care systems in which Level I centers cluster around affluent urban corridors while entire rural regions may lack 24-h surgical coverage. Although a growing number of states now characterize emergency medical services as “essential,” the statutory meaning of that term remains contested, which produces material consequences for financing and oversight. A current National Conference of State Legislatures analysis finds that, as of June 27, 2025, at least 21 states and the District of Columbia have enacted laws explicitly defining EMS as essential, yet the accompanying duties, funding guarantees, and minimum service standards differ markedly across jurisdictions [14]. Some states provide only a declaration without earmarked revenue or enforceable readiness requirements, while others avoid the “essential” label but impose concrete planning or service mandates and, in some cases, authorize dedicated funding streams or taxing authority. Iowa, for example, permits counties to declare EMS essential and to secure voter-approved surtaxes or property levies to support implementation; North Carolina requires every county to ensure access to EMS and empowers counties to regulate franchise numbers, service areas, and rates; and California compels local agencies to submit comprehensive EMS plans addressing manpower, communications, transport, data collection, and disaster response [14]. These heterogeneities complicate regionalization and lead to the paradox that a state may “count” as essential in name without stable financing, while another delivers enforceable coverage standards without the label. A coherent state-level approach should therefore define the obligation, specify minimum coverage and response benchmarks, and tie the designation to predictable funding and transparent reporting. Regional trauma care is predicated on timely patient access to appropriate resources [15]. However, rural areas frequently have limited prehospital resources, protracted transport times, and fewer trauma centers. Existing needs-based assessment tools sometimes recommend adding centers in these sparsely populated areas, but financial and workforce constraints often persist [16]. In contrast, some large urban areas may harbor an overabundance of trauma centers—raising concerns about dilution of expertise and competition rather than cooperation. Recognizing that one size does not fit all, system-wide metrics and a unified yet flexible national research and policy framework are required to improve resource allocation. Data silos reinforce these disparities. Unlike national stroke and myocardial-infarction registries, most state trauma registries are housed in departments of transportation or public safety, collect incompatible variables, and either prohibit or price-gate data sharing across borders. Researchers attempting to link prehospital run sheets with inpatient outcomes often negotiate separate data use agreements for each county or state, a logistical barrier that has stymied large-scale effectiveness studies. The absence of routine linkage to rehabilitation or physician-fee datasets means that policymakers may still judge system performance by in-hospital mortality alone, ignoring long-term disability that accounts for injury-related economic loss. State legislation plays an important role in shaping trauma system funding, data collection, and oversight. States differ widely in their regulatory definitions, EMS oversight agencies, and processes for designating trauma centers [17]. This generates confusion for patients and EMS providers, and perpetuates misalignment of local, state, and federal policies. Addressing these gaps requires coordinated legislative action targeting multiple levels of a health system. Stable funding streams for trauma system infrastructure, robust data repositories, EMS workforce development, and evidence-based triage guidelines are needed. Legislation should incorporate accountability measures where states commit to transparent monitoring of metrics such as under-triage, timely transport of severely injured patients, and interfacility transfer patterns. Disparities among older adults are especially concerning as panel studies reveal that older patients remain disproportionately under-triaged, sometimes because standard physiologic cut-points (e.g., blood pressure, Glasgow Coma Scale thresholds) lack sensitivity for frail or anticoagulated older adults [18]. A national Medicare study reports that almost half (46%) of severely injured adults aged 65 years or older are under-triaged to non-trauma centers [19]. Field triage guidelines, as recommended by the CDC, now contain some modifications for older adults, but real-world under-triage rates remain substantial [11]. Legislating mandatory statewide data integration and adoption of age-specific triage criteria could help. Yet many trauma surgeons caution that simply lowering the thresholds risks swinging the pendulum toward over-triage: broad age-based triggers can relocate older people with low-severity injuries away from family supports, lengthen transport times, and inflate costs without a proven survival benefit. An emerging view therefore is not to send every older adult to a Level I center, but rather to adopt nuanced, age-specific triage algorithms that incorporate frailty indices, anticoagulation status, and mechanism of injury. A 100% catch rate for major injury remains the goal, but it must be balanced against the harms of unnecessary