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Who's on the Mark? - Controversy surrounds EMS pursuit of equal resources, priority & focus in Congress

By Mannie Garza

Most think-tank reports make hardly a ripple before they disappear into file cabinets, never to be seen again. In contrast, Back to the Future: An Agenda for Federal Leadership of Emergency Medical Services, a report from The George Washington University Homeland Security Policy Institute (GWU/HSPI), has created a tsunami of controversy since its May 2 release.

GWU/HSPI leaders had convened a 40-member task force on EMS, which communicated primarily via telephone and e-mail, to consider the current state of EMS preparedness, to determine why EMS has received so little federal support and funding, and to offer recommendations for addressing the root cause. The group agreed that:

EMS is underfunded. Although EMS providers are roughly equal in number to firefighters and law enforcement officers, EMS received only 4% of the 2002 and 2003 funding earmarked for first responders by the Department of Homeland Security (DHS) (Source: DHS). The report states that because of the funding shortfall, "following a WMD attack . EMS providers [would] stand unprotected on the sidelines, unable to treat the patients that are in need of immediate lifesaving help, . or [be forced] to enter a contaminated environment unprotected and thus face almost certain bodily harm."

EMS lacks a national data collection program similar to those provided to other first responder organizations. (Author's note: The report fails to mention the National EMS Information System [NEMSIS] project now underway with support from several federal agencies.)

A national EMS needs assessment has never been conducted in the United States.

EMS has no national training academy. The report notes, however, that EMS providers can participate in courses at the National Fire Academy, the Emergency Management Institute and the Federal Law Enforcement Training Center.

EMS does not have a strong advocate in the federal bureaucracy. "It is housed in a small program office of the Department of Transportation, National Highway Traffic Safety Administration [NHTSA], which focuses little on EMS," the report notes.

To address those shortcomings, the GWU/HSPI Task Force on EMS calls for the establishment of a U.S. Emergency Medical Services Administration (USEMSA), a stand-alone agency within the DHS (not the DOT) that would be "modeled after, and at an equivalent level to," the U.S. Fire Administration. "USEMSA should have a high-ranking administrator and adequate funding appropriated to the office itself and for EMS grants to states and localities," the report says. The task force envisions that USEMSA would:

.Provide a voice for EMS at the federal level; .Lead EMS national policy; .Manage and update EMS education and vehicle standards; .Manage national EMS training programs; .Examine EMS safety issues; .Collect and disseminate EMS data; .Serve as a clearinghouse for EMS information, funding and standards; .Conduct EMS research (including assessments of EMS needs and capabilities); and .Receive funding to achieve these missions.

The process & report

"We are a policy organization, a think tank, not an advocacy group," says GWU/HSPI Deputy Director Daniel J. Kaniewski, NREMT-P, a co-author of the report. "We had no preconceived notion about the final conclusion except that EMS has been underfunded for years. Our goal was to think outside the box and offer innovative recommendations on an issue that's been around for 30 years."

Kaniewski, a former Congressional liaison for Terrorism and Preparedness and Consequence Management at the Federal Emergency Management Agency, served as homeland security fellow in the offices of Reps. Curt Weldon (R-Pa.), and J.C. Watts (R-Okla.) and as EMS advisor to the Congressional Fire Services Institute. He was a volunteer firefighter and an EMT in Minnesota and rides regularly with several volunteer ambulance squads in the D.C. area.

"This started months ago after several people on Capitol Hill asked us what should happen with EMS at the federal level," says Kaniewski. "We said there was no one opinion, and it would be difficult, if not impossible, to convene all the constituencies and come up with a unified voice on the role of EMS in the federal government. We did this [report] without the input of organizations that have disagreed about this for years."

Paul M. Maniscalco, EMT-P, MPA, Dr.BA(c), assistant professor of health sciences at GWU and report co-author, explains: "We created a task force with EMS leaders from all types of delivery models and a steering committee with senior government officials, including [former FEMA Director] James Lee Witt and Judge [William] Webster [former director of both the CIA and the FBI]. The task force chairs put the issues on the table, the task force created a draft, the steering committee lent its advice and support, and, at the end, it bubbled up as . a product that stands on its own. This is about how EMS has been turned into orphaned children."

Maniscalco, a former deputy chief/paramedic for the city of New York, represents EMS on various federal committees related to homeland security and served as chair of the Gilmore National Terrorism Commission's State and Local Response Panel and Threat Reassessment Panel. He is also a board member of the National Association of EMTs. "We had consensus to stay away from how EMS is delivered at the local level, because we didn't want this to be seen as a tacit endorsement of any one delivery model," he says.

