Back to the Future:
An Agenda for Federal Leadership of Emergency Medical Services
THE GEORGE WASHINGTON UNIVERSITY
HOMELAND SECURITY POLICY INSTITUTE
ISSUE BRIEF
Frank J. Cilluffo, Daniel J. Kaniewski, Paul M. Maniscalco Co-Chairs
May 2, 2005
HSPI Steering Committee
HSPI Task Force on Emergency Medical Services
About the Institute
America's first responders proudly serve their communities by responding thousands of times daily to calls for help from the citizens they serve. And as we have seen, catastrophic events such as terrorist attacks will demand significant resources and specialized capabilities from first responders. However, even in a post-9/11 environment, a fundamental component of the first responder community—Emergency Medical Services (EMS)—is a missing piece of the preparedness puzzle.
Today EMS needs a seat at the table, as first responder policy, funding and operations are debated at the federal level. To this end, EMS deserves an appropriate home in the federal bureaucracy that is afforded to the other first responder constituencies. Given the stated intention of the new Secretary to reexamine the Department of Homeland Security’s mission and structure, now is the ideal time to provide EMS with the leadership, resources and stature that have been absent during its recent history. We therefore propose that EMS be transferred from its current home at the Department of Transportation to the Department of Homeland Security (DHS), where a U.S. Emergency Medical Services Administration (USEMSA) should be established.
EMS History: A federal perspective
By some accounts, pre-hospital medical care dates back to 1797 when Napoleon's chief physician implemented a triage and transport system to move the injured from the battleground to aid stations. In the 1860s, ambulance services came to Cincinnati and New York City. But it was not until a series of events in the mid-1960s that modern EMS was born. At the time, morticians—not medical providers—staffed 50 percent of the nation’s ambulances.1 In 1966, The National Academy of Sciences (NAS) authored a white paper, Accidental Death and Disability: the Neglected Disease of Modern Society, which drew attention to preventable injuries as the leading cause of death among persons between the ages of 1 and 37 and placed particular emphasis on the preventable injuries related to automobile collisions.2 The report galvanized the government to address this "injury epidemic" and led to a federal focus on the emerging field and the development of standards for EMS equipment and training.3
As a result of the NAS report, Congress established an EMS office in the newly created Department of Transportation (DOT). Today EMS continues to be led at the federal level by the Department of Transportation, within its National Highway Traffic Safety Administration (NHTSA).4
Several important events outside of the federal government's sphere of influence occurred during the late 1960s and into the 1970s5 and momentum gained with the designation of the Health Services and Mental Health Administration as the lead agency for EMS within the Department of Health, Education and Welfare (HEW).6 HEW provided additional funding for EMS capacity-building, culminating with the passage of the EMS Systems Act of 1973, which funded regional EMS systems. EMS systems across the country grew with this steady stream of federal funding, which reached its pinnacle during the 1970s.
The upward trend in EMS funding quickly fell in the 1980s, principally because the Omnibus Budget Reconciliation Act of 1981 rolled EMS funding into the Preventative Health and Health Services block grants that gave States the discretion to determine funding priorities.7 Most States chose to fund programs other than EMS. After 1981, federal funding for EMS never returned to its previous levels and localities were left to bear the burden of funding EMS.
Without funding, the EMS efforts at the Department of Transportation and the Department of Health, Education and Welfare ground to a halt. By 1983, HEW had lost all of its EMS mission and DOT began to assume additional responsibilities, but because DOT was not vested with the authorities or funding provided to the HEW office, it had neither the carrot nor the stick necessary to encourage States to develop their EMS systems.8 This decentralized approach to EMS began a 20-plus year period of stagnation for EMS at the federal level and facilitated the disjointed approach to systems development and inconsistent standards that characterizes EMS today. Today, there is no one model for EMS delivery, oversight or scope of practice, as States and localities make their individual decisions with almost no assistance or guidance from the federal government.