transfer. Legislative frameworks could encourage telemedicine and remote consultation to support rural EMS providers. Many states' usage of teletrauma has been associated with rural location, and North Dakota, South Dakota, and Arkansas all serve as examples of high rates of reported teletrauma usage [20]. By focusing legislative priorities on coverage for time-critical procedures and trauma center readiness, policymakers could tangibly reduce disparities for older and rural populations. Several states offer operational models to consider looking at: North Carolina's county-level EMS obligations with franchising authority (though it is being partly phased out), and California's statewide planning, trauma registry, and annual EMS performance reporting, attempt to translate statutory intent into enforceable coverage standards and transparent metrics. Workforce capacity is another important limiting factor. Preliminary interviews our group conducted with regional stakeholders point to certain themes: chronic EMS staffing shortages, especially in rural regions, driven by limited professional-development opportunities and stark benefit disparities. Unlike fire and police personnel who can retire after 20 years, paramedics in many states must serve 30 years to receive comparable pensions, and salaries seldom keep pace with those of other public-safety roles. Turnover erodes local expertise just as more sophisticated geriatric triage tools demand higher clinical judgment. Legislation that couples trauma-system funding to competitive EMS wages, tuition assistance, and paid continuing-education stipends, while harmonizing retirement benefits with other first-responder services, would strengthen the human infrastructure needed to deliver equitable trauma care. Providers are also often compelled to make triage decisions amid high rates of ED boarding and crowding (especially since the COVID-19 pandemic), which can degrade the nature of clinical encounters and can be associated with delays and error, especially for patients who self-present rather than arrive by EMS [21, 22]. Incorporating ED boarding time into trauma system metrics, and funding hospital-wide flow solutions, not just ED operations, should be part of the legislative package. A second area of legislative focus lies in post-injury disability and rehabilitation. Too often trauma care policy centers on in-hospital mortality, ignoring functional recovery, mental health, and long-term impacts on quality of life [23]. Data linkages that follow patients after discharge (EMS through acute care and rehabilitation) remain incomplete in many systems. Funding for integrated data systems and mandatory reporting, akin to state-level databases used in stroke or ST-elevation myocardial infarction (STEMI) registries, would help measure outcomes beyond survival. This approach would align with the National Academies of Sciences, Engineering, and Medicine 2016 recommendation to build a national trauma learning health system spanning prehospital, hospital, and rehabilitation phases [9]. Mass casualty incidents showcase the limitations found in current trauma systems. Events ranging from natural disasters to mass shootings strain capacity and reveal fragmented or inadequate planning. Legislative initiatives that formalize and fund robust regional preparedness, with the capacity to rapidly shift resources or coordinate multi-agency responses, could be transformative [24]. These initiatives should include consensus-based operational plans, scalable telemedicine platforms, and refined triage strategies for large-scale incidents. Dedicated, performance-tied financing offers an empirical signal of success. Texas channels revenue from traffic-violation surcharges into the Designated Trauma Facility and EMS Account (Fund 5111). In July 2024, the Department of State Health Services disbursed US $8.74 million from this account to 290 eligible designated trauma hospitals under the FY 2024 Uncompensated Trauma Care allocation, using the statutory formula that awards 15% of available funds equally and 85% in proportion to each hospital's reported unreimbursed trauma charges [25]. The Maryland Trauma Physician Services Fund, financed by a US $5 surcharge on every motor-vehicle registration and renewal, disbursed about US $11.6 million in FY 2023, the great majority of which went to on-call and standby stipends, with the balance covering uncompensated-care and Medicaid supplemental payments to trauma physicians [26]. Attempts to replicate the model elsewhere sometimes founder on the details of the design and its implementation; they may fail if the state legislature strips accountability clauses, if eligibility and distribution formulas are not tied to readiness or unreimbursed trauma care, and might prompt rural legislators to question value for money. Pre-hospital innovation can thrive when statutes uncouple revenue from transport. In Arizona, that decoupling now rests on two complementary mechanisms. First, the state's Treat and Refer Recognition Program authorizes certified EMS agencies to bill Medicaid about US $252 (code A0998 with the “CG” modifier) when a 911 call ends in treatment-in-place or a telehealth-guided hand-off rather than transport to an emergency department [27]. Second, Arizona's Medicaid agency (AHCCCS) joined the CMS Emergency Triage, Treat, and Transport (ET3) model in October 2021, extending equivalent reimbursement to alternate-destination transports such as urgent-care