The reaction

The report quickly began circulating via the Internet, provoking heated discussion and emergency meetings so organizations could determine their positions.

The nation's largest EMS organization, NAEMT, invited members to answer three questions online: 1) Do you support the creation of a single federal EMS agency that is equal in stature to the USFA with separate and distinct sustainable EMS funding? 2) Do you believe that the aforementioned body should be billeted in the Department of Homeland Security, as is the USFA?
3) Do you believe that EMS should remain as an organizational subunit of the U.S. Department of Transportation (DOT)/NHTSA?
The survey was up for only two days, but collected 4,075 responses. Although people could vote multiple times, the results did give some sense of what the nation's EMTs and paramedics think about the issue: 98% answered "Yes"
to question No. 1; 92% answered "Yes" to No. 2; and 93% answered "No" to No.
3.

Many national EMS organizations have taken the opposite position, however, with most supporting a strong continued role for the NHTSA EMS office with the addition of a Congressionally mandated, strong Federal Interagency Committee on EMS (FICEMS).
When Congress passed the Emergency Medical Services Systems Act of 1973, it required the Secretary of the Department of Health, Education and Welfare (HEW, which is now Health and Human Services [HHS]) to convene and chair FICEMS. At that point, HEW had an EMS office charged with implementing the EMS Systems Act, and the office had funding to disburse to help build regional EMS systems. Then the funding dried up, and HEW closed the EMS office in the early 1980s. FICEMS continued to meet; however, as it is currently structured, FICEMS has no mandate, no funding, no power and no responsibilities-except to share information among federal agencies involved in some aspect of EMS.

In the past two years, several national EMS organizations have launched an effort to convince Congress to give FICEMS a new federal mandate so it has some teeth and establish a new 13-member advisory group to represent the many organizations that compose the EMS community. Most of those organizations want to stick with that plan.

Also, many organizations want NHTSA to remain the de facto lead EMS agency-at least for now-working in partnership with other federal agencies and such offices as the HHS EMS for Children program and its Division of Trauma and EMS, the USFA, and the Centers for Disease Control and Prevention.

"We fostered this debate because we heard from the nation's leaders, saying they want to understand EMS and act to help," Kaniewski says. "Congress is ready to act. We will now step back and watch what happens."

FICEMS Redux

Shortly before his death in September 2004, JEMS founder Jim Page wrote an editorial for jems.com. In "FICEMS: A Necessary Resuscitation?" he explained how Congress mandated FICEMS in 1973, shared his recollections of FICEMS meetings he'd attended and summarized the committee's achievements: "In the end, I had to judge it a colossal waste of time and money," Page wrote.
"There's no record of any significant recommendation, resolution or achievement coming from its meetings or proceedings. . If the original Interagency Committee on EMS could produce no significant recommendation, resolution or achievement, what are its chances in the current environment? . Despite the inherent flaws, an interagency committee would be an essential part of a comprehensive national EMS program. . Without a comprehensive national plan and the millions or billions of dollars needed to implement it, agencies on the committee have nothing to talk about."

EMS leaders weigh in

In favor of a separate EMS Administration within DHS

National Association of EMTs President Ken Bouvier, a paramedic supervisor with New Orleans EMS:"The NAEMT Board of Directors voted [May 13] supporting in concept the consolidation of EMS into a single high-level federal EMS agency within DHS, on par with police and fire. Second, we passed a motion that NAEMT will use an independent company to survey its members to see what this federal EMS agency can do for us. After we get the survey pulled together, we're going to put it on the NAEMT Web site (http://www.naemt.org). NAEMT carefully reviewed the report from GWU before taking a position. We wanted to make sure that any decisions we made truly represent the people in the field, because these changes will affect EMS for many, many years. This is very complex, and it's going to take time to resolve it."

Chris Callsen, senior division commander, Austin-Travis County (Texas) EMS; cofounder and chair of Project USEMSA, which has promoted a stand-alone U.S.
EMS Administration within DHS since 2003, and a member of the GWU/HSPI Task Force on EMS:"Having several small programs scattered around the federal government with [insufficient] resources and staff will never let EMS be sufficiently represented at the table. The folks at the [NHTSA] EMS office have done an incredible job, but you have to go through seven layers of bureaucracy to reach [the Secretary of Transportation], who has many other priorities. Strengthening FICEMS would still mean a small group of agencies, each tasked with a small portion of EMS, but no agency with a primary focus on EMS and no agency with primary responsibility. Who would be accountable?
With DHS, EMS has a clear linkage. Most EMS folks see themselves as part of public safety, although we [also] link with public health and health care.
The fire service has been incredibly successful in creating the U.S. Fire Administration; we now have the same opportunity in EMS."

