I 

111TH CONGRESS 

1ST SESSION H. R. 936 

To ensure the continued and future availability of lifesaving trauma health 

care in the United States and to prevent further trauma center closures 

and downgrades by assisting trauma centers with uncompensated care 

costs, core mission services, emergency needs, and information technology. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 10, 2009 

Mr. TOWNS (for himself, Mr. BURGESS, Ms. CASTOR of Florida, Mrs. 

BLACKBURN, Mr. HONDA, Mr. WU, and Mr. GRIJALVA) introduced the 

following bill; which was referred to the Committee on Energy and Commerce 

A BILL 

To ensure the continued and future availability of lifesaving 

trauma health care in the United States and to prevent 

further trauma center closures and downgrades by assisting trauma centers with uncompensated care costs, core 

mission services, emergency needs, and information technology. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘National Trauma Cen5 ter Stabilization Act of 2009’’. 


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1 SEC. 2. FINDINGS. 

2 The Congress finds the following: 

3 (1) Victims of traumatic injury should have ac4 cess to lifesaving care regardless of their geographic 

5 location or ability to pay. Major multisystem trauma 

6 victims receiving care within the first hour following 

7 their injury are substantially more likely to survive. 

8 (2) Maintaining a strong and effective trauma 

9 care system for all victims of traumatic injury re10 quires the availability of a sufficient number of trau11 ma centers at appropriate levels of trauma care ca12 pability in all geographic regions of the Nation. 

13 (3) Regional trauma centers annually treat 

14 678,000 patients, regardless of their ability to pay. 

15 When a trauma victim cannot afford treatment, the 

16 trauma center pays for care that may save the vic17 tim’s life. 

18 (4) The cost of delivering trauma care has 

19 steadily increased during the last decade. Trauma 

20 centers collectively have accrued $230,000,000 per 

21 year in losses for treating victims who are uninsured 

22 or whose care is reimbursed well below the cost of 

23 providing care, putting the Nation’s trauma care 

24 system at-risk. 

25 (5) Substantial uncompensated care costs are 

26 distressing trauma centers and threatening the availVerDate Nov 24 2008 22:25 Feb 13, 2009 Jkt 079200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\H936.IH H936

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1 ability of lifesaving trauma services in numerous 

2 areas across the Nation. Since 2000, 19 hospitals 

3 have closed their trauma centers, and 10 others have 

4 downgraded their trauma service by 1 or 2 levels. 

5 (6) At a time when the threat of mass emer6 gencies is high, financial pressures are placing trau7 ma centers at serious risk. Trauma centers are re8 quired to respond to mass emergencies including 

9 natural disasters, large-scale accidents, and terrorist 

10 attacks. Trauma centers maintain a constant state 

11 of readiness to serve distressed victims. Trauma cen12 ters must also maintain additional capacity and 

13 strong health care facility connections with the local 

14 and regional emergency care community to serve 

15 their regions. 

16 (7) Many trauma centers lack information tech17 nology that could improve the efficiency and effec18 tiveness of trauma care delivery and decrease the 

19 costs of providing care by facilitating patient track20 ing and information flow, and strengthening patient 

21 information sharing within the trauma center and 

22 coordination among other health care providers. 

23 Connecting trauma care centers using health infor24 mation technology is a part of the efforts to make 


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1 health information technology available especially in 

2 medically underserved communities. 

3 SEC. 3. GRANTS FOR CERTAIN TRAUMA CENTERS. 

4 (a) GRANTS FOR CERTAIN TRAUMA CENTERS.—Sec5 tion 1241 of the Public Health Service Act (42 U.S.C. 

6 300d–41) is amended to read as follows: 

7 ‘‘SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS. 