EMS: A primer
Like its law enforcement and fire service counterparts, the nation's EMS agencies have a common function, but do not share a single operational structure. EMS can be delivered by either paid or volunteer personnel at a stand-alone local government EMS agency, fire department, hospital, for-profit or non-profit private company, or by other less common ways, such as a police department or an integrated public safety department. According to a 2004 Journal of Emergency Medical Services study, 44.89 percent of EMS systems are fire-based and 55.11 percent are hospital-based, private, stand-alone government agency or another type of EMS organization.9
The nation's 840,000-plus EMS personnel are trained, generally speaking, to either the basic level (EMT-Basic) or advanced level (EMT-Paramedic).10 EMT-Basics can assess and stabilize patients’ immediate needs, whereas paramedics provide additional interventions, such as intravenous medication delivery, cardiac monitoring and defibrillation, and advanced airway procedures. Many EMS providers also have specialized training in the areas of patient extrication and rescue, incident command, hazardous materials response, crisis intervention, mass casualty response and injury prevention.11 Each State sets its own requirements for training and certification, though the EMT-Basic and EMT-Paramedic curricula are based upon a national standard developed by DOT.
Regardless of the delivery method or level of training, EMS strives to quickly respond to, care for and transport the sick and injured during their time of need. Such emergency assistance is required for the thousands of heart attacks, automobile collisions and other "everyday" emergencies. But there is also a significant need for EMS response for infrequent, but high-consequence crises, such as natural disasters or terrorist acts. EMS must therefore be adequately prepared for both the ordinary and extraordinary events.
Key Issues
Several significant issues must be addressed if EMS is to be a true partner in the first responder community—responding to daily emergencies and mass casualty events alike.
Funding
Though EMS providers are roughly equal in numbers to firefighters and law enforcement officers, they receive only four percent of the first responder funding allocated by DHS.12 This is unsurprising from the federal perspective, given that EMS is not located in DHS, but disturbing, given that EMS is as critical a component of the first responder community as the other groups. This means, for example, that following a weapons of mass destruction (WMD) attack, firefighters and law enforcement officers will be donning their personal protective equipment that was paid for by the federal government, while EMS providers stand unprotected on the sidelines, unable to treat the patients that are in need of their immediate lifesaving help. The only other option available to EMS personnel will be to enter a contaminated environment unprotected and thus face almost certain bodily harm. Unprotected EMS personnel will become victims themselves, leading to further casualties and creating an unmitigated disaster.
Unlike law enforcement and the fire service, EMS has no grant programs dedicated to its basic operating needs.13 EMS has many unfilled equipment specialized equipment for medical interventions and rescue), as well as demands for the recruitment and retention of personnel, particularly volunteers.
Data collection
EMS lacks a data collection program similar to the federal programs provided to its first responder counterparts. Thanks to the U.S. Fire Administration, we know that there were 1.6 million fires causing $12.3 billion in damage during 2003.14 And the Bureau of Justice Statistics tells us that 1,068,500 violent crimes were reported in 2003 and police made 597,000 arrests.15 No federal agency collects data on EMS responses—a major shortcoming that undercuts the EMS community’s ability to conduct research to improve itself, or even justify its mission.
Needs assessment
There has never been an assessment of the needs of EMS in the United States. There has, however, been a recent effort for the fire service. In 2002, the U.S. Fire Administration commissioned the National Fire Protection Association (NFPA) to conduct a modern needs assessment of the American fire service. According to NFPA President James M. Shannon:
The results of this study identify many areas where additional resources are needed for the fire service to operate effectively and safely, in both traditional response and the new challenges faced by homeland security. Firefighters and the citizens they protect deserve the best we have to offer.16
Given the value of this study to the fire service, a similar study for EMS would be equally valuable and is critically needed.