clinics. The official ET3 policy goals emphasize trimming unnecessary ambulance runs, freeing crews for high-acuity events, and lowering system costs without requiring prior authorization, thereby turning clinical discretion, rather than mileage, into the basis for payment [28]. Experience at the federal level has been more nuanced: in CMS's ET3 model, most treatment-in-place encounters were handled through on-scene tele-consults and, while short-term mortality matched that of similar low-acuity ambulance patients taken to emergency departments, 5-day hospital-admission rates were modestly higher; the program's reach was also blunted by COVID-19-era start-up delays, workforce constraints and partner unfamiliarity with the new pathways [29]. Teletrauma has matured from a proof-of-concept into a plausible system lever for achieving parity among rural and urban areas, but its adoption trails other telehealth uses and remains uneven. In a national survey of more than 4500 emergency departments, only 8.4% reported using teletrauma in 2020, despite far higher uptake of other telehealth services and despite strong associations with rural location and critical-access status, which implies that the sites with the greatest need are adopting yet still at low absolute rates [20]. Real-time trauma consultation can also potentially reduce avoidable transfers, conserve capacity at Levels I and II centers, and accelerate transfers of critical cases when needed, all the while to costs without in-hospital mortality Many have for the of teletrauma as a for the of who lack timely access to Levels I and II while that reimbursement and data are for robust and these States can to teletrauma by a of coverage regional plans, by requiring parity of emergency by through in and and by teletrauma encounters into statewide trauma registries that under- and over-triage metrics triage as as transfer. a transfer is more as the COVID-19 capacity constraints have in many regions, patients to in and as national analyses transfer access and disparities in transfer and mortality transfer rates and in public reporting, and explicitly in decisions in could also help align with the of capacity and health a of trauma systems beyond the example, in a cluster of public the about fewer per per fewer per with a in quality of life and a thresholds EMS and its associated In another was associated with care higher of of services, and fewer to long-term care and through of such While these studies were conducted in among older adults, the mechanism of avoidable and ED EMS and ED capacity for time-critical is that could for use cases and and linkage of encounters to trauma registries and to on transfers, and functional has benefits in a capacity a matched of patients with acute myocardial or chronic a was associated with fewer at and fewer emergency department the and costs, with no reported a policy states can formalize trauma system plans, authorize payment for and and linkage of encounters to state trauma registries and datasets that functional and outcomes are beyond the should coverage with such as discharge after major or where risk and to care support are likely to translate into benefits for patients and for EMS is often the that can improve survival example, after established regional Trauma with ambulance to Trauma the system patients at care, and adoption of and by by a in of survival for severe injury and a of benefit of per patients each In the of an statewide trauma system with prehospital to Trauma Services was associated with substantial mortality with similar in trauma and injury and in the regionalization of trauma care functional outcomes among major trauma for those at Level I Trauma Services In a of adults at Level trauma centers inpatient mortality from to an to in while from to with mortality in and and in and In the United States, while patient outcomes may be for those at trauma centers (especially when more the absence of a unified national system and rural gaps have been uneven. can accelerate state action without to has for trauma systems (e.g., the Trauma and of Emergency Care and trauma the and and full funding through could on state adoption of standards (e.g., data geriatric triage transfer akin to other health offer a to some of the minimum standards of care while design to can also be used to some to the emergency care states federal could an annual trauma system with such as under- and over-triage transfer rates for ED boarding time for trauma patients, and to functional Several states already and annual reports (e.g., California statewide Trauma annual is some to this In with these to address some of the concerns data it is that states could and trauma registry a state data that linkage across EMS discharge trauma registries, and a trauma system transfer times, ED boarding for and functional and requiring as a of Several states of this (e.g., California statewide annual and funding state consultation reports that explicitly and transfer A evidence-based trauma system requires at the state and federal levels to address stemming from or natural cause may also be when as severe a focus on research to its (Table legislation at the state data geriatric and rural triage integrated research and mass casualty readiness, offers a these through a health systems approach be essential to reduce resource allocation, and care across the trauma The have to The declare no of Data sharing not to this as no datasets were or the current