8 ‘‘(a) IN GENERAL.—The Secretary shall establish 4 

9 programs to award grants to trauma centers meeting the 

10 qualifications described in subsection (b). Of the 4 pro11 grams— 

12 ‘‘(1) one shall be for grants to assist in defray13 ing substantial uncompensated care costs; 

14 ‘‘(2) one shall be for grants to further the core 

15 mission of the trauma center, including by defraying 

16 costs associated with patient stabilization and trans17 fer, trauma education and outreach, coordination 

18 with local and regional trauma systems, and essen19 tial personnel and other fixed costs; 

20 ‘‘(3) one shall be for grants to provide emer21 gency relief to ensure continued and future avail22 ability of trauma service by— 

23 ‘‘(A) trauma centers at risk of closing or 

24 losing capacity to deliver trauma care; 


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1 ‘‘(B) centers operating in an area where a 

2 closing or loss of trauma service availability has 

3 occurred within their primary service area; or 

4 ‘‘(C) centers in need of financial assistance 

5 after the area in which they are located is af6 fected by a natural disaster or other cata7 strophic event, such as a terrorist attack; and 

8 ‘‘(4) one shall be for grants to support the de9 velopment and maintenance of innovative informa10 tion technology systems, including through the use 

11 of electronic health records and by facilitating the 

12 interconnection of trauma care facilities (including 

13 Internet-based connectivity) with other local and re14 gional health facilities, for the purpose of— 

15 ‘‘(A) improving information sharing and 

16 coordination between trauma centers, ambu17 lances, helicopters, and other health care pro18 viders, such as physician practitioners, commu19 nity health centers, and rehabilitation facilities, 

20 to facilitate continuity of care for trauma pa21 tients throughout their recovery; and 

22 ‘‘(B) improving patient tracking and infor23 mation flow within trauma centers and between 

24 health facilities (including developing, updating, 

25 and maintaining databases) to improve the 


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1 overall delivery of trauma care and community 

2 health care. 

3 ‘‘(b) MINIMUM QUALIFICATIONS OF CENTERS.— 

4 ‘‘(1) PARTICIPATION IN TRAUMA CARE SYSTEM

5 OPERATING UNDER CERTAIN PROFESSIONAL GUIDE6 LINES.—Subject to paragraph (2), the Secretary 

7 may not make a grant under subsection (a) unless 

8 the trauma center involved is a participant in a sys9 tem that— 

10 ‘‘(A) provides comprehensive medical care 

11 to victims of trauma in the geographic area in 

12 which the trauma center is located; 

13 ‘‘(B) is established by the State or political 

14 subdivision in which such center is located; and 

15 ‘‘(C) has either adopted State guidelines 

16 for the designation of trauma centers, and for 

17 triage, transfer, and transportation policies, or 

18 adopted guidelines equivalent to (or more pro19 tective than) the applicable trauma care des20 ignated guidelines developed by the American 

21 College of Surgeons or utilized in the model 

22 plan established under section 1213(c). 

23 ‘‘(2) EXCEPTION.—The requirements of para24 graph (1) do not apply with respect to a trauma cenVerDate Nov 24 2008 22:25 Feb 13, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H936.IH H936

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1 ter located in a State with no existing trauma care 

2 system described in such paragraph. 

3 ‘‘(3) PUBLIC OR NONPROFIT STATUS.—The 

4 Secretary may not make a grant under paragraph 

5 (1), (2), or (4) of subsection (a) unless the trauma 

6 center involved is a public or nonprofit entity. 

7 ‘‘(4) LEVELS OF CARE.—The Secretary may 

8 not make a grant under subsection (a)(1) (relating 

9 to uncompensated care costs) unless the trauma cen10 ter demonstrates to the Secretary’s satisfaction at 

11 least one of the following: 

12 ‘‘(A) At least 20 percent of the visits in 

13 the emergency department of the hospital in 

14 which the trauma center is located are ones for 

15 which there is no insurance coverage or other 

16 third-party payment. 

