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socio-economic status, with high-grade TSCI, and experienced frequent pressure ulcers. In contrast, 53%
of chronic TSCI patients were considered Low Utilizers. These patients on average visited the ED 0.1 times
[38]
per year and only stayed in the hospital 0.3 days per year .

MILITARY VETERANS SUSTAINING TRAUMATIC SPINAL CORD INJURY
According to the department of veterans affairs, the VHA is the largest network of TSCI care in the
country, with over 1,200 integrated healthcare facilities distributed throughout the country. As of 2018,
there are over 19 million United States military veterans, and approximately 9.15 million of those veterans
are enrolled in the veterans affairs (VA) health care system; making the VHA a healthcare provider for
approximately 2.8% of the American population [43,44] . In order for a military veteran to qualify for VA-
sponsored healthcare, they must have served under active duty and have been honorably discharged.
Veterans sustaining a TSCI while in active military service are eligible for monthly disability compensation
[45]
in addition to the healthcare coverage that all VHA-eligible veterans receive . Veterans who are injured in
connection to their military service are entitled to comprehensive healthcare coverage with zero monetary
[46]
responsibility falling onto the patient . The VHA provides an interesting perspective on health care
resource allocation due to eligible veterans being the sole TSCI population in the United States with no
financial responsibility for their post-injury TSCI care.

Traumatic spinal cord injury costs in the veterans affairs health care system
According to the VHA, there are approximately 26,000 TSCI patients who are eligible to receive VHA-
sponsored treatment, half of which chose to undergo specialty treatment within the VA health care
system . The first 12 months post-injury were found to be the costliest, with the average patient being
[45]
charged $606,349 within the first year. Patients were then charged an average of $92,454 annually for long-
[47]
term care . However, these charges can vary greatly depending on the severity and extent of the injury.
Veterans with C1-C4 tetraplegia accrue an average of $1,064,716 in costs within the first year with $184,891
annually, while veterans who still retain some motor function at all levels average $347,484 in costs within
[48]
the first year and $42,206 annually .
Prescription medication coverage for those with TSCI
Considering the high cost of many prescription medications, 88% of veterans with TSCI obtain prescription
medication coverage through the VHA. The remaining 12% utilize either a combination Medicare Part
D & VHA (9.5%) or Part D alone (2.8%). This trend is likely to continue as most veterans with TSCI are
exempt from medication co-payments through the VHA. Patients sustaining a TSCI or secondary co-
morbidity (i.e., pressure ulcer, UTI, diabetes) were found to rely less on Medicare Part D and more on the
[49]
VHA for their prescription medication needs .

UNEMPLOYMENT AND BANKRUPTCY FOLLOWING TRAUMATIC SPINAL CORD INJURY
It is unsurprising that TSCIs of all severities are one of the most debilitating injuries a person can
[50]
experience, often causing significant undue financial strain . Despite many TSCI patients having a desire
and capability to work, data show that only 35% of those having sustained TSCI eventually return to active
[54]
employment [51-53] . Five years post-injury, 25% of these patients were found to file for bankruptcy . TSCIs
decrease the quality of life in patients due to their consequent inability to work and increased healthcare
[55]
costs . Following a TSCI, mobility/physical impairments and incontinence issues may limit the type of
work available to TSCI patients [56,57] . Following a TSCI, skilled labor jobs may no longer be an option and
many patients unable to return to their old jobs are forced to find new avenues of employment [58,59] .Realizing
this difficulty, the Rehabilitation Act of 1973 was amended in 1992 to include supported employment (SE),
which promotes disabled persons to return to the workforce. SE encourages those with significant disability
[60]
to find jobs with competitive pay and have supportive services provided to those that in need .