EMS legislation, whereas others had legislated specifically what prehospital clinicians could do, potentially hampering the flexibility needed for successful local development. Lack of national conformity or agreement precluded the development of universally accepted national standards in most areas of EMS.
On 26 October 1978, a memorandum of understanding was signed by DOT and DHEW describing each organization’s responsibilities relating to development of EMS systems. The agreement was an attempt to coordinate government activities and assign national level responsibility for EMS development and direction. DOT, in coordination with DHEW, was to “develop uniform standards and procedures for the transportation phases of emergency care and response.” DHEW was responsible, in coordination with DOT, for developing “medical standards and procedures for initial, supportive, and definitive care phases of EMS systems.” Research and technical assistance were to be performed cooperatively, and both agencies agreed to exchange information and “establish joint working arrangements from time to time” [53].
Because the roots, constituencies, and operating philosophies of DOT and DHEW were markedly different, the 1978 agreement quickly failed. Over the four subsequent years, the lack of coordination continued [54].
In 1980, the EMS directors from each state banded together to form the National Association of State EMS Directors (now NASEMSO). With membership from all 50 states and the territories, it attempted to take a leadership role with regard to national EMS policy, and to collaborate on the development of effective, integrated, community‐based, and consistent EMS systems. Its strategy was to “achieve our mission by the participation of all the states and territories, by being a strong national voice for EMS, an acknowledged key resource for EMS information and policy, and a leader in developing and disseminating evidence‐based decisions and policy” (https://nasemso.org/about/overview).
Financing
By 1978, termination of federal funding in most regions was imminent, and the potential effect on operations and future development began to raise concerns. The 1976 and 1979 amendments to the EMS Systems Act reflected concerns about future funding and had consequently demanded evidence of financial self‐sufficiency as one basis for further support. DOT estimates of non‐federal monies spent annually between 1968 and 1980 ranged up to $800 million.
In 1979, DHEW officials estimated in testimony that 90% of regions with paramedic service had achieved financial self‐sufficiency by 1978 [44]. However, the Comptroller General, in a 1976 report entitled Progress in Developing Emergency Medical Services Systems, cited considerable inconsistency in the degree and duration of support provided by community resources [55]. A few years later, in 1979, the Comptroller General testified on the financial status of the EMS regions after analyzing grant applications under the 1976 amendments. By the 1980s, the discrepancy between DHEW’s and the Comptroller General’s estimates of financial self‐sufficiency of EMS systems suggested serious unrecognized difficulties in the continued underwriting of EMS systems.
The financial demands on an EMS system were considerable, related to four major elements: prehospital care, hospital care, communications, and management. The specific costs varied by community. The original 1966 NAS‐NRC report estimated that ambulance services accounted for about one‐fourth of total EMS system costs, with 75% of that amount for personnel. Communications costs varied from 7% of total cost when there was integration with existing public services, to 35% when completely new systems needed to be established. Although management costs were high during the development phases, they were originally expected to account for less than 2% of the total cost during the operational phase [52].
Health insurance reimbursement did not keep pace with EMS costs, which presented a real problem for EMS providers. Health care benefits were often limited to hospital care and had maximum fixed reimbursements. For example, 20% of Blue Cross patients were not covered for emergency transport, and, of those covered, one‐third were only covered after a motor vehicle crash. EMS reimbursement was focused on the transportation aspect of the service, a financial problem that has continued to plague EMS. By 1982, the NAS‐NRC wrote, “Availability of advanced emergency care throughout the nation is a worthy objective, but the cost of such services may prohibit communities from obtaining them” [52].
Research
A total of $22 million was appropriated between 1974 and 1979 for EMS research. The National Center for Health Services Research, in coordination with DHEW, funded various clinical and systems research projects. During the 1979 legislative hearings, testimony from DHEW and the leadership of academic research centers stressed the need for continued EMS research. Annual reports from DHEW detailed the types of research under way, the questions being studied, and the scope of long‐term and short‐term research projects funded under Section 1205 of Title XII [51]. These projects included “methods to measure the performance of EMS personnel, evaluate the benefits and the costs of ALS systems, examine the impact of categorization efforts, determine the clinical significance of response time, and explore the consequences of alternative system configurations and procedures” [56]. Other projects focused on “developing systems of quality assurance, designing and testing clinical algorithms, and examining the relationships between emergency departments and their parent hospitals (including rural‐urban differences)” [56].
In early 1979, the Center for the Study of Emergency Health Services at the University of Pennsylvania urged continued support of EMS research. It claimed, “Dollars spent in EMS research have great potential to help control rising health care costs, [and can] have a significant and visible effect in preventing death and enhancing the quality of patient life following emergency events” [57]. The center suggested research identifying EMS cost control potentials because the phasing out of federal funds, coupled with the effects of local tax revolts, would certainly reduce financing. As the 1980s progressed, the demand for more efficient, effective systems would become universal. Managers of EMS systems, just like their counterparts elsewhere, needed to know which components of the system were crucial and which could be deleted if funding was limited. The answers to those questions were anything but clear.
1981: The Omnibus Budget Reconciliation Act
Late in the summer of 1981, President Reagan signed comprehensive cost containment legislation that converted 25 Department of Health and Human Services (DHHS) [formerly the DHEW] funding programs into seven consolidated block grant programs [58]. EMS was included in the Preventive Health Block Grant, along with seven other programs such as rodent control and water fluoridation. Individual states were then left to determine how much money from the block grants would be distributed locally. Although existing EMS programs were temporarily guaranteed minimal support, a state could later decide to withdraw all block grant money from one or more regional EMS programs. This concept, simply a fundamental premise of conservative federal government, evolved quite differently in each state. As with decisions regarding how to implement clinician levels and assure competence, the funding process was generally quite political, with little direct input from the public or the EMS or medical communities.
The 1976 Forward Plan for the Health Services Administration made it clear that, by 1982, all federal EMS system financial support would end, and regional EMS programs would be the responsibility of the regional agencies. The federal role was to be “one of technical assistance and coordination” [59]. These changes significantly curtailed federal funding for EMS program development and evolution.
1982–1996: Changing Federal Roles
The public health initiative for developing a national EMS system came to a gradual, quiet, and unceremonious demise after the 1981 legislative changes. In most regions, the remnants of the old DHEW program were left to die off slowly under the cloud