17 ‘‘(B) At least 40 percent of the visits in 

18 such emergency department are ones for which 

19 there either is no such coverage or payment or 

20 for which such coverage or payment is provided 

21 only under the Medicaid program under title 

22 XIX of the Social Security Act. 

23 ‘‘(C) The average annual uncompensated 

24 care costs in such hospital that are attributable 

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1 erage or other third-party payment is at least 

2 $5,000,000 during each of the 3 most recent 

3 fiscal years before the first fiscal year for which 

4 the center is applying for the grant. 

5 ‘‘(D) The trauma center qualifies for funds 

6 under a low-income pool or safety net care pool 

7 established through a waiver approved under 

8 section 1115 of the Social Security Act. 

9 ‘‘(c) SUBMISSION AND APPROVAL OF LONG-TERM

10 PLAN.—The Secretary may not make a grant under sub11 section (a)(1) of this section unless the trauma center in12 volved— 

13 ‘‘(1) submits to the Secretary a plan satisfac14 tory to the Secretary that— 

15 ‘‘(A) is developed on the assumption that 

16 the center will continue to incur substantial un17 compensated care costs in providing trauma 

18 care; 

19 ‘‘(B) provides for the long-term continued 

20 operation of the center at similar or greater lev21 els of medical care than in prior years notwith22 standing such uncompensated care costs; 

23 ‘‘(2) agrees to implement the plan according to 

24 a schedule approved by the Secretary; and 


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1 ‘‘(3) demonstrates that such center has policies 

2 in place— 

3 ‘‘(A) to assist patients who cannot pay for 

4 all or part of the care they received, including 

5 a sliding fee scale; and 

6 ‘‘(B) to ensure fair billing and collection 

7 practices.’’. 

8 (b) PREFERENCES IN MAKING GRANTS.—Section 

9 1242 of the Public Health Service Act (42 U.S.C. 300d– 

10 42) is amended to read as follows: 

11 ‘‘SEC. 1242. PREFERENCE IN MAKING GRANTS. 

12 ‘‘(a) SUBSTANTIAL UNCOMPENSATED CARE

13 COSTS.—In making grants under section 1241(a)(1), the 

14 Secretary shall— 

15 ‘‘(1) reserve 95 percent of the amounts allo16 cated pursuant to subsections (b)(1) and (c) of sec17 tion 1246 for grants to level I and level II trauma 

18 centers; 

19 ‘‘(2) reserve 5 percent of the amounts allocated 

20 pursuant to subsections (b)(1) and (c) of section 

21 1246 for grants to level III and level IV trauma cen22 ters; 

23 ‘‘(3) if there are not sufficient qualifying cen24 ters to obligate the 95 percent reservation in para25 graph (1) or the 5 percent reservation in paragraph 


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1 (2), reallocate the funds for grants under section 

2 1241(a)(1) to other qualifying centers; and 

3 ‘‘(4) subject to paragraphs (1), (2), and (3), en4 sure that funding for grants under section 

5 1241(a)(1) is divided equally among qualified appli6 cants. 

7 ‘‘(b) CORE MISSION.—In making grants under sec8 tion 1241(a)(2), the Secretary shall— 

9 ‘‘(1) reserve 25 percent of the amount allocated 

10 pursuant to section 1246(b)(2) for grants to level III 

11 and level IV trauma centers, but shall reallocate the 

12 funds to level I and level II centers if there are not 

13 sufficient qualifying level III and IV centers to obli14 gate the 25 percent set-aside; and 

15 ‘‘(2) give preference to— 

16 ‘‘(A) any application made by a trauma 

17 center in a geographic area where growth in de18 mand for trauma services exceeds capacity, as 

19 determined by the Secretary based on such fac20 tors as local and regional population trends, 

21 loss or downgrading of neighborhood trauma 

22 centers, loss or reduction of physician trauma 

23 specialty availability, high malpractice liability 

24 costs, or the necessity to provide physician on25 call pay; or 


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1 ‘‘(B) any application made by a trauma 

2 center which demonstrates State or political 

3 subdivision financial support. 

