[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 733 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                 S. 733

 To ensure the continued and future availability of life saving 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, and emergency needs.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 26, 2009

  Mrs. Murray (for herself and Mr. Isakson) introduced the following 
  bill; which was read twice and referred to the Committee on Health, 
                     Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
 To ensure the continued and future availability of life saving 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, and emergency needs.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``National Trauma Center Stabilization 
Act of 2009''.

SEC. 2. FINDINGS.

    Congress makes the following findings:
            (1) Victims of traumatic injury should have access to 
        lifesaving care regardless of their geographic location or 
        ability to pay. Major multi-system trauma victims receiving 
        care within the first ``Golden Hour'' following their injury 
        are substantially more likely to survive.
            (2) Maintaining a strong and effective trauma care system 
        for all victims of traumatic injury requires the availability 
        of a sufficient number of trauma centers at appropriate levels 
        of trauma care capability in all geographic regions of the 
        United States.
            (3) Regional trauma centers annually treat 678,000 
        patients, regardless of their ability to pay. When a trauma 
        victim cannot afford treatment, the trauma center pays for care 
        that may save their life.
            (4) The cost of delivering trauma care has steadily 
        increased in the last decade. Trauma centers collectively have 
        incurred $230,000,000 per year in losses for treating victims 
        who are either uninsured or whose care is reimbursed well below 
        the cost of providing care.
            (5) Substantial uncompensated care costs are distressing 
        trauma centers and threatening the availability of life-saving 
        trauma services in numerous areas across the United States. 
        Since 2000, 20 hospitals have closed their trauma centers, and 
        13 others have downgraded their trauma service.
            (6) At a time when the threat of mass emergencies are high, 
        financial pressures are placing trauma centers at serious risk. 
        Trauma centers are required to respond to mass emergencies 
        including natural disasters, large scale accidents and 
        terrorist attacks. By their very nature, trauma centers 
        maintain a constant state of readiness, extra capacity, and 
        strong healthcare facility connections with the local and 
        regional emergency care community.
            (7) Medical liability exposure and its related costs have 
        contributed to the closing of trauma centers and downgrading of 
        trauma levels. It is important to find ways to minimize risk to 
        those who provide lifesaving care in those initial critical 
        hours following a trauma event.
            (8) The supply of trauma surgeons in the United States is 
        rapidly declining. Trauma fellowships are only 60 percent full.
            (9) There is a limited pipeline to replace retiring trauma 
        surgeons and surgical specialists. The average age of an 
        American College of Surgeons Fellow is 58 years and most 
        hospitals do not require trauma surgeons to take calls after 
        the age of 60.
            (10) A national survey of surgeons conducted by the Robert 
        Wood Johnson Foundation revealed that 50 percent of respondents 
        would abandon emergency calls if it were not mandated to 
        maintain staff privileges.
            (11) Increasing numbers of trauma centers are closing their 
        emergency departments or downgrading their trauma center 
        designation level due to factors that include a lack of access 
        to on-call specialists.
            (12) The lack of surgical availability is concentrating 
        trauma care in regional trauma centers as the only source of 
        surgical specialty care for hundreds of miles for patients 
        historically cared for in community trauma centers. This causes 
        a lack of surge capacity and results in an inability to accept 
        severely injured patients at the regional trauma center level.

                      TITLE I--TRAUMA CARE CENTERS

SEC. 101. GRANTS FOR TRAUMA CARE CENTERS.

