Consider how the American sport system typically functions in high schools. The school identifies an athletic director, whose budgetary expenses include coaches, uniforms, equipment, transportation, officials, and facility maintenance.
“And after they’re done with all of that, they ask themselves if they have enough money for an athletic trainer,” Korey Stringer Institute CEO Douglas Casa said at the Aspen Institute’s Future of Sports conversation on how schools can grow access to athletic trainers. “We have to change the mindset. The priority has to be the health and safety of the athletes.”
Although about 80% of high school athletes have access to an athletic trainer, just 56% of schools have one, down 10% since 2017, according to the Korey Stringer Institute. Rural and inner-city schools have far less access than those in the suburbs.
When the NFL provided grants to its teams several years ago to temporarily support athletic trainers in their communities, “the struggle was how to scale it,” said Jeff Miller, NFL executive vice president. “Part of it was economic, but part of it was awareness because I don’t think we had enough schools trying to figure out where in their business plan an athletic trainer fit. In some places, it worked great. In other places, they simply said we’re never going to have a budget for this, so we won’t get it in the first year for something we’ll be stuck with for three years that we won’t be able to afford.”
Insurance companies can provide a valuable “carrot” to incentivize spending on athletic trainers, said Tyrre Burks, founder of Players Health, an insurance company designed to build better health solutions for young athletes.
“We only make money when we pay less in claims than we collect in premium,” Burks said. “The only way for us to have lower claims is if we invest in risk management. We know if an athletic trainer is present, health care is going to be more cost effective, we’ll get ahead of incidents, and it will lower the risks of a catastrophic incident.”
After the Greenville (South Carolina) County School District partnered with a local health system to implement a systematic health care model for sports, injury rates for athletes decreased 22% and insurance premiums went down by more than 50%, according to a 2019 study published by the National Athletic Trainers’ Association (NATA) in the Journal of Athletic Training. Yearly sports participation in Greenville was relatively stable over this time while the percentage of premiums, claims and losses decreased.
“The study was really eye-opening because we started to blend health care, triage and support with claims,” Burks said. “We’re now starting to see they’re not separate in any way. They’re connected.”
Several school district athletic directors say that it’s incredibly challenging to find athletic trainers who want to work odd hours and for the amount being offered by schools. The athletic training profession is transitioning to now require a master’s degree instead of only a bachelor’s in order to be certified. Some athletic directors say this is reducing the pool of talent available at high schools, but the NATA says that’s not the reason schools may have fewer options.
“We believe we have been underpaid for a very long time, and we now have a lot of options as a profession for any athletic trainer,” said Kathy Dieringer, NATA president. “What we’re seeing, which isn’t unique to our profession, is a greater focus on work culture, work-life ratio and being paid what we’re worth. If your school district is prioritizing those things, they’re not having trouble hiring athletic trainers. But it has to start there.”
Athletic trainer salaries vary greatly depending on the hiring organization, geographic location for the job, and experience of the candidate. Ziprecruiter.com lists the average high school athletic trainer salary in the U.S. at $49,684, with pay ranging from $17,506 to $87,401. The majority of salaries currently range between $35,983 to $53,002.
Casa, a kinesiology professor at the University of Connecticut, said high schools must be prepared to pay athletic trainers salaries similar to that of a nurse or occupational therapist. “A bunch of my master’s students last year were outbid by other high schools, corporations and the military,” Casa said. “There are a lot of people realizing the value of an athletic trainer and it’s competitive. Just because a high school isn’t getting them doesn’t mean there’s not enough.”
In Hawaii, 91% of high schools have an athletic trainer because the state earmarks $4.28 million annually in the public school budget. That’s enough for all but the smallest high schools to have at least two athletic trainers. This was a long process for advocates that led to Hawaii starting a pilot program in 1993 by investing $371,000 to hire 10 athletic trainers. The law allowed for a gradual increase in funding until, after every five years, every public high school in the state could have a full-time athletic trainer on staff.
Advocates for state funding turned the topic into a health care issue and came to the state legislature with data. One study showed 82% of athletic health care at the time was being provided by coaches – and 29% of those coaches had no health care training. The other 18% of athletic health care came from emergency medical technicians or non-certified athletic trainers who had no training in sports injuries. Other data showed that major injuries were regularly going untreated.
“If Hawaii could do it at that population size, why not Vermont, Rhode Island or Delaware?” Casa said. “That certainly seems feasible it could happen in other places of similar size.”
For schools that can’t afford full-time athletic trainers, telemedicine offers another option. Some schools use the Go4 app, which connects schools with on-demand athletic trainers who are NATA members. It’s a quick way to get medical coverage for games. Jobs get posted for free without contracts. Schools set their hourly or monthly rate. Also, many schools partner with local health providers for relationships to have athletic trainers on site.
“Those are outside-the-box ways that we have to start thinking about differently,” Burks said. “Some (athletic trainer) coverage is better than none.”
Athletic training experts say the most critical need now for the safety of young athletes is passing a proposed law in California to exercise licensing, regulatory and disciplinary functions for athletic trainers. Despite its massive population size, California is the only state that does not regulate athletic trainers.
The California Athletic Trainers’ Association estimates that 20% of people employed as California high school athletic trainers have not graduated from a certified program or passed a national certification exam. “That’s a little scary,” Dieringer said.
Nationally, U.S. states mandate an average of 54% of the policies proven to reduce deaths related to cardiac arrest, heat/neck injuries, exertional heat stroke and exertional sickling, according to the Korey Stringer Institute. California mandates only 31% of those policies; Florida, New Jersey and Georgia each require over 80% of the recommended policies.
The Smart Heart Sports Coalition, a new collaboration launched by the NFL with many pro sports leagues and health organizations, is advocating for every state to adopt these three policies:
Emergency Action Plans for each high school athletic venue that are widely distributed, posted, rehearsed and updated annually
Clearly marked automated external defibrillator (AEDs) at each athletic venue or within 1-3 minutes of each venue where high school practices or competitions are held
CPR and AED education for coaches.
Only seven states currently implement all three policies, and 12 states have done none. “The standard of care is being set,” Miller said. “I think the states are going to have to understand that and hopefully fall in line and adopt the policies they don’t currently have.”
The nuances of working with superintendents and people unfamiliar with sports will be critical in adopting new policies, Casa said.
“They think they have an emergency action plan, but it’s not specific to sports. We have to make sure we’re starting to shift to policies that are specific to athletics,” he said. “These schools will have nurses during the day, but from 3-7 pm we don’t give them a medical provider when we have these super, high-risk potential situations in sports.”
If Casa had his way, every school that offers athletics would also utilize an athletic trainer. “I would never want to rely on coaches to do this,” he said. “Coaches should be educated as much as possible so they can identify and emergency and mobilize the athletic trainer.”
Jon Solomon is editorial director of the Aspen Institute Sports & Society Program.