When Maria Gonzalez was severely injured in a car accident near Tampa, Florida, she was treated at a local trauma center and never needed to be transferred to another hospital. Her experience, it turns out, may have been shaped less by her injuries and more by the laws of her state.
A new study from Northwestern Medicine finds that severely injured car crash victims in states with no-fault insurance laws are roughly 70 percent less likely to be transferred between hospitals compared to patients in states with traditional at-fault policies. The research, published in the journal Injury, analyzed hospital records from nearly 6,500 Medicare patients who suffered serious injuries in car crashes between 2016 and 2021, comparing outcomes in Florida and New York—two states with no-fault laws—against Maryland and Wisconsin, which use at-fault systems.
The difference was stark. While 8.1 percent of severely injured crash patients in at-fault states were re-triaged, meaning they were moved from one hospital to another during emergency care, only 2.3 percent of patients in no-fault states experienced the same. After adjusting for variations in patient populations and hospital capabilities, researchers calculated that no-fault states had 69 percent lower odds of re-triage.
The implications matter because transfers aren't merely inconvenient—they can be dangerous. "The re-triage process is challenging because finding another hospital that agrees to provide care, finding an ambulance and the time-sensitive nature of injury care can all be cumbersome," said Dr. Anne Stey, the study's senior author and a trauma surgeon at Northwestern Medicine. "Unfortunately, unexpected problems can arise." Delays in reaching definitive care can compound injuries, and additional transfers mean added costs for patients and families already in crisis.
To confirm that insurance policy was the driving factor—and not simply differences in regional trauma systems—the researchers also examined re-triage rates for severe fall injuries, which are not reimbursed through auto insurance. In that comparison, no significant difference emerged between the four states, strengthening the case that car insurance laws directly shape hospital behavior.
The mechanism is straightforward: in no-fault states, drivers are required to carry personal injury protection that automatically reimburses hospitals for trauma care. In at-fault states, hospitals may wait months for compensation while liability is established—assuming it ever is. That financial uncertainty appears to incentivize some hospitals to transfer complex cases rather than absorb the risk of non-payment.
Stey said the findings raise questions that extend beyond insurance mechanics to the sustainability of emergency care itself. "It is up to the private citizens and state policymakers if they value access to trauma care more highly, or the choice to have lower car insurance premiums," she noted. She pointed to alternative funding models, including earmarking revenue from cigarette taxes or traffic violations, or expanding health insurance coverage so that injured patients aren't caught in a system designed around fault.
For now, the data suggest that where you live—and what kind of insurance your state requires—may shape not just your premiums, but whether you stay close to home when you're hurt most.