Chief Donald W. Walsh, PhD, assistant deputy fire commissioner for EMS, Chicago Fire Department (CFD), and cofounder of Project USEMSA (His comments do not imply a CFD position on this issue.):"Our vision is a stand-alone EMS agency in DHS right next to USFA-not with USFA or run by USFA-[with] a National EMS Academy and EMS data collection. I ask people why they're afraid of this. There's paranoia out there that if EMS gets grant money from DHS, [then] all the fire service money will dry up. But it's really the opposite. The [DOT/NHTSA] is not the right place for EMS. The EMS office within DOT has done the best job it could with its limited budget and staff, but I recommend we transfer that entire staff to DHS. The concept of FICEMS is good, but until we have a central EMS agency, nothing will happen. I've talked with people in Congress, and they're drafting bills. The bottom line is that this is the right thing to do."

Ben Hinson, president of Mid-Georgia Ambulance Service, Macon, Ga., and a member of the GWU/HSPI Task Force on EMS:"The political reality is that the money that will be allocated for emergency response will come from DHS; that's where we have the best chance to get funding. EMS got placed in DOT when the main reason for EMS in America was to work crashes. Jim Page and Johnny and Roy [on the TV show Emergency!] made people aware that EMS is more than that. I don't think they should shut down the NHTSA EMS office, but they should move it over to DHS. It's misplaced and stifled within NHTSA. The NHTSA Web site doesn't even mention EMS. Will we get lost in DHS?
I don't think we shouldn't go up to bat just because we don't know if we can hit a home run."

Chief Jon Politis, MPA, NREMT-P, Colonie EMS Department, Colonie, N.Y., and member of the GWU/HSPI Task Force on EMS:"EMS needs a national seat at the table and to be treated with equality. Since the federal development grants ended in the early 1980s, we have had nobody leading EMS in this country.
Even the 1996 Agenda for the Future calls for a single, national EMS lead agency. NHTSA isn't it. While millions have been pumped into infrastructure development for police and fire, many communities are unprepared to handle the resulting medical component of a WMD catastrophe. WMD is a big hazmat MCI that's mostly a medical incident. Unfortunately, EMS is untrained and unequipped to handle it. Why? No money, no focus on responder safety or preparedness. We [need] a national infrastructure to deliver meaningful programmatic assistance. We need medically focused programs, national in scope, along with a program development and delivery infrastructure. EMS needs the same type of national academy as police and fire."

Division Chief Gregg C. Lord, EMS coordinator for the Cherokee County (Ga.) Fire Department, a National Association of EMTs board member and a member of the GWU/HSPI Task Force on EMS (His comments reflect only his views and not necessarily those of the CCFD or NAEMT.):"When the big ones come down, both [private ambulance services] and fire departments will respond, and they need to be prepared and equipped. Clearly we need a single agency to represent EMS. Putting it in DHS may not be the perfect answer, but where else would you put it? I had separate conversations with three Congress members, all of whom asked, 'Why is EMS in DOT and not part of DHS?' That's a hard question to answer. We haven't been able to get the resources we need because [EMS has] been split up. And now that we have a chance to consolidate and Congress is listening, the EMS community is acting divisively. NAEMT did a really cool thing by putting out a survey to hear from the street guys if they're getting the resources they need. . Their perception is that they need this. Can all the street providers be wrong?
This will literally take an act of Congress. I'm sure Congress will ask for hearings to hear from all constituent groups and study the issues. Then who knows what will come from this."

In favor of a decentralized, collaborative approach

NHTSA Administrator Jeff Runge, MD:"As an emergency physician and former EMT, I understand the vital need for EMS systems to be prepared for any emergency. Several current national reports correctly point out the need for additional EMS resources. However, we need to think carefully about changing the EMS system configuration, at any level, to 'follow the money.'
Dismantling the long-standing NHTSA EMS program, or that of any other federal agency, in the quest for additional, and perhaps time-limited, funding streams is not good policy-not good for the patients, not good for EMS field providers and not good for the nation. Enhancing the EMS expertise and resources of federal agencies and better coordinating federal EMS efforts [are] the key[s]. This coordinated federal approach is included in the [DOT's] reauthorization legislation . [which] calls for a strengthened [FICEMS] and a $10 million grant program, administered by NHTSA, to support state EMS offices. Through [collaboration] and consensus-building, NHTSA has consistently demonstrated its national EMS leadership role. We will continue to work closely with [the] U.S. Fire Administration and the NIMS Integration Center to develop National Incident Management System training for EMS and [to] ensure EMS systems are on track to meet the nation's preparedness objectives. And we will continue to work closely with EMS for Children, the CDC and our other federal partners to enhance national EMS system development. As it has been for nearly 40 years, NHTSA is committed to improved emergency medical services."

