The origins of the modern EMS delivery model can be traced to the mid-1960s when the National Academy of Sciences published a white paper called Accidental Death and Disability: The Neglected Disease of Modern Society. Referred to as "Death in a Ditch," the white paper described the deplorable state of prehospital emergency care in the United States and strongly advocated for national attention and action. During the Nixon administration, a number of pilot projects looked at different EMS delivery methods and some local communities from coast to coast embarked on individual programs to improve out-of-hospital care.
In the early- to mid-1970s, national standard-training curricula were developed and the concept of trauma systems began to grow and mature. The emphasis throughout this early developmental period was on system design and standardization of training. The decisions about who would deliver EMS or how really didn't matter, as long as it was done within a system and based on some minimum standards.
At the national level, from the very beginning, a number of different agencies have been involved in EMS—in recognition that EMS touches many disciplines and exists primarily at the intersection of public safety and public health. These agencies include the National Highway Traffic Safety Administration within the Department of Transportation, the Department of Health and Human Services (HHS), the Department of Homeland Security and its subsidiaries like FEMA and the U.S. Fire Administration, the General Services Administration and the Department of Defense, among others.
There has always been tension between these various federal agencies when it comes to EMS, for a variety of reasons, but they work together to move EMS forward.
Likewise, in our communities and on the streets, EMS has evolved in a number of organizational homes, such as the fire service, hospitals, government third services, private nonprofits and private for-profit organizations. How to structure and implement an EMS delivery system is largely a policy decision at the local level. There are excellent examples of each and there are also terrible examples of each. It's not about the patch on the uniform; it's about the quality of service being provided. As with the federal government agencies, there has always been tension between the various entities providing EMS in our communities.
In recent years, the tension between the various organizations and agencies involved in EMS has increased as competition and limited resources strain organizations. This has resulted in lots of name-calling and claims about who is better at providing EMS. In the midst of all of this noise, a piece of legislation, known as the Field EMS Bill (H.R. 809/S. 2400), has been introduced in the U.S. Congress. It has been languishing in Congress for some time, but seems to have found new energy lately.
The piece of legislation has become quite polarizing in the EMS community, and it's being characterized as advocating one type of system over another or favoring one type of delivery model over another. That's not what it's about at all.
The IAFC has publicly opposed the Field EMS Bill and, contrary to what some would have you believe, it's not a fire-versus-private-EMS delivery issue. We have concerns about the legislation because we believe it is simply bad policy. We have three primary areas of concern.
Grants for Private EMS Companies – The Field EMS Bill establishes a grant program known as the EQUIP Program. It is much like AFG/SAFER grants. The only requirements for eligibility are for a recipient to be a licensed EMS agency and to have a medical-oversight and quality-improvement program.
These very lenient eligibility guidelines would permit funding for private, for-profit corporations. At a time when funding is being reduced and grants are being eliminated, we don't believe it is appropriate public policy for the Congress to be giving scarce support to private, for-profit companies. Think government gifts to Apple or Microsoft—it just doesn't make sense.
Elimination of Federal EMS Partners – The Field EMS Bill proposes to shift the primary home of EMS to HHS as the lead federal agency for EMS. As described earlier, currently several federal agencies have significant interests in EMS because EMS is a public service that touches many disciplines and perspectives. It is part public health, part public safety, part homeland security, etc. The current agencies communicate and coordinate with each other through the Federal Interagency Committee on EMS, which seems to be working just fine.
Focusing the federal involvement in a single agency would narrow the view of EMS and push many vitally important aspects of EMS to the periphery, ignoring the many important roles EMS providers play. It's not that we have a particular favorite among the federal agencies. Instead, we fail to see how the creation of a new federal agency within HHS and the bureaucracy that goes with it will accomplish anything of real benefit. It looks a lot like a solution in search of a problem.
Ineffective Funding Mechanism – The Field EMS Bill proposes using a check-off box on tax returns to fund the grant programs and the HHS Office of EMS. Donations would be permitted in $1, $5 and $10 increments to fund the estimated $321 million cost of the bill. These contributions would increase the public's tax bill or reduce their refunds. In 2013, there were 146 million individual income tax returns. Even at the highest contribution of $10, more than 32 million donors, or 22% of all taxpayers, would be needed to fully fund the Field EMS Bill—a turnout unlikely to be realized. The instability of similarly funded programs, such as the Presidential Election Campaign Fund, which received support from just 6% of taxpayers in 2012, shows how the Field EMS Bill could introduce another unsustainable federal program.
While the Field EMS Bill should be credited for prompting important discussions about the future of EMS and innovative EMS delivery systems, we simply believe that the reforms it proposes are at best unnecessary and at worst bad public policy that will actually do damage to our nation's EMS system. The IAFC has engaged in numerous discussions with the Field EMS Bill's supporters in an attempt to resolve our concerns, without success. As long as the bill continues forward in its current form, we will continue our opposition to this initiative.
Just as the field of EMS today looks nothing like it did 50 years ago, it will also look very different 50 years from now. The IAFC's priority is to ensure that all of the progress made in the first 50 years of the modern EMS model is sustained into the future without getting dragged down into debates about who delivers better service or damaged by the implementation of well-intentioned but bad public policy.
We stand ready to work with all parties to identify and deal with the real problems facing EMS systems today. The Field EMS Bill falls far short of that mark.
Bill Metcalf, EFO, CFO, is the IAFC president and chairman of the board. He is fire chief for the North County Fire Protection District in Fallbrook, Calif.