4 For any of the purposes specified in section 

5 1241(a)(2) for each fiscal year during which pay6 ments are made to the center from the grant, such 

7 financial support may be demonstrated by, but is 

8 not limited to, State or political subdivision funding 

9 for the trauma center’s capital or operating expenses 

10 including through State trauma regional advisory co11 ordination activities or Medicaid funding under title 

12 XIX of the Social Security Act designated for trau13 ma services, or other governmental funding. State 

14 funding derived from Federal support provided 

15 through the Trauma Systems Planning Grants pro16 vided to States or political subdivisions does not con17 stitute State or local financial support for purposes 

18 of preferential treatment under this section. 

19 ‘‘(c) EMERGENCY RELIEF.—In making grants under 

20 section 1241(a)(3), the Secretary— 

21 ‘‘(1) shall give preference to any application 

22 made by a trauma center that— 

23 ‘‘(A) is providing trauma care in a geo24 graphic area in which the availability of trauma 

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1 sult of a trauma center in the area permanently 

2 ceasing participation in such system as of the 

3 date on which the application is submitted, or 

4 where growth in demand for trauma services 

5 exceeds capacity, as determined by the Sec6 retary based on such factors as local and re7 gional population trends, loss or downgrading of 

8 neighboring trauma centers, loss or reduction of 

9 physician specialty availability, high malpractice 

10 liability costs, or the necessity to provide physi11 cian on-call pay; 

12 ‘‘(B) will, in providing trauma care during 

13 the 1-year period beginning on the date on 

14 which the application for the grant is sub15 mitted, incur uncompensated care costs in an 

16 amount rendering the center unable to continue 

17 participation in such system, resulting in a sig18 nificant decrease in the availability of trauma 

19 care in the geographic area; 

20 ‘‘(C) operates in a rural area where trau21 ma care availability will significantly decrease if 

22 the trauma center is forced to close or down23 grade service and uncompensated care costs are 

24 contributing to a likelihood of closure or down25 grade; or 


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1 ‘‘(D) the Secretary determines warrants fi2 nancial assistance if the trauma center is in a 

3 geographic location substantially affected by a 

4 natural disaster or other catastrophic event 

5 such as a terrorist attack; and 

6 ‘‘(2) shall reallocate any funds available for 

7 grants under section 1241(a)(3), but not awarded 

8 due to insufficient or a lack of qualified applications, 

9 to grants under section 1241(a)(1). 

10 ‘‘(d) INFORMATION TECHNOLOGY.—In making 

11 grants under section 1241(a)(4), the Secretary shall— 

12 ‘‘(1) make grants only to applicants who are eli13 gible to receive a grant under section 1241(a)(1); 

14 ‘‘(2) give preference to qualified applicants 

15 who— 

16 ‘‘(A) demonstrate the greatest financial 

17 need; and 

18 ‘‘(B) are level I or level II centers; and 

19 ‘‘(3) not make an award less than $1,000,000 

20 for a fiscal year unless such award would cover the 

21 full cost of an applicant’s proposed project. 

22 ‘‘(e) DESIGNATIONS OF LEVELS OF TRAUMA CEN23 TERS IN CERTAIN STATES.—In the case of a State which 

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1 ner described in this section, any reference in this section 

2 to— 

3 ‘‘(1) a level I or level II trauma center is 

4 deemed to be a reference to a trauma center within 

5 the highest two levels of trauma centers designated 

6 under State guidelines; and 

7 ‘‘(2) a level III or IV trauma center is deemed 

8 to be a reference to a trauma center not within such 

9 highest two levels.’’. 

10 (c) CERTAIN AGREEMENTS.—Section 1243 of the 

11 Public Health Service Act (42 U.S.C. 300d–43) is amend12 ed to read as follows: 

13 ‘‘SEC. 1243. CERTAIN AGREEMENTS. 