    Section 1241 of the Public Health Service Act (42 U.S.C. 300d-41) 
is amended by striking subsections (a) and (b) and inserting the 
following:
    ``(a) In General.--The Secretary shall establish 3 programs to 
award grants to qualified public, non-profit, Indian Health Service, 
Indian tribal, and urban Indian trauma centers--
            ``(1) to assist in defraying substantial uncompensated care 
        costs as defined in section 1246;
            ``(2) to further their core missions, including by 
        addressing costs associated with patient stabilization and 
        transfer, trauma education and outreach, coordination with 
        local and regional trauma systems, and essential personnel and 
        other fixed costs; and
            ``(3) to provide emergency relief to ensure the continued 
        and future availability of trauma services by trauma centers at 
        risk of closing or centers operating in an area where a closing 
        has occurred within their primary service area.
    ``(b) Minimum Qualifications of Trauma Centers.--
            ``(1) Participation in trauma care system operating under 
        certain professional guidelines.--Subject to paragraph (2), the 
        Secretary may not award a grant to a trauma center under 
        subsection (a) unless the trauma center involved is a 
        participant in a trauma system that substantially complies with 
        section 1213.
            ``(2) Exemption.--Paragraph (1) shall not apply to trauma 
        centers that are located in States with no existing trauma care 
        system.
            ``(3) Qualification for substantial uncompensated care 
        costs.--The Secretary shall only award substantial 
        uncompensated care grants under subsection (a)(1) to trauma 
        centers meeting at least 1 of the criteria in 1 of the 
        following 3 categories:
                    ``(A) Category a.--The criteria for category A are 
                as follows:
                            ``(i) At least 50 percent of the visits in 
                        the emergency department of the hospital in 
                        which the trauma center is located were charity 
                        or self-pay patients.
                            ``(ii) At least 70 percent of the visits in 
                        such emergency department were Medicaid (title 
                        XIX of the Social Security Act) and charity and 
                        self-pay patients combined.
                    ``(B) Category b.--The criteria for category B are 
                as follows:
                            ``(i) At least 35 percent of the visits in 
                        such emergency department were charity or self-
                        pay patients.
                            ``(ii) At least 50 percent of the visits in 
                        such emergency department were Medicaid (title 
                        XIX of the Social Security Act) and charity and 
                        self-pay patients combined.
                    ``(C) Category c.--The criteria for category C are 
                as follows:
                            ``(i) At least 20 percent of the visits in 
                        such emergency department were charity or self-
                        pay patients.
                            ``(ii) At least 30 percent of the visits in 
                        such emergency department were Medicaid (title 
                        XIX of the Social Security Act) and charity and 
                        self pay patients combined.
            ``(4) Trauma centers in 1115 waiver states.--
        Notwithstanding paragraph (3), the Secretary may award a 
        substantial uncompensated care grant to a trauma center under 
        subsection (a)(1) if the trauma center qualifies for funds 
        under a Low Income Pool or Safety Net Care Pool established 
        through a waiver approved under section 1115 of the Social 
        Security Act.
            ``(5) Designation.--The Secretary may not award a grant to 
        a trauma center unless such trauma center is verified or 
        designated by the American College of Surgeons or an equivalent 
        State or local agency.
    ``(c) Additional Requirements.--The Secretary may not award a grant 
to a trauma center under subsection (a)(1) unless the trauma center 
involved--
            ``(1) submits to the Secretary a plan satisfactory to the 
        Secretary that--
                    ``(A) is developed on the assumption that the 
                center will continue to incur substantial uncompensated 
                costs in providing trauma care; and
                    ``(B) provides for the long-term continued 
                operation of the center at similar or greater levels of 
                medical care than in prior years notwithstanding such 
                substantial uncompensated costs;
            ``(2) agrees to implement the plan according to a schedule 
        approved by the Secretary; and
            ``(3) has policies in place to assist patients who cannot 
        pay for part or all of the care they receive, including a 
        sliding fee scale, and to ensure fair billing and collection 
        practices.''.

SEC. 102. CONSIDERATIONS IN MAKING GRANTS.

