Texas features one of the largest trauma care systems in the country, but behind the emergency room doors lies a complex web of funding mechanisms, regional coordination, and public policy decisions—many shaped directly by the Texas Legislature. In short, the trauma care system in Texas is the safety net that keeps people alive after car crashes, falls, gunshots, and other critical emergencies. But ensuring that the safety net is strong, well-funded, and responsive takes continuous legislative attention, especially in a state as vast and diverse as Texas.
Below we describe the Texas Trauma Care System, its funding, and why the issue continues to recur on lawmakers’ agendas.
What Is the Texas Trauma Care System?
At its core, the trauma care system is the network of trauma hospitals, emergency medical services (EMS), air ambulances, and local providers that treat the most serious, life-threatening injuries. It’s designed to provide fast, organized, and high-quality care when minutes make the difference between life and death.
Texas organizes this system across 22 defined geographic Trauma Service Area (TSA)—urban, rural, or somewhere in between. Each TSA is led by a Regional Advisory Council (RAC). RACs are the backbone of the trauma system. They connect all the pieces and ensure coordination and effectiveness within their trauma service area and among trauma services areas. RACs are responsible for planning and coordination, system improvements, data collection, disaster preparedness and response, and education and training. that coordinates trauma care. These councils help hospitals and EMS providers communicate, share resources, and make sure trauma patients are transported to the right facility with the right capabilities.
A hospital must be designated as a trauma facility (Level I to IV, with Level I being the highest) to officially participate. Think of it as a certification—if a hospital wants to be recognized as a trauma center, it has to meet strict criteria for staffing, equipment, training, response times, coordination, reporting, and tracking outcomes. Presently, Texas boasts 296 hospitals designated trauma centers in Texas.
- 22 Level I trauma centers
- 27 Level II trauma centers
- 62 Level III trauma centers
- 185 Level IV trauma centers
EMS serves as the critical first point of contact. They provide rapid assessment, stabilization, and transport of trauma patients to the most appropriate designated trauma center based on injury severity and regional protocols.
DSHS oversees the state’s trauma system to make sure patients get immediate, proper care after serious injuries. It sets rules for trauma hospitals, EMS providers, and RACs to follow, and checks that they meet safety and care standards. DSHS also collects data, supports training, and helps pay for trauma care to improve the system across Texas.
Why It Matters: Texas Has Big Trauma Challenges
Texas leads the nation in roadway mileage and traffic injuries and fatalities. In 2023, there were 18,800 people seriously injured in motor vehicle accidents and 4,291 deaths in Texas. Rural areas of the state accounted for 52 percent of the state’s traffic fatalities. According to the National Safety Council, the average economic cost per fatality is almost $2 million per incident.
Additionally, oilfield-related injuries in places like the Permian Basin, violent incidents in urban centers, and the sheer scale of rural Texas make trauma care not just a healthcare issue—but a public safety and transportation issue as well. In these settings, trauma care isn’t optional—it’s a critical infrastructure component. But as demand grows, especially in rural areas with hospital closures or thin EMS coverage, Texas must wrestle with how to keep this system operational and accessible to all Texans.
Legislative Role: Oversight, Funding, and Fixes
Funding the System: Account 5111
The Texas Legislature plays a central role in maintaining and improving the trauma care system. Here’s how:Much of the trauma care system’s funding comes from a dedicated fund created by the Legislature in 2003: the Designated Trauma Facility and Emergency Medical Services Account, also known as Account 5111.
This account collects revenue from traffic fines and court costs, including:
- Surcharges from the Driver Responsibility Program (now repealed, more on that below)
- Certain court fees for traffic offenses
- Criminal conviction surcharges related to alcohol or drugs
Originally, the idea was simple: use money from traffic violations to fund the hospitals and emergency services that respond to those crashes. It was a way to connect cause and effect—and free up General Revenue for other priorities.