14 ‘‘(a) COMMITMENT REGARDING CONTINUED PAR15 TICIPATION IN TRAUMA CARE SYSTEM.—The Secretary 

16 may not make a grant under section 1241(a)(1) (relating 

17 to uncompensated care costs) unless the trauma center in18 volved agrees that— 

19 ‘‘(1) the center will continue participation in 

20 the system described in section 1241(b)(1), except 

21 as provided in section 1241(b)(2), throughout the 

22 grant period; and 

23 ‘‘(2) if the center violates the agreement made 

24 pursuant to paragraph (1), the center will be liable 


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1 to the United States for an amount equal to the sum 

2 of— 

3 ‘‘(A) the amount of assistance provided to 

4 the center under section 1241(a) for the fiscal 

5 year involved; and 

6 ‘‘(B) an amount representing interest on 

7 the amount specified in subparagraph (A). 

8 ‘‘(b) PERIOD OF CERTAIN GRANTS.—The period of 

9 a grant under section 1241(a)(3) (relating to emergency 

10 relief) shall be 3 fiscal years, except that the Secretary 

11 may waive the application of this subsection to a trauma 

12 center and authorize the center to receive payments under 

13 such section for 1 additional fiscal year. 

14 ‘‘(c) MAINTENANCE OF FINANCIAL SUPPORT.—With 

15 respect to activities for which a grant under section 1241 

16 is authorized to be expended, the Secretary may not make 

17 such a grant unless the trauma center involved agrees 

18 that, during the grant period, the center will maintain ac19 cess to trauma services at levels not less than the prior 

20 year, taking into account reasonable volume fluctuation 

21 not caused by— 

22 ‘‘(1) intentional trauma boundary reduction or 

23 downgrading of level; or 

24 ‘‘(2) diversion of services in excess of 5 percent. 


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1 ‘‘(d) SUPPLEMENT, NOT SUPPLANT.—The Secretary 

2 may not make a grant under section 1241 unless the trau3 ma center involved agrees that funds received through the 

4 grant will be used to supplement and not supplant funding 

5 otherwise available for the activities and costs described 

6 in such section. 

7 ‘‘(e) TRAUMA CARE REGISTRY.—The Secretary may 

8 not make a grant under section 1241(a) unless the trauma 

9 center involved agrees that— 

10 ‘‘(1) the center will— 

11 ‘‘(A) operate a registry of trauma cases in 

12 accordance with guidelines developed by the 

13 American College of Surgeons or similar guide14 lines applicable to the center in the State in15 volved; and 

16 ‘‘(B) begin operation of the registry not 

17 later than 6 months after the date on which the 

18 center submits to the Secretary the application 

19 for the grant; and 

20 ‘‘(2) in carrying out paragraph (1), the center 

21 will maintain information on the number of trauma 

22 cases treated by the center and, for each such case, 

23 the extent to which the center incurs uncompensated 

24 care costs in providing trauma care.’’. 


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1 (d) GENERAL PROVISIONS.—Section 1244 of the 

2 Public Health Service Act (42 U.S.C. 300d–44) is amend3 ed to read as follows: 

4 ‘‘SEC. 1244. GENERAL PROVISIONS. 

5 ‘‘(a) APPLICATION.—The Secretary may not make a 

6 grant under section 1241(a) unless an application for the 

7 grant is submitted to the Secretary and the application 

8 is in such form, is made in such manner, and contains 

9 such agreements, assurances, and information as the Sec10 retary determines to be necessary to carry out this part. 

11 ‘‘(b) LIMITATION ON AMOUNT OF GRANT.—The 

12 amount of a grant under section 1241 for a fiscal year 

13 may not exceed $2,000,000. 

14 ‘‘(c) ELIGIBILITY.—Receipt of or eligibility for a 

15 grant under any 1 of the 4 grant programs described in 

16 section 1241(a) shall not preclude a trauma center from 

17 receipt of or eligibility for a grant under any of the other 

18 programs described in such section. 

19 ‘‘(d) NOTICE OF ELIGIBILITY.—The Secretary shall 

20 annually determine and notify trauma centers of their eli21 gibility to receive a grant under section 1241. 