    Section 1242 of the Public Health Service Act (42 U.S.C. 300d-42) 
is amended by striking subsections (a) and (b) and inserting the 
following:
    ``(a) Substantial Uncompensated Care Awards.--
            ``(1) In general.--The Secretary shall establish an award 
        basis for each eligible trauma center for grants under section 
        1241(a)(1) according to the percentage described in paragraph 
        (2), subject to the requirements of section 1241(b)(3).
            ``(2) Percentages.--The applicable percentages are as 
        follows:
                    ``(A) With respect to a category A trauma center, 
                100 percent of the uncompensated care costs.
                    ``(B) With respect to a category B trauma center, 
                not to exceed 75 percent of the uncompensated care 
                costs.
                    ``(C) With respect to a category C trauma center, 
                not to exceed 50 percent of the uncompensated care 
                costs.
    ``(b) Core Mission Awards.--
            ``(1) In general.--In awarding grants under section 
        1241(a)(2), the Secretary shall--
                    ``(A) reserve 25 percent of the amount allocated 
                for core mission awards for Level III and Level IV 
                trauma centers, and reallocate such amount to Level I 
                and Level II trauma centers if there are not sufficient 
                qualifying Level III and IV centers to which such funds 
                may be obligated;
                    ``(B) reserve 25 percent of the amount allocated 
                for core mission awards for large urban Level 1 trauma 
                centers that--
                            ``(i) have at least 1 graduate medical 
                        education fellowship in trauma or trauma 
                        related specialties, including neurological 
                        surgery, surgical critical care, vascular 
                        surgery, and spinal cord injury for which 
                        demand is exceeding supply;
                            ``(ii) have either annual uncompensated 
                        care costs exceeding $10,000,000 or where at 
                        least 20 percent of emergency department visits 
                        are charity or self-pay or Medicaid patients; 
                        and
                            ``(iii) are not eligible for substantial 
                        uncompensated care awards under section 
                        1241(a)(1); and
                    ``(C) give preference to any application made by a 
                trauma center--
                            ``(i) in a geographic area where growth in 
                        demand for trauma services exceeds capacity; or
                            ``(ii) that demonstrates the financial 
                        support of the State or political subdivision 
                        involved.
            ``(2) Financial support.--For purposes of paragraph 
        (1)(C)(ii), for any of the purposes specified in section 1241 
        for each fiscal year during which payments are made to the 
        trauma center involved from the grant, such financial support 
        may be demonstrated by State or political subdivision funding 
        for the trauma center's capital or operating expenses 
        (including through State trauma regional advisory coordination 
        activities or Medicaid funding designated for trauma services, 
        or other governmental funding). State funding derived from 
        Federal support provided through the Trauma Systems Planning 
        Grants awarded to States or political subdivisions shall not 
        constitute State or local financial support for purposes of 
        preferential treatment under this subsection.
    ``(c) Emergency Awards.--In awarding grants under section 
1241(a)(3), the Secretary shall--
            ``(1) give preference to any application submitted by a 
        trauma center that demonstrates the financial support (in 
        accordance with subsection (b)(2)) of the State or political 
        subdivision involved for any of the purposes specified in 
        section 1241 for each fiscal year during which payments are 
        made to the center under the grant;
            ``(2) give preference to any application submitted by a 
        trauma center that--
                    ``(A) is providing trauma care in a geographic area 
                in which the availability of trauma care has either 
                significantly decreased as a result of a trauma center 
                in the area permanently ceasing participation in such 
                system as of a date occurring during the 2-year period 
                preceding the fiscal year for which the trauma center 
                is applying to receive a grant under section 
                1241(a)(3), or in geographic areas where growth in 
                demand for trauma services exceeds capacity;
                    ``(B) will, in providing trauma care during the 1-
                year period beginning on the date on which the 
                application for the grant is submitted, incur 
                substantial uncompensated costs in an amount that 
                renders the center unable to continue participation in 
                such system and results in a significant decrease in 
                the availability of trauma care in the geographic area; 
                or
                    ``(C) operates in rural areas where trauma care 
                availability will significantly decrease if the center 
                is forced to close or downgrade service and substantial 
                uncompensated costs are contributing to a likelihood of 
                such closure or downgradation; and
            ``(3) reallocate any emergency awards funds not obligated 
        due to insufficient, or a lack of qualified, applications to 
        the significant uncompensated care award program.''.

SEC. 103. CERTAIN AGREEMENTS.

    Section 1243 of the Public Health Service Act (42 U.S.C. 300d-43) 
is amended by striking subsections (a), (b), and (c) and inserting the 
following:
    ``(a) Commitment Regarding Continued Participation in Trauma Care 
System.--The Secretary may not award a grant to a trauma center under 
section 1241(a) unless the trauma center involved agrees that--
            ``(1) the center will continue participation in the system 
        described in section 1241(b), except as provided in subsection 
        (b)(2) of such section, throughout the grant period beginning 
        on the date that the center first receives payments under the 
        grant; and
            ``(2) if the agreement made pursuant to paragraph (1) is 
        violated by the center, the center will be liable to the United 
        States for an amount equal to the sum of--
                    ``(A) the amount of assistance provided to the 
                center under section 1241(a); and
                    ``(B) an amount representing interest on the amount 
                specified in subparagraph (A).
    ``(b) Maintenance of Financial Support.--With respect to activities 
for which a grant awarded under section 1241 are authorized to be 
expended, the Secretary may not award such a grant unless the trauma 
center involved agrees that, during the period in which the center is 
receiving payments under the grant, the center will maintain access to 
trauma services at levels not less than the levels for the prior year, 
taking into account reasonable volume fluctuation that is not caused by 
intentional trauma boundary reduction, downgrading of the level of 
services, or diversion of services in excess of 5 percent.
    ``(c) Trauma Care Registry.--The Secretary may not award a grant 
under section 1241(a) unless the trauma center involved agrees that--
            ``(1) not later than 6 months after the date on which the 
        center submits a grant application to the Secretary, the center 
        will establish and operate a registry of trauma cases in 
        accordance with guidelines developed by the American College of 
        Surgeons; and
            ``(2) in carrying out paragraph (1), the center will 
        maintain information on the number of trauma cases treated by 
        the center and, for each such case, the extent to which the 
        center incurs substantial uncompensated costs in providing 
        trauma care.''.

