NHTSA Notes

COMMENTARY: MOTORCYCLE HELMET LAWREPEAL: WHEN WILL WE LEARN . . . OR TRULYCARE TO LEARN?

[Vaca F. Commentary: Motorcycle Helmet Law Repeal:When Will We Learn . . . Or Truly Care To Learn? AnnEmerg Med. 2006;47:204-206.]

It is amazing how sometimes history painfully repeats itself.Unfortunately, when it comes to motorcycle helmet laws, itdoes so at the needless loss of hundreds of lives every year,which is particularly disturbing because motorcycle helmets are35% effective in preventing fatalities and 67% effective inpreventing brain injuries.1 Two years after the repeal of theuniversal motorcycle helmet law in Arkansas (1997), Texas(1997), Kentucky (1998), and Louisiana (1999), motorcyclecrash fatalities increased by 29%, 37%, 58%, and 109%,respectively.2,3 This month’s NHTSA Notes focuses on therecent NHTSA document Evaluation of the Repeal of the All-Rider Motorcycle Helmet Law in Florida.4 Contained within thepublication, we find the unsettling outcomes of yet another statethat has chosen to repeal its all-rider motorcycle helmet law.

In July 2000, a new policy was implemented, voted on byFloridians, that eliminated the legal requirement that allmotorcycle riders wear helmets. The new state law requiredhelmet use only for riders younger than 21 years or those olderthan 21 years who did not carry at least $10,000 of medicalinsurance. As each one of us might have predicted, theoutcomes were and continue to be devastating and represent theloss of important injury prevention reforms through a decreasein helmet use, lost lives, and lost dollars in insurance andmedical costs. Although some might question the worth ofrepeating the “same old story,” I find it important to remind usof the impact that health policy revision has on the lives of thosewe treat in our emergency departments (EDs) and traumacenters, no matter how trivial the policy modification may seemwhen it is first proposed.

Although it has been several years since the repeal of Florida’sall-rider helmet law, it continues to have a profound negativeeffect on motorcycle helmet use throughout the state. In 1998, a13-county observation research study conducted by the Centerfor Urban Transportation Research at the University of SouthFlorida found that motorcycle helmet use was nearly 100%.5 By2002, the use rate had dropped to approximately 53%.6

Furthermore, among individuals killed in motorcycle crashesbetween 1997 and 1999 (515 fatalities), only 9% were not usinga helmet at the crash, which is in contrast to the 933 motorcyclecrash fatalities from 2001 to 2003, in which 61% were found tobe nonhelmeted. Worse yet, for motorcyclists younger than 21years for the same respective periods, 9 versus 45 deaths werefound to be of nonhelmeted riders. It is sobering to think thatcollectively, these untimely deaths represent hundreds of yearsof potential productive life lost, and we can only begin toimagine the extent of the “ripple effect” that these losses havehad and continue to have on Floridian families and their

communities.

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Although the observational and crash data clearly reveal thesubstantial decline in helmet use after the law change, they alsoshow a significant and troubling ongoing decline in helmet useamong riders younger than 21 years. Ironically, this is thespecific age group that the modified policy was designed tocontinue to protect. Knowing this, I would have to say thatthese helmet-use findings leave the future of nonhelmetedmotorcyclists in Florida, particularly young riders, bleak.Further, although some might believe that the increase innonhelmeted fatalities could be attributed to the increase inmotorcycle registrations after the law change, the analysis in thisNHTSA document shows a substantial increase in thenonhelmeted fatal motorcycle crash rate per 10,000 registeredmotorcycles, even while controlling for new registrations (0.7 in1998 versus 6.1 in 2002).

The number of motorcyclists killed in crashes has increasedsince the repeal of the all-rider helmet law in Florida, which isno surprise. The combined number of deaths in 2001 and 2002(575) was found to be 71% greater than that in 1998 and 1999(331). Similarly, the number of motorcyclists killed across thenation has continued to increase. In 2003, there were 3,661motorcyclists who were killed in crashes, which is more than1,500 more deaths than in 1997. The Table shows the 2003additional number of motorcycle crash fatalities compared withthat of 1997 for the 5 states that repealed their universal helmetlaw between 1997 and 2003.

Though opponents of the all-rider helmet law might againargue that the increase in motorcycle crash fatalities is a naturalfunction of the increasing annual motorcycle registrations, thecalculated expected number of fatalities for the first 30 monthsafter the law change was 242. The actual number of motorcyclefatalities encountered for the same time was 301, 59 morefatalities than that estimated to be attributed to registrations andan increase of 24%.