Training academy
There is no national training academy dedicated to emergency medical services providers. The Federal Emergency Management Agency provides firefighters with the National Fire Academy and emergency managers with the Emergency Management Institute. Police officers have opportunities with such training sites as the Federal Law Enforcement Training Center and the FBI Academy. Although EMS providers can participate in courses held at some of these sites, none are focused exclusively on EMS training and educational needs and none integrate well the medical aspects of emergency response. The existing inventory of federally funded courses that address EMS-specific operational or medical response issues is minimal at best.17
Beyond the short, topic-based training courses, the broader educational programs taught at the flagship centers for police and firefighters have brought us the leaders for the next decades in the fire service and spawned aggressive training and educational programs all over the country. Clearly, the public would benefit if the same attention were paid to the professional development of EMS providers.
Bureaucracy
Unlike the fire service, with its home in the Department of Homeland Security's USFA, EMS does not have a strong advocate in the federal bureaucracy. The irony here is that, unlike the other groups,needs (personal protective equipment and EMS has many of its standards codified in law. Such standards include the regulations for ambulances and EMS training curricula.18 Unfortunately, though the federal government already possesses much of the authority to provide it with guidance and support, EMS is buried deep in the bureaucracy in DOT, making it nearly impossible to effect change or advocate policies. At the federal level, EMS is an all-but-forgotten component of emergency response, and thus needs to be in a federal department that embraces its first responder mission.
These shortcomings reflect the lack of federal leadership on EMS. Two reports addressed these issues, but fell short in their recommendations.
EMS shortcomings highlighted
With much anticipation from the EMS community, a working group funded by the Department of Transportation developed the EMS Agenda for the Future in 1996.19 One of the report's goals highlighted the need for federal EMS leadership. Written in the context of an ideal state for EMS, it proposed the following:
There is a federal lead EMS agency. The agency is mandated by law, sufficiently funded and credible, and is recognized by the health care and public safety systems. It directs nationwide EMS development, provides coordination among federal programs/agencies affecting EMS, serves as a central source for federal EMS-related research and infrastructure creation funding, provides an information clearinghouse function, and oversees development of national guidelines.20
Unfortunately this dream has not become reality. The EMS Agenda for the Future, a much heralded effort in the 1990s, has since all but been forgotten. The subsequent "implementation guide" does little more than to encourage the EMS stakeholder organizations to form partnerships.21
A recent report by New York University highlighted well some of the issues EMS faces, but its solution to the problems—pointing to the existing federal inter-agency committee—is inadequate.22 The Federal Interagency Committee on EMS (FICEMS) is a toothless tiger that focuses on EMS coordination between federal agencies with limited EMS roles. It has no ability to lead federal policy, influence budgets or address state or local EMS issues. Subsequent legislation introduced by Senator Susan Collins (R-ME) and Congressman Joel Hefley (R-CO) proposed this FICEMS "solution."23 Such legislation will do virtually nothing to address the challenges EMS faces.
A much more comprehensive—and ambitious—effort is necessary if we are to address the federal EMS leadership and funding gaps that have persisted for more than two decades.
A new home for EMS: The U.S. Department of Homeland Security
EMS has no true federal advocate. It is housed in a small program office of the Department of Transportation, National Highway Traffic Safety Administration (NHTSA), which itself focuses little on EMS. In fact, there is no mention of EMS or any related function on the "Who we are and what we do" section of the NHTSA website:
NHTSA is responsible for reducing deaths, injuries and economic losses resulting from motor vehicle crashes. This is accomplished by setting and enforcing safety performance standards for motor vehicles and motor vehicle equipment, and through grants to state and local governments to enable them to conduct effective local highway safety programs.
NHTSA investigates safety defects in motor vehicles, sets and enforces fuel economy standards, helps states and local communities reduce the threat of drunk drivers, promotes the use of safety belts, child safety seats and air bags, investigates odometer fraud, establishes and enforces vehicle anti-theft regulations and provides consumer information on motor vehicle safety topics.
