The Mississippi Trauma Care System, a model for trauma teams nationwide, is in danger of losing some of its funding for the first time since the Legislature created it in 2008.
The reason lies in a controversial bill passed at the end of the 2016 legislative session that directed millions of dollars from trauma care into the state’s general fund. And while lawmakers in both political parties agree that paying for trauma care should be a priority, some are worried the nationally lauded system could become a casualty of the state’s ongoing budget woes.
“The money is gone and it’s jeopardizing this important system and why? It was done to cover a major budget shortfall,” said Rep. Jay Hughes, D-Oxford. “And now we’re in jeopardy of going from first to worst.”
The Budget Transparency and Simplification Act stirred controversy from the moment it was proposed. Advocates said the law would free up millions of dollars by sweeping fees that state agencies paid each other for services into the general fund. But detractors cried foul, accusing the Republican-led Senate of using the swept dollars to cover an unexpected hole in the state budget.
Regardless of the reasons, the law has been a headache for legislators and agency heads alike. Many agency heads admit they have struggled to understand how the new rules apply to their departments’ budgets. Some issues have been resolved. But for the Department of Health, one big question remains: Will the agency have to pull $4.5 million from its budget to plug the hole in the trauma system’s funds?
One of the trauma care system’s unique features is the way it is funded. Rather than rely on an annual general fund appropriation, in 2008 the Legislature attached a series of fines and fees to the types of “risky behavior” that make a trauma care system necessary, such as speeding tickets or ATV purchases. A statute mandated that these fines would then flow directly into the trauma care fund — and once in that fund, no other department could touch them.
But the sweeps bill included a runaround on this, diverting a portion of these fees into the general fund before they touched trauma care. These “criminal assessment” fees included the moving vehicle violations that annually make up a third of the $22 million trauma care system budget and all of the $2 million emergency medical systems budget. The other two-thirds of trauma care fees remained untouched.
When contacted by Mississippi Today, many advocates of the trauma care system said they believed its funds were diverted by accident and, as a result, restoring these funds would be a top priority for the session in January.
“Every legislative member I’ve talked to understands how important trauma care is and EMS, and so I think in their attempt to pass (the sweeps bill), which was done pretty close to the end of the session, I think there was an oversight that caused some challenges that we have to look at and see if we can modify,” said Bill Oliver, chairman of the ad hoc Trauma System Task Force, which the Board of Health created this summer to address the funding issues.
The Department of Health has made it clear that it would like the Legislature to amend the sweeps bill for fiscal year 2018 so that all trauma-related fees would once again flow directly into trauma care.
“Those original funds were created for trauma care,” said Dr. Mary Currier, the state health officer. “So we would like it to go back to the way it was, and I believe that is what people (in the Legislature) want to do.”
But some Republican leaders said the rerouted trauma fees are better off in the general fund, where the Legislature can vet how the trauma care system spends its money.
“I think the idea of getting those (fees) into the general fund and reappropriating them out is a transparent act. It’s not just the trauma funds, it’s all those funds, making sure they know how those dollars are being spent, what the benefit of how they’re spent is,” said Sen. Terry Burton, R-Newton. “… Maybe it was unintentional, but whatever the reason we’re going to make sure they get the funds.”
And for some lawmakers, the location of the funds isn’t as important as how they’re spent. Rep. Bubba Carpenter, R-Burnsville, who also works as a paramedic, said one of the bill’s authors, former Rep. Herb Frierson, personally assured him that the Legislature would never appropriate trauma care funds to anything but trauma care. And he said he never would have voted for the bill if he had believed otherwise.
“We were sure that when we voted for the sweeps bill that the EMS money couldn’t be touched,” said Carpenter. “… You’ll see a heck of a fight on the floor if that changes.”
But the statute that protects the funding has already been changed. Regardless of how many legislators promise trauma funds will go to trauma, money in the general fund can go to any department. And some Republican leaders say this was always part of the plan.
“It just falls in line with everything else,” said Sen. Buck Clarke, R-Hollandale, who co-authored the Budget Transparency and Simplification Act. “It’s hard to say education funding is a priority, health care is a priority. What I like to say is the budget’s my priority.”