As if the overall increase in fatalities after the law changewere not enough evidence of a policy change gone bad, theNHTSA publication also indicates that in 2002, many moremotorcyclists died at the scene of the crash and died after beingtransported to the hospital than did before the law change. In

Table. Excess mortality from motorcycle crashes in 5 statesafter repeal of all-rider helmet laws, comparing 1997 (beforerepeal) and 2003 (after repeal).*

StateAdditional Fatalities

in 2003Increase in Fatalities

in 2003, %

Arkansas 36 200Texas 201 180Kentucky 30 125Louisiana 55 290Florida 180 101

*Source: NHTSA, Evaluation of the Repeal of the All-Rider Motorcycle HelmetLaw in Florida, August 2005.4

1998, 173 motorcyclists died in Florida. Fifteen of these riders

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NHTSA Notes

were not wearing a helmet, 6 died at the scene of the crash, and9 died after being transported to the hospital. In 2002, 301motorcyclists died. One hundred ninety-eight werenonhelmeted, 100 died at the scene, and 98 died after beingtransported to the hospital.

In the 30 months immediately after the law change inFlorida, the state encountered a 40% increase in the number ofadmissions of motorcyclists to hospitals for injury treatment.Head, brain, and skull injuries were the principal injury for22% of motorcyclists admitted to the hospital after the lawchange compared with nearly 17% of those admitted before thelaw change. However, an increase of more than 82% in headinjury–related hospital admissions occurred during this sametime. Internal organ injury–related admissions increased bynearly 49%. Principal diagnosis is based on the InternationalClassification of Diseases, Ninth Revision, Clinical Modificationcoding system, and it represents the condition established afterstudy to be mainly responsible for the admission of the patientto the hospital.

Given the increase in the number of motorcyclecrash–related injury hospital admissions, one has to wonderabout costs of treatment and who ultimately pays for the care.To further evaluate this and other hospital cost-relatedquestions, NHTSA researchers analyzed hospital admission anddischarge data. The medical cost for treatment in crash-injuredriders in Florida was greater than anticipated, proving insurancecoverage limit provisions in the law to be of little value. Forexample, in the post–law-change period 75% of the admittedhead-, brain-, or skull-injured riders were charged $12,000 ormore, and the remainder were charged less. With the $10,000minimum insurance coverage provision for those riders olderthan 21 years who chose not to wear a helmet, only about 25%were sufficiently insured. According to the Florida Agency forHealth Care Administration data, 63% of injured admittedriders had commercial insurance ($31 million), 16% were “self-pay” ($8 million), and 21% of riders had their costs billed tocharitable and public sources ($10.5 million).

Further, 30 months before the law change in Florida, 52motorcyclists with head, brain, or skull principal injury diedafter admission to the hospital. Average treatment costs for theseriders were $48,126. Thirty months post–law change, 115motorcyclists died after admission. Adjusting for inflation, theaveraged cost per case was $52,450. Once again, the insuranceprovision in the law does not appear to be able to serve itsdesigned purpose. Instead, it is more likely that the public is leftto close the cost gap of injured motorcyclists in Florida.

The highlighted NHTSA report does not go into great detailabout hospital discharge functional status for injured riders orthe extent of rehabilitation needed. However, it does note arecent Florida study by Hotz et al 7 that found that half of thepost–law change injured motorcyclists they followed up at 1year had continuing physical deficits, and only a fraction werestill riding motorcycles, with more than 90% of them using

helmets. It is distressing to think that maybe the injuries of

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these motorcyclists served as the definitive catalyst thatencouraged riders to wear a helmet.

As history continues to repeat itself with Florida being addedto the list of states that have repealed their universal motorcyclehelmet law, there needs to be responsibility for the hundreds of

19 States, Washington, DC, and Puerto Rico Required Use forAll Riders

Alabama New JerseyCalifornia New YorkDistrict of Columbia North CarolinaGeorgia OregonMaryland Puerto RicoMassachusetts TennesseeMichigan VermontMississippi VirginiaMissouri WashingtonNebraska West VirginiaNevadaNot Required in 3 StatesColoradoIllinoisIowa28 States Require Use for a Specific Segment of Riders (Usually

Younger Than 18 Years)Alaska MontanaArizona New HampshireArkansas New MexicoConnecticut North DakotaDelaware* Ohio¶

