Editor’s Note: This is Part Two of a two-part series. Read the first part here.
Introduction
Emergency medical services (EMS) stand at the crossroads of public health, public safety, and human rights, offering a critical lens through which to examine the obligations of governments and communities towards their citizens.
In the broadest sense, EMS encompasses a range of urgent and non-urgent medical services provided in response to accidents, disasters and acute health episodes. As the demand for immediate medical attention continues to escalate globally, the role of EMS as a human right, a public good and an essential service merits a thorough examination.
EMS as a Human Right
As previously discussed, the recognition of health as a fundamental human right is enshrined in numerous international declarations and legal frameworks, notably the Universal Declaration of Human Rights (1948)1 and the International Covenant on Economic, Social and Cultural Rights (1966).2 These documents assert the right of every individual to a standard of living adequate for health and well-being.1,2
EMS, as a critical component of health services, it directly correlates to this right, providing lifesaving care that is essential for realizing the highest attainable standard of health. The World Health Organization (WHO) reinforces this perspective, identifying the accessibility of emergency care as a cornerstone of the right to health.3
EMS as a Public Good
There is a complex relationship between healthcare and economic structures. Certain aspects of healthcare do not conform to the normal operation of market forces.4 In the context of EMS, in light of this point of view, EMS in reality is a government-regulated, government operated monopoly.
Access to EMS is controlled through 9-1-1. Service providers are controlled by government entities, either through competitive bid or a governmental provision. Given the immediacy and unpredictability of emergency situations, the users of emergency services are not in a position to ‘shop around’ for the best deal or to negotiate prices.
From an economic perspective, EMS represents a quintessential public good. Public goods are defined by their non-excludability and non-rivalrous consumption, qualities that perfectly describe emergency medical services. No one can be feasibly excluded from accessing EMS in crises, we do not inquire as to ability to pay when you call 9-1-1, and providing the service for one person does not diminish the availability for another person or group of people.5
This inherent characteristic underscores the role of government in funding and regulating EMS, ensuring its availability and accessibility irrespective of individual ability to pay, thereby aligning with the principles of equity and justice in public service provision.
Economics at Play
Healthcare, and by extension EMS, is indeed a special economic entity, marked by societal obligation, moral imperative and risk unpredictability. “Healthcare is not a market in the traditional sense.”6 In emergencies, the question of ability to pay is secondary to the immediacy of need.
The core functions of EMS, maintaining life, alleviating suffering, promoting health, transcend market dynamics.7 This is central to the precept of the Emergency Medical Treatment and Active Labor Act; a hospital cannot make any inquiry into ability to pay when people present with a medical emergency in the emergency department.
The fee-for-service model of EMS funding, where providers are reimbursed for each service rendered, can prove problematic in economically disadvantaged communities and regions with low population density. In urban areas, high demand often leads to under-compensation for services provided to patients unable to pay.8
Conversely, in rural and frontier regions, the low demand can result in insufficient funding to maintain service availability and response times.9 Communities are not homogeneous, and as such the types of calls and the requests for EMS will vary between towns that are right next door to one another. Just as the types of requests for EMS are different, the payer mix ix different as well, making an increase in re-imbursement difficult to quantify.
Who’s Paying?
Yet we see state officials, trade associations, and special interest’s groups shouting to raise the re-imbursement rates, which such disparity this will exacerbate the problem, not solve it.
If anyone of us or our families were diagnosed with cancer or heart disease, we would seek out the best in the field to care for us. The socially and economically disadvantaged members of society do not have agency over their own health care in many situations.
Yet, when our patients (who are socially and economically disadvantaged) cannot access primary care; when they cannot afford their medications; when the medically indigent cannot afford to take time off from work to see their healthcare providers; chronic conditions become urgent, or emergent, and in some cases catastrophic.
Ripples in the water become a tsunami. They turn to the only health care provider who can help them and that is EMS. This is not their first choice for their health care.
Moreover, the operational structure of EMS as a government-regulated service ensures uniformity in accessibility and quality of care, which is crucial for upholding public health standards.
The fee-for-service model, while prevalent, poses significant challenges, especially in economically disadvantaged and rural areas where the demand may not align with sustainable funding levels. These disparities highlight the necessity for a more equitable funding mechanism that reflects the diverse needs of various communities.
By recognizing EMS as a public good, we affirm our commitment to a just and equitable healthcare system that prioritizes the well-being of all citizens, particularly the most vulnerable among us. This approach not only enhances public health outcomes but also embodies the moral imperative of providing lifesaving services without discrimination.
EMS as an Essential Service
The designation of EMS as an essential service is critical for prioritizing resources and ensuring continuity even in the face of challenges such as natural disasters, pandemics and other societal disruptions. Essential services are those considered crucial to preserving life and maintaining societal functioning.10
In many countries, this categorization compels governments to maintain uninterrupted EMS operations, safeguarding against potential service gaps and promoting resilience in healthcare systems.