Model for other states
Mississippi’s state trauma care system, an intricate network of hospitals and emergency medical services established by the Legislature in 2008, has been a jewel in a state where health ranks “overall number one in all the wrong ways,” according to Thad Waites, a member of the state Board of Health.
In a 2012 study, the Journal of Trauma Care and Acute Care Surgery praised the program and its funding structure as “foresighted” and a successful model for other states to consider.
The goal of Mississippi’s trauma care system is to decrease injury and death due to traumatic injury, and by all accounts it has worked. In 2008, Mississippi had 26.6 motor vehicle deaths for every 100,000 residents. By 2014, that number had dropped to 20.3 deaths for every 100,000 residents, a 24 percent decline. By comparison, the national rate dropped 17 percent over that same time period.
“The concept of great trauma care was always that the patients were taken to the right place at the right time with the golden hour being the key factor in that, how quick the EMS providers got to the scene, how quick they were able to get them to the right hospital,” Oliver said. “So what this did was it created a system of care where hospitals throughout the state were working together with EMS providers on protocols, so we know which hospitals can best handle certain (incidents).”
One area everyone can agree on is that an efficient trauma system is expensive. Trauma surgeries are by nature unplanned, so whole teams have to be stationed at the systems’ hospitals, 24-hours a day. These teams include trauma surgeons, nurses, anesthesiologists — and lots of specialized equipment.
“You’re not planning to receive a trauma patient at a certain time of day, so you don’t schedule them the way you’d schedule someone for a knee replacement. So you’ve got to have them on site or on call to handle them when they come in, and that’s a very high cost,” said Richard Roberson, vice president for policy at the Mississippi Hospital Association.
Roberson said restoring the funding to the trauma care system is a top priority for the upcoming legislative session. And he said numerous conversations with lawmakers have led him to believe it will be fixed.
“I believe folks when they say it was an unintended consequence,” Roberson said.
Funds that can’t be touched
There is irony in the trauma system’s current funding woes. Some say legislators originally bypassed the state general funds because they wanted to be sure future legislatures couldn’t touch the system’s funding in the event of a budget shortfall.
“There was a legislative task force that recommended it be created with funding mechanisms such as these moving violations so they could ensure future funds would be there specifically for a system of care referred to as trauma care,” Oliver said.
Still, some in the Legislature point out that the trauma care system is almost a decade old, and its funding may be due for a reassessment.
“One of the concerns I’ve had for a long time is that some things that were done years ago … were not really sound anymore. There’s no good reason for (that money) to be there, and you may have another area of the state that desperately needs those funds,” said Sen. Briggs Hopson, R-Vicksburg. “The idea was to put it all in a big pot and let the agencies come in and explain why they have their needs.”
The trauma care system actually has fallen short of its funding goals for years, according to a recent report from the Center for Mississippi Health Policy. In 2008, the Legislature estimated that the trauma care fund would generate approximately $38 million a year. But the funding levels for the trauma care system have instead averaged about 60 percent of the authorized amount since 2009. In 2016, this totaled approximately $24.5 million for the trauma care system and EMS operating fund combined.
“So it’s become more apparent that we need to make sure we don’t reduce those trauma funds to maintain the efficient system that we have in the state right now,” Oliver said.
The biggest criticism Democratic legislators have lobbed at the sweeps bill is that Republican leaders rushed the 184-page bill through the Legislature in a matter of hours, barely giving House and Senate members time to read it.
“Had we had time to read it and see that (trauma funding) was actually in there and that this was going to effect it — I think that the bill itself would have been in jeopardy had it been delayed because more questions would have been asked,” Hughes said. “… Instead we had to rely on the assurances from (the leadership) that “this is what it really says — take my word for it.”
Hughes said he remembers Frierson assuring Carpenter on the floor of the House that trauma care funds would not be touched.
Frierson could not be reached for comment on that point. But Frierson, who was appointed Department of Revenue commissioner earlier this year, made an emotional apology to the House in June for what he said were $56 million in errors made in the crafting of the law.
Republican leaders, however, say these issues are par for the course for big pieces of legislation and easily fixed come January.
“If there are any issues with the trauma care fund, it can be addressed in the 2017 Legislative session,” said Laura Hipp, spokeswoman for Lt. Gov. Tate Reeves, in an email.
So where are the funds?
