Friday, July 22, 2011

Trauma center cuts leave hospitals more reliant on Driver Responsibility surcharge

Speaking of the Driver Responsibility Program (DRP), the Lubbock Avalanche Journal had a recent story ("THA representatives visit with Lubbock, hospital officials," July 13) about a Texas Hospital Association meeting where medical officials discussed a legislative development I wasn't aware of, but which will make it much more difficult to abolish the problematic surcharge in the future: A whopping 23% cut in trauma center funding. A critical passage from the article reads:
Patients may also see hospitals adjust funding to continue trauma care. The state budget cut trauma funding by 23 percent, however numerous attempts to repeal the Driver Responsibility Program, a major source of funding, failed.

The Driver Responsibility Program was created in 2003 to establish a system that assesses points and surcharges for certain traffic offenses. ... Those surcharges fund a program that, in turn, funds trauma centers.

“We’re grateful for what we have, but at the end of the day they ought to appropriate the funds they passed legislation for,” [THA President Dr. Dan] Stultz said of the amount of funding appropriated by the Legislature through the Driver Responsibility Program.

The cuts could have a large impact on Covenant, a level-two trauma center, and University Medical Center, a level-one trauma center, the highest level of care out of the country's five-part trauma care structure. ...
One Texas hospital dropped from a level-three to a level-four trauma center after the legislation passed, Stultz said.
That's pretty pathetic: The majority of surcharges assessed go unpaid, but with legislative cuts of 23% to trauma care budgets, increasingly the Driver Responsibility surcharge has become the pivotal, if a precarious method for funding Texas trauma hospitals. What's more, as alluded to in the quote above, the Legislature doesn't even allocate all the DRP money to hospitals, instead diverting millions to balance the budget.

The DRP's original, stated purpose - at which it's miserably failed - was to encourage drivers to purchase liability insurance, renew their licenses, and to discourage DWI. Instead, the surcharge has caused about 2 million drivers to lose their licenses for non-payment, with around 1.2 million remaining unlicensed to this day. That in turn leaves them ineligible for insurance, including thousands of drunk drivers. (Nearly a quarter of Texas drivers statewide remain uninsured.) Though only 3% of those assessed the surcharge were convicted of  DWI, for them the surcharge is so draconian that prosecutors have begun pleading DWI charges down to things like "reckless driving" or obstructing a roadway," resulting in a 29% decline in total DWI convictions in the first four years after the surcharge was implemented, even though DWI arrests increased over the same period.

If it was a public-policy error to create the DRP to supplement hospital funding, it's an even greater mistake to reduce other state funds to trauma centers so that the DRP becomes - from the hospitals' fiscal perspective - utterly indispensable, even though a few years ago the surcharge didn't even exist. The public-policy goal should be to reduce trauma centers' reliance on the surcharge, not to maximize its importance for them.

There's a saying in politics: "Let the big dogs eat." Hospitals are a big dog and they need to get theirs. So I want them fully funded both for political reasons and because I want reliable trauma centers available when terrible things happen. (High functioning trauma centers are arguably a bigger driver of declining murder and automobile death rates than ever-more traffic laws or improved police tactics.)  But the Driver Responsibility surcharge is a problematic and unreliable financing method.  As a practical matter, nobody wants to see trauma hospitals receive even fewer funds than they get now, so abolishing the Driver Responsibility surcharge (in some future legislative session) will require creative thinking about how to replace that money. In other words, for those of us who'd like to defenestrate the surcharge like some 15th century Prague city councilman, there's not just one task but two: Abolish the surcharge AND find another, better, more reliable funding mechanism for trauma centers. The former likely cannot happen unless and until the latter does, too.

On a final note, the 23% haircut for Texas trauma center hospitals contrasts dramatically with the paltry reduction in spending at the Department of Criminal Justice (where the Lege spent more in some areas and concentrated most cuts in probation and diversion programming). This dissimilitude provides a clear expression of priorities: What got cut and whose funds got saved? To the 82nd Legislature, incarceration funding was virtually a sacred cow while trauma centers - where average people are taken if they're seriously injured - were deemed a secondary priority that it's okay to axe. (Ditto for schools.) Budgets are moral documents and the morality expressed in Texas' most recent one seems suspect, at best.


Soronel Haetir said...

Sorry, I would have to disagree with you on that last. There is perhaps nothing that is more legitimately the arena of government than punishing those who transgress the law. Everything else (and I would definitely include both education and health care in this category) is nice if there is money for it, dispensable otherwise.

Gritsforbreakfast said...

Yes, Soronel, but perhaps you'll agree your views about the extremely limited role of government are an outlier. Perhaps you'll also even agree that prisons don't get great bang for the buck.

Where we may differ is that IMO trauma hospitals are public goods that, because of their tremendous expense, couldn't exist left to the devices of the market. If you want to reduce deaths from DWI or murder, for example, funding trauma centers is arguably as or more important than funding law enforcement to the gills, if priorities must be set.

Soronel Haetir said...


My stance is evidently not that far out on the fringe as prisons did not get cut very much while pretty much everything else felt the knife to a painful degree.

Gritsforbreakfast said...

Soronel, your self-proclaimed stance is that nearly all offenders should be executed on the first offense and the government has virtually no other function but law enforcement. That's not a view tbe Texas Legislature has ever endorsed.

Soronel Haetir said...


Prioritizing law enforcement above pretty much everything else, however, is evidently a view endorsed by the legislature.

Gritsforbreakfast said...

Fine, SH, just don't take that as some endorsement of your overall worldview, which is pretty out there.

And yes, your final, rather restrained observation was in fact the concluding point of my post: The Lege decided keeping the prisons stuffed and farming more contracts out to their friends and contributors in the private-prison industry was more important than funding trauma centers or schools. The question is are those voters' priorities? Check back after the 2012 election and if the Republicans still hold that 101 member supermajority in the Texas House, then voters will have endorsed that path. We'll see.

Soronel Haetir said...

I am fully willing to admit that my views on criminal justice are far out on the tail of the distribution, that does not however mean I am unable or unwilling to find common cause with those closer to the middle.

It was only the last sentence of your post "Budgets are moral documents and the morality expressed in Texas' most recent one seems suspect, at best." that I have any objection to.

Sandy said...

I agree wholeheartedly with Grits on this one. Budgets do reflect morality and it seems to me we budget much more for the dark side of life (1,000s of new laws every year, more and bigger prisons, etc.) than the positive and productive (healing the sick and educating the populace).

I am sick of our punish-everything society. I'd so much rather we ditched most laws, returned the state and nation to the land of the free, and play nice for a change. It's possible and that's how I cast my votes.

The Comedian said...

When your only tool is a hammer, all you see are nails. At home, it's prisons. Abroad, it's warfare.

But then when you see the lack of political, diplomatic and negotiating skills, not to mention just plain old-fashioned civility, in our current crop of pols, this is no surprise.

Of course many of our pols are being well paid by their corporate masters not to negotiate in good faith or compromise on anything.

“The genius of American politics is compromise.” - Shelby Foote