Throughout the 1970s and 1980s, and even in some communities today, profit-oriented ambulance operators (not, I note, "EMS professionals") told city and county fathers, "You shouldn't have to put a dollar of tax money in to this - just give me the exclusive franchise and I will take care of it for you."

When you could charge (and even hope to collect) any rate you set, there were communities in which this approach could work.  In the Pacific Northwest, for example, ambulance bills in the 1990s could be $700-$1100, and that would support enough ambulances to make 8:59, 90% of the time (or almost, anyway). 

That was then, this was now.  We've got the National Medicare Fee Schedule, Medicaid that pays less than NMFS, and insurance companies that have followed suit.  Cost shifting the full cost of a system has become very difficult, in all but the most affluent of communities.

But wait a minute!  Why is "subsidy" a dirty word, when it comes to an EMS system?  We subsidize libraries, schools, highways, etc.  Our health care system is pretty bad, because we've kept it totally in the private sector (so that a few can make lots of money off of the rest).  Isn't an EMS system an element of the quality of life in a community?  Shouldn't all of us share the cost of having timely, skilled EMS response?  And I submit that 8:59 is not nearly quick enough (I know, there's no "outcome data" to support that, but that's ONLY because nobody has done or can ethically do a prospective, randomized controlled study that will settle the question). 

Never mind that -- when my loved ones need EMS, I want it to come in 3 or 4 minutes, just like if my house is on fire - not in 8 or 10 minutes!!  I value my health at least as much as my property, and I'm willing to pay to get the service that I want.

So, when you wonder why we're scraping by on bare-bones budgets, with long response times, poorly compensated staff, and barely adequate systems, thank our past and present-day profiteers.  THEY are the ones who educated our elected and appointed officials that they should not spend tax dollars on the EMS system in YOUR community.

Then get out there, show them what you do, and start the re-education process.  Maybe in 10 or 20 years we can have an EMS system more like the ones in England or Australia, where EMS is delivered to everyone, by health care professionals, and worries about "the bill" are not part of every patient contact.

Skip Kirkwood, M.S., J.D., EMT-P