Repeal of the Driver Responsibility Program (2019)
But the system hasn’t always worked as planned. Over the years, trauma funds were used to help balance the budget instead of going to directly support the trauma system.
A major shake-up came in 2019, when the Legislature repealed the controversial Driver Responsibility Program (DRP), which had been one of the main sources of revenue for trauma care. While widely seen as punitive and ineffective (often trapping low-income Texans in debt), its repeal left a funding hole.
To compensate, lawmakers redirected other criminal fines and court fees into Account 5111, but revenue levels dropped. Since then, the Legislature has faced repeated pressure from hospitals, EMS providers, and RACs to find more stable, long-term funding.
Trauma Care Funding Methodology
The Legislature allocates trauma funding through appropriations and by statute with certain percentages going to components of the trauma system: trauma facilities, EMS, RACs, and DSHS. 94 percent of the appropriated funding must go to reimburse uncompensated trauma care. The statute also allows for the funding intended for trauma facilities to be used to draw down additional federal funding through the Health and Human Services Commission (HHSC). This mechanism maximizes the funding available for uncompensated trauma care. The trade-off of the methodology is that smaller hospitals including rural hospitals do not get as much money because they are not eligible for the federal funding. This creates challenges in maintaining Level IV facilities across the state to serve rural patients.
The Legislature also allocates funding to RACs , EMS, and DSHS to support coordination of the trauma system, the immediate lifesaving care provided on scene, and the transport to a trauma care facility.
- Up to two percent of appropriated trauma funds go to RACs.
- Three percent of appropriated trauma funding goes to EMS providers to support their role in the trauma system.
- One percent of appropriated trauma funds are used by DSHS to administer the Texas trauma system.
The question remains as to whether there is sufficient funding to adequately support all components of the trauma system.
Key Challenges and Ongoing Legislative Issues
Several recurring topics appear on the legislative radar when it comes to trauma care:
• Rural Trauma Gaps
As rural hospitals close or reduce services, access to trauma care gets more uneven. Some parts of Texas are hundreds of miles from the nearest Level I or II trauma center. The Legislature is under growing pressure to fund telemedicine, support rural EMS providers, and expand the reach of RACs in underserved areas.
• Uncompensated Care
Many trauma patients are uninsured or underinsured. Hospitals must stabilize them regardless of ability to pay, as required by federal law (EMTALA). This leads to millions in uncompensated trauma care costs—especially for Level I and II facilities in border and urban regions. Lawmakers often hear calls to boost reimbursement or increase trauma funding to offset these costs. However, there is an inherent tension between the urban areas with the most trauma care and the rural areas with more limited access to care.
• Air Ambulance Regulation
Given the distances in Texas, air ambulances play a big role in the trauma system. However, their regulation is complicated—partly governed by federal aviation rules. Some stakeholders have pushed for more state-level control over pricing, service quality, and coordination with RACs.
• Workforce Shortages
Keeping qualified trauma surgeons, other physicians, nurses, and EMS professionals in Texas—especially in rural areas—is another priority. Lawmakers have considered various workforce incentives and training grants, often tied to medical schools or rural health initiatives.
A Real-World Example: Senate Bill 1018 (89th Legislature)
In 2025, the Texas Legislature passed Senate Bill 1018. The bill changes the percent distribution of state traffic fines to increase the amount of funding to trauma account 5111. This change was undertaken to stabilize the funding to the trauma system.
Final Thoughts: A System That Needs Constant Tending
Texas’ trauma care system isn’t something you set and forget. It requires ongoing investment, strategic oversight, and—frankly—a lot of legislative elbow grease. As funding mechanisms evolve and population growth stretches resources thinner, lawmakers will continue to grapple with how to keep the trauma safety net intact.
For Texans on the road, on the job, or at home, the next trip to the ER might depend on decisions made in a Capitol hearing room months—or even years—before. That’s why the Legislature’s role in trauma care policy remains as urgent as the sirens behind the scenes.