Excerpts from a joint position statement from National Association of State EMS Directors, National Association of EMS Physicians and National Association of EMS Educators:"We agree . that EMS has long been overshadowed in receiving federal support, including homeland security first responder funding. We also agree it needs high-level executive branch attention.
However, we believe that the proposal to move EMS out of NHTSA and into a newly created EMS administration at [DHS] is the wrong solution. . Instead, we support creation of an EMS office within DHS to provide leadership and support for EMS terrorism preparedness and response, a dedicated program of EMS first responder funding and the passage of legislation to create a Federal Interagency Committee on [EMS] to improve coordination among the many federal agencies that involve EMS. . [Legislation now in Congress] creates the FICEMS and a 13-member advisory panel made up of members of the EMS community. .
"NHTSA has a productive history as a lead federal EMS coordinating agency since the late 1960s. .The EMS system represents the intersection of public health, public safety and health-care delivery. NHTSA, whose current administrator is an emergency physician, is a public safety and public health agency with strong ties to the medical community. . [GWU/HSPI] states, 'EMS lacks a data collection program.'. This is true, but NHTSA, in cooperation with the Health Resources and Services Administration, has already developed plans to address this problem, and Congress has already appropriated initial funding to implement the National [EMS] Information System. . Finally, the Institute of Medicine is in the middle of the comprehensive two-year study of national EMS needs . [and] major structuring of federal agency support for EMS should wait for the benefit of the IOM review."

Mary F. Hedges, Minnesota EMS director, chair of the NASEMSD Government Affairs Committee and chair of Advocates for EMS, a coalition of EMS organizations founded and led by NASEMSD and NAEMSP:"[We need] stepped-up efforts by the EMS community to educate and inform policy-makers-particularly on Capitol Hill, but also at the state and local levels-about EMS needs and the fact that they have not been met. . We have the statistic that only 4% of federal preparedness dollars have gone to EMS [because] Advocates succeeded in requiring DHS [to] report the proportion of dollars going to EMS. The next step is to ensure that more of that funding is going to EMS.

"Theoretically, a stand-alone U.S. EMS Administration would seem to be logical. The reality, however, is that EMS cannot be squeezed into a single discipline. . EMS is a convergence of disciplines, [which] is one reason why a shared role has evolved among [NHTSA, several agencies within HHS] and more recently DHS, involving EMS issues. I do believe it would be beneficial to have an EMS office within DHS, but not one that serves as the sole federal EMS agency. . If at some point in the future one of these agencies evolves into the lead EMS agency because of its clear success in championing EMS, that would be a different matter. A statutorily mandated FICEMS could accomplish a great deal. . [Although] some individuals have mistakenly compared the newly proposed FICEMS with an earlier version of the informal group that lacked authority, the new FICEMS would be a much different organization. . I believe what has the best chance of success in the existing landscape is incremental change."
NAEMSP President Robert E. O'Connor, MD, director of education and research, Department of Emergency Medicine, Christiana Care Health System, Newark, Del.:"The preamble to the GWU report is on target. EMS has not historically gotten the funding compared to other public health or public safety sectors.
But moving EMS from NHTSA to DHS would not be good. EMS needs more of a health background than DHS could offer. We need to have EMS as a stand-alone entity on the federal level with consistent funding; but for the short-term, we need FICEMS. We have some momentum on Capital Hill to get the FICEMS bill passed, and we need to move that forward. It's not the final solution, but it paves the way for the rational decision about where EMS should be housed.
To say that moving EMS to DHS would guarantee more money is not a given. .
Preparedness funding that is not earmarked does not get to EMS. We need distinct funding so we don't have to compete with other groups."