SEC. 104. GENERAL PROVISIONS.

    Section 1244 of the Public Health Service Act (42 U.S.C. 300d-44) 
is amended by striking subsections (a), (b), and (c) and inserting the 
following:
    ``(a) Application.--The Secretary may not award a grant to a trauma 
center under section 1241(a) unless an application for the grant is 
submitted by the center to the Secretary and the application is in such 
form, is made in such manner, and contains such agreements, assurances, 
and information as the Secretary determines to be necessary to carry 
out this part.
    ``(b) Limitation on Duration of Support.--The period during which a 
trauma center receives payments under a grant under section 1241(a)(3) 
shall be for 3 fiscal years, except that the Secretary may waive such 
requirement for the center and authorize the center to receive such 
payments for 1 additional fiscal year.
    ``(c) Limitation on Amount of Grant.--Notwithstanding section 
1242(a), a grant under section 1241 may not be made in an amount 
exceeding $2,000,000.
    ``(d) Eligibility.--Except as provided in section 
1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under 
section 1241(a) shall not preclude a trauma center's eligibility for 
the other grants described in such section.
    ``(e) Funding Distribution.--Of the total amount appropriated for a 
fiscal year under section 1245, 70 percent shall be used for 
substantial uncompensated care awards under section 1241(a)(1), 20 
percent shall be used for core mission awards under section 1241(a)(2), 
and 10 percent shall be used for emergency awards under section 
1241(a)(3).
    ``(f) Minimum Allowance.--Notwithstanding subsection (e), if the 
amount appropriated for a fiscal year under section 1245 is less than 
$25,000,000, all available funding for such fiscal year shall be 
utilized for substantial uncompensated care awards under section 
1241(a)(1).
    ``(g) Substantial Uncompensated Care Award Distribution and 
Proportional Share.--Notwithstanding section 1242(a), of the amount 
appropriated for substantial uncompensated care grants for a fiscal 
year, the Secretary shall--
            ``(1) make available--
                    ``(A) 50 percent of such funds for category A 
                trauma center grantees;
                    ``(B) 35 percent of such funds for category B 
                trauma center grantees; and
                    ``(C) 15 percent of such funds for category C 
                trauma center grantees; and
            ``(2) provide available funds within each category in a 
        manner proportional to the award basis specified in section 
        1242(a)(2) to each eligible trauma center.
    ``(h) Report.--Beginning 2 years after the date of enactment of the 
National Trauma Center Stabilization Act of 2009, and every two years 
thereafter, the Secretary shall biennially--
            ``(1) report to Congress on the status of the grants made 
        pursuant to section 1241; and
            ``(2) evaluate and report to Congress on the overall 
        financial stability of trauma centers in the United States.''.

SEC. 105. AUTHORIZATION OF APPROPRIATIONS.

    Section 1245 of the Public Health Service Act (42 U.S.C. 300d-45) 
is amended to read as follows:

``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.

    ``For the purpose of carrying out this part, there are authorized 
to be appropriated $100,000,000 for fiscal year 2009, and such sums as 
may be necessary for each of fiscal years 2010 through 2015. Such 
authorization of appropriations is in addition to any other 
authorization of appropriations or amounts that are available for such 
purpose.''.

SEC. 106. DEFINITION.

    Part D of title XII of the Public Health Service Act (42 U.S.C. 
300d-41 et seq.) is amended by adding at the end the following:

``SEC. 1246. DEFINITION.

    ``In this part, the term `uncompensated care costs' means 
unreimbursed costs from serving self-pay, charity, or Medicaid 
patients, without regard to payment under section 1923 of the Social 
Security Act, all of which are attributable to emergency care and 
trauma care, including costs related to subsequent inpatient admissions 
to the hospital.''.

                 TITLE II--TRAUMA SERVICE AVAILABILITY

SEC. 201. ESTABLISHMENT OF GRANT PROGRAM.