Florida† OklahomaHawaii Pennsylvania#

Idaho Rhode Island**Indiana South CarolinaKansas South DakotaKentucky‡ Texas††

Louisiana§ UtahMaine� WisconsinMinnesota Wyoming

Source: NHTSA Traffic Safety Facts: Laws, April 2004.*Required for riders younger than 19 years, and helmets must be in thepossession of other riders, even though use is not required.†Required for riders younger than 21 years and for those without $10,000of medical insurance that will cover injuries resulting from a motorcyclecrash.‡Required for riders younger than 21 years, riders operating a motorcyclewith an instruction permit, riders with less than 1 year’s experience, or rid-ers who do not provide proof of health insurance to county clerk (insuranceprovision repealed effective July 15, 2000).§Required for riders younger than 18 years and those who do not have ahealth insurance policy with medical benefits of at least $10,000. Proof ofpolicy must be shown to law enforcement officer on request.�Required for riders under age 15 years of age, novices, and holders oflearners permits.¶Required for riders younger than 18 years and first-year operators.#Required for riders younger than 21 years and aged 21 years or older whohave had a motorcycle operator’s license for fewer than 2 years or whohave not completed an approved motorcycle safety course.**Required for riders younger than 21 years and first-year operators.††Required for riders aged 20 years and younger and those who have notcompleted a rider training course or who do not have $10,000 of medicalinsurance coverage.

Figure. State motorcycle helmet use requirements.

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lost lives. Certainly Floridians and their policy decisionmakersshould be made well aware of the impact of their choice toaccept their fatally flawed motorcycle helmet law. If you are aFlorida resident serving your community in emergency andtrauma care, I would encourage you to help mount a response asa result of this NHTSA report by teaming up with medicalorganizations and advocacy groups to educate your legislatorsabout the miserable policy failure and to overturn the existingpolicy. If you are not a Florida resident and you are not surewhat your state motorcycle helmet policy is, refer to the Figure.Because 19 other states retain their universal helmet law, we canbe assured that most, if not all, will come under attack withfaulty arguments of how motorcycle helmets never saved the lifeof a rider and how they might even be putting riders at greaterrisk. When our graphic stories of clinical encounters withseverely or fatally injured motorcyclists are released for thepublic, agency leaders, and decisionmakers to hear, a cascade ofprofound change can begin. If this does not move legislators torethink their decisions, then remind them that in 1991, the USGeneral Accounting Office (now known as the GeneralAccountability Office) thoroughly researched the pros and consoffered to states that had a universal motorcycle helmet law andfound that “. . .non-helmeted riders were more likely to needambulance service, be admitted to a hospital as an inpatient,have higher hospital charges, need neurosurgery and intensivecare, need rehabilitation, and be permanently impaired and

need long-term care.”8 It appears to me that not having a

206 Annals of Emergency Medicine

universal motorcycle helmet law in your state can be ofsignificant detriment to ED crowding and severely limit thecapacity of a hospital to treat its communities, but this isaltogether another story we have to tell.

doi:10.1016/j.annemergmed.2005.12.007

REFERENCES1. US Department of Transportation. Benefits of Safety Belts and

Motorcycle Helmets: Report to Congress February 1996, Based onData from the Crash Outcome Data Evaluation System (CODES).Washington, DC: US Department of Transportation; 1996.

2. Preusser DF, Hedlund JH, Ulmer RG. Evaluation of MotorcycleHelmet Law Repeal in Arkansas and Texas. Washington, DC: USDepartment of Transportation; 2000. DOT HS 809 131.

3. Ulmer RG, Preusser DF. Evaluation of the Repeal of MotorcycleHelmet Laws in Kentucky and Louisiana. Washington, DC: USDepartment of Transportation; 2003. DOT HS 809 530.

4. Ulmer RG, Shabanova Northrup V. Evaluation of the Repeal of theAll-Rider Motorcycle Helmet Law in Florida. Washington, DC: USDepartment of Transportation; 2005. DOT HS 809 849.

5. Center for Urban Transportation Research. 1998 FloridaObservational Motorcycle Helmet Use Study. Tampa: University ofSouth Florida; 1998. WPI 0510822.

6. Turner P, Hagelin C. Florida Motorcycle Helmet Use ObservationalSurvey and Trend Analysis. Tampa: Center for Urban TransportationResearch, University of South Florida; 2004. BC 353 RPWO 36.

7. Hotz GA, Cohn SM, Mishkin D, et al. Outcome of motorcycle ridersat one year post-injury. Traffic Injury Prev. 2004;5:87-89.

8. US General Accounting Office. Highway Safety: Motorcycle HelmetLaws Save Lives and Reduce Costs to Society. Washington, DC:

US General Accounting Office; 1991.

CORRECTION

In the November 2005 issue, in the article by Rosh (“Diagnosing Pneumonia by History and Physical Examination”;pages 465-467), David H. Newman, MD, should have been listed as an author.

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