NHTSA also conducts research on driver behavior and traffic safety, to develop the most efficient and effective means of bringing about safety improvements.24
While DOT/NHTSA might have been the appropriate home for EMS in the federal government during the early years of EMS when its focus was on transporting automobile accident victims, EMS has long outgrown such vestigial ties.25 The time is ripe for EMS to move to a more suitable federal agency.
We are not alone in our desire for EMS to have a true federal leader. Outside experts, such as the Advisory Panel to Assess the Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction (a.k.a. "Gilmore Commission") have called for a federal EMS agency to support EMS operations and systems issues.26
The most appropriate solution to the EMS quandary of being housed in a department in which it no longer fits is to move it to a department that leads the federal government’s first responder efforts.
The Department of Homeland Security is the ideal home for EMS at the federal level. One of the department's primary missions, to "minimize the damage from potential attacks and natural disasters" fits well with the role of EMS as an essential member of the first responder community. DHS has developed and now administers the National Incident Management System (NIMS). This system emphasizes interoperability and prescribes the role of EMS in the incident response template.27 Thus, it is logical that, since EMS is a key component of NIMS, it be incorporated into DHS.
Within DHS, EMS needs an advocate for the funding, training, education and exercising as well as the equipment afforded to other first responder groups. Therefore, we call for the establishment of the U.S. Emergency Medical Services Administration (USEMSA) that should be modeled after, and be at an equivalent level to, the U.S. Fire Administration (USFA). As is the case for the USFA, USEMSA should have a high-ranking administrator and adequate funding appropriated to the office itself and for EMS grants to states and localities. It should have the informal powers, such as access to senior DHS leaders and a seat at the table when first responder policies are discussed and debated. It should also have an associated national training center.
In summary, the USEMSA should posses, at a minimum, the following results-oriented characteristics:
- Lead national EMS policy
- Be funded at an appropriate level for this critical national mission
- Manage and update existing EMS education and vehicle standards
- Be the EMS providers' voice in the federal government
- Examine EMS responder safety issues
- Collect and disseminate EMS data, as USFA and the Bureau of Justice Statistics do for the other first responder constituencies
- Be the central clearinghouse for EMS information, funding and standards
- Manage national training programs
- Conduct research, including needs and capabilities assessments
Though this proposal is ambitious, it is not unprecedented in scope. When DHS was created in 2002, critics argued that the bureaucracy could not be rapidly overhauled. Today, with 22 agencies and 180,000 employees, DHS has accomplished its goal of consolidating the nation’s homeland security efforts.28 29
Without appropriate representation and integration into the federal government’s first responder activities, EMS issues will continue to go unaddressed, and lack of policy coherence and funding will continue unabated. Some would argue that EMS is in the right place in the federal bureaucracy since transporting patients is what EMS does. This view fails to recognize the evolution of EMS over the past 30 years and continues the misperception of EMS as merely a transportation mode. EMS must not fall victim to what Peter Principle author Laurence J. Peter found: "Bureaucracy defends the status quo long past the time when the quo has lost its status."
Conclusion
In Secretary Michael Chertoff’s March 16, 2005 vision speech at The George Washington University, he stated, "Old categories, old jurisdictions, old turf will not define our objectives or the measure of our achievements. Because bureaucratic structures and categories exist to serve our mission, not to drive it." Moving EMS into DHS with the funding and status it deserves resonates well with the Secretary's mission-oriented vision.
We should pull a page from the history books and see, that in the 21st century, EMS deserves a renaissance to its high water mark 30 years ago. By reinvigorating EMS leadership at the federal level in a department that embraces first responders, EMS personnel on the front lines will be better prepared to respond to the full spectrum of emergencies—from the ordinary to the extraordinary. And since better prepared EMS providers mean a better prepared nation, this is one lesson we cannot afford to forget.
About the Co-Chairs
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Posted 09.12.05