John Sinclair, fire chief of Kittitas County (Wash.) Fire District and chair of the IAFC EMS Section:"The EMS Section and its parent organization, IAFC, respect the folks that put this report together, but we disagree with their conclusions. Although I don't think they intended it that way, calling for a separate EMS administration is a backhanded slap at the small group of very dedicated people in NHTSA after all their outstanding work. IAFC has gone on record as supporting the FICEMS bill. To help providers on the street, we need to feed additional money to the existing infrastructure. But the paper is calling for creating a new bureaucracy requiring front-load capitalization and transition costs. All emergency responders should be getting prepared. There's a whole lot of funds flowing through [DHS] to the states and largest cities, and if that money isn't flowing into EMS, it's because at the local levels they are making decisions about how to fill their biggest holes. Being prescriptive and saying that money must go to EMS may mean that money doesn't go where it most needs to go. We should also be focusing on pumping more money into EMS through [the Centers for Medicare & Medicaid Services], because the Medicare fee schedule has hurt a lot of EMS organizations. We need to get CMS to change the rules on paying for such things as treat and release and transporting people someplace like a doctor's office or clinic. We all need to come together, have a spirited debate and come up with a third option that no one has put forth."

Lori Moore, DrPh, MPH, EMT-P, assistant to the president, International Association of Fire Fighters:"There are never enough resources dedicated to public service of any nature. However, the report misconstrues the facts on which [GWU] bases the claim that EMS needs more. . The task force states that even in a post-9/11 environment, EMS is a missing piece of the preparedness puzzle. Nothing could be further from the truth. . EMS is a service provided by myriad entities and individuals. EMS is not an isolated component, but is a time-critical, essential public service function. EMS may be delivered by fire protection, law enforcement or municipal or federal government providers . and, therefore, EMS is receiving some funds (albeit not enough) through other agencies. . EMS is much more likely to receive attention working through the agencies that exist now rather than forming "new" entities that require a portion of any funding allocated to operate. .
To simply suggest that all federal partners that examine EMS issues . be rolled into a new division of DHS, thereby improving funding and federal support, is short-sighted. . NHTSA is certainly the lead agency for EMS. .
We (IAFF) are much greater advocates of a [FICEMS] like the one suggested in the Collins bill, [but the] interagency committee suggested in the Collins bill should have been called by another name to get away from [the FICEMS] reputation."

Middle ground

Jay Fitch, PhD, president of Fitch & Associates, a national emergency services consulting firm in Kansas City, Mo.:"I agree that EMS needs more federal attention, but having just read the document, I'm not sure what I think is the best solution. There's a reasonable argument for putting EMS into DHS; that's where the money and allied organizations are. But my concern is that we don't lose the balance between medicine and public safety. EMS is both health care and public safety, and there has always been a struggle to get people to understand the needs of EMS and that the 'M'
stands for 'medical.' [Although] it's been a curse not to have a strong federal presence, leadership has come from lots of places. I think the world of [NHTSA EMS Chief] Drew Dawson and his staff, [whose work has] been drastically underfunded. At a minimum, what should come out of this is for NHTSA to use this as an opportunity to create upward mobility for EMS within DOT."

Tristan North, American Ambulance Association vice president for government affairs:"The AAA has not taken a position on the report. When the House Committee on Homeland Security was looking to mark up the [DHS] appropriations bill [during the last week of April], there was an amendment* offered by [Reps.] Bennie Thompson [D-Miss.] and Bill Pascrell [D-N.J.] to create an EMS office [in DHS] strictly for preparedness and response. It failed because members of the committee wanted to do more research. On Sunday [May 1, the day before GWU/HSPI released the report], the AAA board voted to support the language in that amendment. Since the board had already taken a position on the language of the amendment, we felt that was our focus."

Conclusion

"Once again, we are letting our differences overcome the need to work together for the common good," says NASEMSD President Bob Bass, MD, Maryland EMS director. "Every time we seem to be getting close to building an effective national presence, some issue derails the process."

Maniscalco says, "This paper was meant to provoke spirited discussion, and it has succeeded. This will probably be seen as an exciting time because EMS is finally getting attention at the highest levels of government."

Rep. Bennie Thompson (D-Miss.), the ranking democrat on the House Committee on Homeland Security, tells JEMS: "As a former first responder, I am very concerned about the current level of EMS support through first responder grant programs. I look forward to working with the EMS community on legislation and hearings to improve EMS representation within the Department of Homeland Security."

Numerous members of Congress have expressed similar sentiments. But now that Congress is listening, it remains to be seen if the EMS community can put aside its differences and unite around a common goal. No matter what your position, now is the time to let your elected members of Congress know that EMS deserves an equal voice, and more federal support and funding.


*Author's note: The amendment offered by Thompson and Pascrell states, DHS "will be responsible for creating an [EMS] Administration within the Emergency Preparedness and Response Directorate, to coordinate and advocate EMS issues within the Department." (FEMA resides in that directorate, and USFA is within FEMA.)

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