    Title XII of the Public Health Service Act (42 U.S.C. 300d et seq.) 
is amended by adding at the end the following:

                 ``PART H--TRAUMA SERVICE AVAILABILITY

``SEC. 1281. GRANTS TO STATES.

    ``(a) Establishment.--To ensure universal access to trauma care 
services provided by trauma centers and trauma-related physician 
specialties, the Secretary shall provide funding to States to enable 
such States to award grants to eligible entities for the purposes 
contained in this section.
    ``(b) Awarding of Grants by States.--Each State may award grants to 
eligible entities within the State to--
            ``(1) improve the availability of trauma services in 
        underserved areas;
            ``(2) address trauma center over-crowding;
            ``(3) enhance trauma surge capacity;
            ``(4) address shortages of trauma surgeons and certain 
        other trauma related physician subspecialties, including 
        providing reimbursement for the unreimbursed costs to trauma 
        centers for trauma-related physician compensation to ensure the 
        availability of such physicians to protect against trauma 
        center closures or downgrades; and
            ``(5) improve trauma service coordination and the 
        appropriate transport of trauma patients to trauma centers.
    ``(c) Eligibility.--
            ``(1) In general.--To be eligible to receive a grant under 
        subsection (b) an entity shall--
                    ``(A) be--
                            ``(i) a public or non-profit trauma center 
                        that meets that requirements of paragraphs (1), 
                        (2), and (5) of section 1241(b);
                            ``(ii) a safety net public or nonprofit 
                        trauma center that meets the requirements of 
                        paragraphs (1) through (5) of section 1241(b) 
                        for the purposes of grants to carry out 
                        activities described in paragraphs (1) and (2) 
                        of subsection (d);
                            ``(iii) a consortium of public or non-
                        profit trauma centers; or
                            ``(iv) a hospital that seeks to establish 
                        new trauma services in underserved areas (as 
                        defined by the State); and
                    ``(B) submit to the State an application at such 
                time, in such manner, and containing such information 
                as the State may require.
            ``(2) Limitation.--A State shall utilize at least 40 
        percent of the amount available to the State under this part 
        for a fiscal year to award grants to entities described in 
        paragraph (1)(A)(ii).
    ``(d) Use of Funds.--The recipient of a grant under subsection (b) 
shall carry out one or more of the following activities consistent with 
subsection (b):
            ``(1) Providing safety net trauma centers with funding to 
        support physician compensation in trauma-related physician 
        specialties where shortages exist in the region involved.
            ``(2) Providing for individual safety net trauma center 
        fiscal stability and costs related to 24-hour a day, 7 days a 
        week, service availability with priority provided to safety net 
        trauma centers located in urban, border, and isolated rural 
        areas.
            ``(3) Activities to reduce trauma center overcrowding.
            ``(4) Establishing new trauma services in underserved 
        areas.
            ``(5) Enhancing regional systemic coordination of trauma 
        service availability.
            ``(6) Making capital improvements to enhance access and 
        expedite trauma care, including providing helipads and 
        associated safety infrastructure.
            ``(7) Enhancing regional trauma surge capacity.
            ``(8) Ensuring expedient transport by ground or air to the 
        appropriate trauma center.
    ``(e) Limitation.--A State may use not to exceed 20 percent of the 
amount available to the State under this part for a fiscal year for 
administrative and systemic costs of the State in awarding grants, 
including coordination with other States to recognize existing or 
otherwise appropriate patient transfer patterns that may exist beyond 
State boundaries while remaining consistent with the State trauma and 
emergency medical service systems of each State.
    ``(f) Distribution of Funds.--
            ``(1) Population.--Except as provided in paragraph (2), 
        from the amount appropriated for each fiscal year to carry out 
        this part, the Secretary shall distribute to each State an 
        amount that bears the same ratio to such appropriated amount as 
        the population of the State involved (as reported in the most 
        recent decennial census) bears to the total population of the 
        United State (as reported in the most recent decennial census).
            ``(2) Minimum amount.--Notwithstanding paragraph (1), a 
        State shall at a minimum receive an amount for a fiscal year 
        that is not less than 1 percent of the amount appropriated for 
        such fiscal year.

``SEC. 1282. AUTHORIZATION OF APPROPRIATIONS.

    ``For the purpose of carrying out this part, there is authorized to 
be appropriated $100,000,000 for each of fiscal years 2010 through 
2015.''.
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