22 ‘‘(e) REPORT.—Beginning 2 years after the date of 

23 enactment of the National Trauma Center Stabilization 

24 Act of 2009, and every 2 years thereafter, the Secretary 

25 shall— 


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1 ‘‘(1) report to the Congress on the status of the 

2 grants made pursuant to section 1241; 

3 ‘‘(2) evaluate and report to the Congress on the 

4 overall financial stability of trauma centers in the 

5 United States; 

6 ‘‘(3) report on the populations using trauma 

7 care centers and include aggregate patient data on 

8 income, race, ethnicity, and geography; and 

9 ‘‘(4) evaluate the effectiveness and efficiency of 

10 trauma care center activities using standard public 

11 health measures and evaluation methodologies.’’. 

12 (e) DEFINITION.—Part D of title XII of the Public 

13 Health Service Act (42 U.S.C. 300d–41 et seq.) is amend14 ed— 

15 (1) by redesignating section 1245 as section 

16 1246; and 

17 (2) by inserting after section 1244 the fol18 lowing: 

19 ‘‘SEC. 1245. UNCOMPENSATED CARE COSTS DEFINED. 

20 ‘‘In this part, the term ‘uncompensated care costs’ 

21 means, with respect to a hospital, unreimbursed costs of 

22 the hospital from serving patients for which there is either 

23 no insurance coverage or other third-party payment or for 

24 which such coverage or payment is provided only under 

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1 rity Act, which are attributable to emergency care and 

2 trauma care in the hospital— 

3 ‘‘(1) including costs related to inpatient admis4 sions to the hospital subsequent to receiving such 

5 care in the hospital; and 

6 ‘‘(2) excluding payments under section 1923 of 

7 the Social Security Act.’’. 

8 (f) AUTHORIZATIONS OF APPROPRIATIONS.—Section 

9 1246 of the Public Health Service Act, as redesignated 

10 by subsection (e), is amended to read as follows: 

11 ‘‘SEC. 1246. AUTHORIZATIONS OF APPROPRIATIONS. 

12 ‘‘(a) IN GENERAL.—For the purpose of carrying out 

13 this part, there are authorized to be appropriated— 

14 ‘‘(1) with respect to grants under paragraphs 

15 (1), (2), and (3) of section 1241(a), $100,000,000 

16 for each of fiscal years 2010 through 2015; and 

17 ‘‘(2) with respect to grants under paragraph (4) 

18 of section 1241(a), $25,000,000 for each of fiscal 

19 years 2010 through 2015. 

20 Authorizations of appropriations pursuant to this section 

21 are in addition to any other authorizations of appropria22 tions available for carrying out this part. 

23 ‘‘(b) FUNDING DISTRIBUTION.—Of the amount ap24 propriated pursuant to subsection (a)(1) for a fiscal year, 

25 the Secretary shall reserve— 


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1 ‘‘(1) 70 percent for grants under section 

2 1241(a)(1) (relating to substantial uncompensated 

3 care costs); 

4 ‘‘(2) 20 percent for grants under section 

5 1241(a)(2) (relating to the core mission of a trauma 

6 center); and 

7 ‘‘(3) 10 percent for grants under section 

8 1241(a)(3) (relating to emergency relief). 

9 ‘‘(c) MINIMUM AMOUNT FOR SUBSTANTIAL UNCOM10 PENSATED CARE COSTS.—Notwithstanding subsection 

11 (b), if the amount appropriated pursuant to subsection 

12 (a)(1) for a fiscal year is less than $25,000,000, such 

13 amount shall be used exclusively for grants under section 

14 1241(a)(1).’’. 

15 (g) CONFORMING AMENDMENT.—The heading of 

16 part D of title XII of the Public Health Service Act (42 

17 U.S.C. 300d–41 et seq.) is amended to read as follows: 

18 ‘‘PART D—GRANTS FOR CERTAIN TRAUMA CENTERS’’. 

Æ 


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