An in-depth understanding of the economic problems confronting trauma centers is essential for their continued development and to address impending changes of health care reform. A comprehensive financial and demographic survey was sent to 839 hospitals identified as potential trauma centers. A total of 313 surveys from 48 states were returned. Extensive information was collected in several areas including financial status (58% reported serious financial problems and 36% reported minor financial problems; 68% reported a financial loss), cost containment and management strategies, marketing, "halo" effect (53% reported positive effect), operational impacts, physician support (47% reported problems), malpractice (92% reported no special problem), role of auto insurance reimbursement, and access to rehabilitation. Detailed financial data of actual costs and reimbursements (95 respondents) were analyzed with the costing method used by the Health Care Financing Administration (HCFA). These data will allow us to develop better strategies to deal with the problems of uncompensated and underfunded trauma care and improve trauma center viability.