Regardless of why the Legislature rerouted the trauma care funds, one question remains: What has happened to the $4.5 million swept from trauma care this fiscal year?
The Legislative Budget Office says this amount has already been appropriated to the Department of Health, as part of its $63 million general fund appropriation for 2017.
“The health department for FY 17 was appropriated special funds and general funds in order to maintain that same level of funding. They made the first payment in the fall and the second one will be paid in (January),” the Legislative Budget Office said in a statement.
Clarke backs this, saying funding for trauma care was included in the Department of Health’s 2017 general fund appropriation.
“That’s all in their appropriation bill,” Clarke said. “And yes we’ve maybe had to cut them a little bit (but we said) here’s the money for the trauma centers … that money was added to their budget.”
But in a conversation with Mississippi Today on Dec. 9, Dr. Currier, the state health officer, was unaware that the money was already part of her agency’s 2017 appropriation.
“We’re still responsible for paying out that money that we paid out in 2015 so that’s ($4.5 million) that has to come out of health department appropriation,” Currier said.
When asked about trauma care appropriations for 2017, legislators and agency heads often gave conflicting numbers. Many Democratic and Republican lawmakers claimed that the Legislature diverted approximately $9 million into the general fund for this year, and, as a result, this is what the Department of Health needed for its appropriations.
The actual amount of missing funds is closer to $4.5 million because trauma care funds for fiscal year 2017 were collected in calendar year 2016. This means the trauma care system received half of its funding before the law took effect July 1. In 2018, however, the Department of Health projects that the full amount, approximately $9 million, will be swept.
The 2017 Budget Bulletin does not contain a line item for trauma care. The health department’s appropriations bill does mention trauma care in relation to the sweeps bill, but only to say that the trauma fund’s criminal assessment fees are the only health-related court assessments that the Legislature won’t reimburse. The Legislature states it will reimburse all other court assessments in a lump sum equal to the amount collected in fiscal year 2015.
Rep. Toby Barker, R-Hattiesburg, said that trauma funds were excluded from these reimbursements only to give trauma care a chance to pull in more funds than it did in fiscal year 2015.
“The reason for excluding the Trauma Care Systems Fund was so that the amount would not be capped in FY 2017 (in the event that assessments exceeded 2015 levels),” Barker wrote in an email. “…However, after the session it was determined that the amounts collected for the Trauma Care Systems Funds has been decreasing over the past few years.”
The Legislative Budget Office said the Legislature ultimately appropriated nearly $9 million for trauma care in 2017, an amount that Barker said exceeded what the fund would have collected had the funds flowed directly into the trauma care fund.
According to the Budget Bulletin for 2017, the Legislature cut the Department of Health 3 percent from 2016 to 2017, from $65 million to $63 million. If the Department of Health’s $63 million appropriation in fiscal year 2017 also includes an extra $4.5 million for trauma care, the cut would be 10 percent.
The same seems to hold true for 2018. Clarke said the Legislature plans to give the Department of Health $9 million from the state’s general fund to replenish the swept trauma care funds. But the Joint Legislative Budget Committee, in its first budget proposal for fiscal year 2018, recommended an 8.24 percent cut to health. Combined with the governor’s mid-year budget cuts, this brings the 2018 general fund appropriation to the health department down to $57 million.
If this $57 million also includes $9 million for trauma care, then over a quarter of the Department of Health’s general fund appropriation has been trimmed between 2016 and 2018.
“That is hypocrisy and heresy that the board of health would make up (the difference) when their budget has been so traumatized itself in the last eight years,” said Rep. Steve Holland, D-Plantersville, who authored the 2008 legislation establishing the trauma care fund. “There’s no way that can happen.”
The Department of Health, for its part, said it plans to continue working with the Legislature on this issue when the session starts next week.
“We do realize this is a process, but what we need is to ensure the right person gets to the right place at the right time because this saves lives. The trauma care system is very important to the state of Mississippi,” said Liz Sharlot, communications officer for the Department of Health.
Oliver, however, said he’s optimistic that this mistake is a temporary hiccup for the trauma care system and that the Legislature will quickly work to restore the funds.
“It’s something that the state should be proud of, and I think is proud of, so we just want to make sure it’s adequately funded,” said Oliver.