Defining EMS as an Essential Service
The International Labor Organization defines essential services as those services “whose interruption would endanger the life, personal safety or health of the whole or part of the population.”10
Under this definition, EMS is clearly essential as we provide life-saving interventions in emergencies such as accidents, heart attacks, major disasters and during public health emergencies, such as pandemics.
Governmental Obligations and Policy Implications
The designation of EMS as an essential service imposes specific obligations on governments. These include ensuring adequate funding, maintaining robust regulatory frameworks, and fostering continuous improvement in service delivery.
Governments must also ensure that EMS systems are resilient, able to maintain operations during disasters and crises, and integrated within the broader healthcare and public safety networks.
Legal and Ethical Considerations
The legal framework governing EMS as an essential service often includes mandates that prevent service interruption, guaranteeing the right to receive care irrespective of the patient’s financial capacity.
Ethically, the provision of EMS aligns with the principles of beneficence and justice, emphasizing the duty to provide care and ensure equitable access for all segments of the population.3
The Essential Nature of EMS
EMS systems are designed to be the first line of response in health emergencies, providing assessment, initial treatment, and transport to definitive care. These services are characterized by their readiness to respond 24/7, regardless of weather, time or external conditions.
The essential nature of EMS is underscored by their operational standards, which require rapid response times and the ability to provide advanced life support in the field.11
Despite their critical role, EMS systems face numerous challenges including resource limitations, workforce shortages, and increasing demand. Future policy directions must address these challenges through sustainable funding models, innovations in service delivery, and enhanced integration with other components of the health care system.12
Conclusion
EMS occupies a unique space at the intersection of human rights, public welfare, and essential societal functions. A deeper understanding of EMS from these multidimensional perspectives not only highlights its critical importance but also fosters a more robust dialogue about the responsibilities of states to uphold the health and safety of their populations through sustainable and equitable EMS systems.
EMS is frequently the healthcare provider of last resort for the socially and economically disadvantaged in the United States. This is due to a confluence of systemic healthcare barriers. Many disadvantaged individuals lack access to primary care services because of financial constraints, lack of insurance and limited availability of healthcare providers in underserved areas.
This lack of access results in a reliance on EMS for urgent medical needs that could have been managed or prevented with regular primary care. Additionally, social determinants of health such as poverty, inadequate housing, and food insecurity exacerbate health issues, leading to more frequent and severe medical emergencies that necessitate EMS intervention.
Furthermore, the complexities of the healthcare system pose significant challenges for disadvantaged populations. Limited health literacy, language barriers and bureaucratic hurdles make it difficult for these individuals to navigate the healthcare system effectively. Consequently, EMS becomes the default option when immediate health care is needed.
This reliance on EMS for non-emergent issues not only strains EMS resources but also underscores the urgent need for systemic reforms to address healthcare disparities. Enhancing access to primary care, improving health literacy and addressing social determinants of health are crucial steps toward reducing the burden on EMS and ensuring equitable healthcare for all.
Emergency medical services are a cornerstone of public health, designated as essential due to their role in preserving life and preventing deterioration during acute health crises. The effective management and support of EMS are imperative to their success and reliability.
Policymakers must elevate EMS to a central focus within health planning, recognizing it as an indispensable public good, essential service and fundamental human right. By ensuring robust funding, strategic integration, and equitable access, we can guarantee that EMS effectively meets the diverse needs of all communities.
This commitment not only enhances public health and safety but also reinforces our societal obligation to provide comprehensive and just healthcare for every individual, regardless of their socioeconomic status. EMS is not just an emergency response; it is a cornerstone of a fair and humane healthcare system.
References
1. United Nations. (1948). Universal Declaration of Human Rights.
2. United Nations. (1966). International Covenant on Economic, Social and Cultural Rights.
3. World Health Organization. (2019). Health Systems: Emergency Care Systems.
4. Reinhardt, U. E. (2015) The pricing of US hospital services: Chaos behind a veil of secrecy. Health Affairs, 25(1), 57-69
5. Samuelson, P.A. (1954). The Pure Theory of Public Expenditure. Review of Economics and Statistics, 36(4), 387-389.
6. Reinhardt, U. E. (2003). Does the aging of the population really drive the demand for health care? Health Affairs, 22(6), 27-39.
7. Reinhardt, U. E. (2008). The pricing of U.S. hospital services: chaos behind a veil of secrecy. Health Affairs, 25(1), 57-69.
8. Pines, J., Hollander, J., Localio, A., & Metlay, J. (2009). The Association Between Emergency Department Crowding and Hospital Performance on Antibiotic Timing for Pneumonia and Percutaneous Coronary Intervention. Academic Emergency Medicine, 16(3), 149-155.
9. Wingrove, G. (2007). EMS Funding: More Than a Rural Challenge. JEMS : A Journal of Emergency Medical Services, 32(11), 56–63.
10. International Labor Organization. (2020). Identification of Essential Services and Key Economic Sectors.
11. American Heart Association. (2020). Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
12. National Academies of Sciences, Engineering, and Medicine, Institute of Medicine. 2007. Emergency Medical Services: At the Crossroads. Washington, DC: The National Academies Press. https://doi.org/10.17226/11629.
