Mr. Smith Goes to Washington

     EMS is ternary: part public health, part healthcare and part public safety. No single federal agency operates fully in all three domains. Because of that, federal support of EMS comes from several places. This is a guide to that spectrum of federal support.

     This lack of a single federal identity is also a function of EMS' roots. Most people credit the evolution of modern EMS to a 1966 National Academy of Sciences report, Accidental Death and Disability: The Neglected Disease of Modern Society. That report discussed how people were dying every day on the nation's roads because trauma care was neglected. Concurrently, Congress passed and President Lyndon Johnson signed the Highway Safety Act of 1966. This law and the NAS report contributed to the establishment of the Division of Emergency Treatment and Transfer of the injured at the National Highway Safety Bureau. The Division and Bureau have since transitioned to the Office of EMS at the National Highway Traffic Safety Administration (NHTSA), within the Department of Transportation (DOT).

     Many states followed the federal lead by creating or shoring up state and regional programs using highway funds. Until just a few years ago, Minnesota's state EMS office was funded from gas tax receipts (it is now funded by the state general fund). Some states still have remnants of this period, with programs like driver's license surcharges dedicated to EMS support.

     In the 1970s Congress allocated trauma-related funds to the U.S. Department of Health, Education and Welfare (now Health and Human Services) to work on building systems of emergency care. Those early funds were dedicated to the first generation of EMS communications and regional development. They were the start of EMS evolving from funeral home-based ambulance services to freestanding agencies disconnected from funeral home businesses.

     Over time Congress shifted the EMS grant funds to other projects in a way that wrapped some of the programs into public health block grants. States provided further EMS office and regional support from these grants. Some still do, but as these grants have grown smaller, many states have shifted EMS office support, and some have reduced or eliminated regional program support. As a result, some states still have strong regional EMS structures, while others have none at all. (As an interesting historical note, the Institute of Medicine's 2006 Crossroads report on EMS also argued strongly for regionalization.)

     The shifts from Congressional funding to the use of block grants to, post-9/11, the creation and funding of certain EMS public safety functions through the Department of Homeland Security have led to a diverse landscape of federal support. DHS, HHS and DOT/NHTSA all play some role in supporting EMS. Additional EMS-related programs are housed within the Department of Commerce, at the FCC and in other places.

     In an early recognition of the boundaries EMS crosses, when Congress provided EMS funding to HEW in 1973, it mandated the creation of the Interagency Committee on Emergency Medical Services. Although this statutory committee later expired, it evolved over time into a nonstatutory committee, the Federal Interagency Committee on EMS (FICEMS), coordinated by the U.S. Fire Administration (USFA).

     In 2005 Congress passed a law designating FICEMS as a statutory committee with official responsibilities to:

• Ensure coordination among federal agencies involved with state, local, tribal and regional EMS and 9-1-1 systems;
• Identify EMS needs;
• Recommend new or expanded programs;
• Streamline federal agency support;
• Assist state, local, tribal and regional EMS systems in setting priorities; and
• Advise, consult and make recommendations on the coordination of state programs.

     FICEMS consists of representatives from the departments of Transportation, Homeland Security, Health and Human Services, and Defense, and from the FCC. NHTSA now coordinates it.

     In 2008 the DOT also appointed the National EMS Advisory Council (NEMSAC). NEMSAC is made up of 25 individuals representing specific EMS disciplines. While it just started meeting, NEMSAC will advise NHTSA's EMS Office and FICEMS on a variety of issues that affect EMS agencies. NEMSAC has already submitted its first recommendations to DOT.

     Over the last decade or so, several federal agencies have been teaming up to pool resources to help both services and providers. The DOT's national standard curricula are being replaced with National EMS Education Standards. Projects like this, the EMS Agenda for the Future, Rural EMS Agenda for the Future and others have been possible because federal agencies mixed funds from limited budgets to fund them.

     Independently DHS, HHS and the FCC have established offices to support EMS functions. The DHS Office of Health Affairs is led by a well-known EMS medical director, Dr. Jon Krohmer, and among other things is responsible for disaster medical readiness. The HHS Assistant Secretary for Preparedness and Response is responsible, in part, for the National Disaster Medical System. The FCC's Public Safety and Homeland Security Bureau is responsible, in part, for assuring the recovery of EMS communications affected by disasters.

     On a more local level, the Agency for Healthcare Research and Quality, Emergency Medical Services for Children (EMS-C) program and Office of Rural Health Policy (ORHP) within the HHS' Health Resources and Services Administration have a variety of downloadable tools and make periodic grants. Often, NHTSA, EMS-C, ORHP and others pool funds for specific projects.

     All in all, the state of EMS support at the federal level is in decent shape—arguably the best it's ever been. No, we don't have a sole lead agency. But given the three environments in which we work, a sole agency likely wouldn't support all the functions our communities require of us. We do have a number of agencies demonstrating the ability to work together under the FICEMS structure. The EMS Office at NHTSA demonstrates impressive leadership and does a remarkable job with limited resources.

     What's missing for EMS is any structured pool of grant funds or dedicated research funding. That isn't the fault of the federal agencies. That is our collective fault. Federal agency budgets are dictated by Congress. Collectively, EMS can influence Congress for more support, but it means agencies representing public health, public safety and healthcare environments must come together to do it. Facilitating this, there is now an EMS advocate on Capitol Hill. One good way to start building Congressional support for EMS is for providers to support Advocates for EMS by being individual or organizational members. For more, see www.advocatesforems.org.

     Federal support of rural EMS is not always obvious, but several key programs could not exist without federal funding. Some examples include:

     Rural EMS and Trauma Technical Assistance Center—The federal Office of Rural Health Policy funded REMSTTAC for three years. Congress then cut the funding, but the contractor, the Critical Illness and Trauma Foundation, still maintains the website (www.remsttac.org) and a toll-free technical assistance line, and continues to contribute to the Center's work. REMSTTAC's website contains a number of resources, including a resource page with current federal grant opportunities; a listing of current events; a products page containing a state directory of farm rescue resources, a rural ambulance budget model, a rural chief's guide to implementing the Rural and Frontier EMS Agenda for the Future, a community-based needs assessment tool, a rural manager's awareness program, and others; a learning and resource center; and a research page.

     Rural Assistance Center—The RAC is also funded by the ORHP, and its website contains a variety of resources, including frequently asked questions, tools, funding, published documents, journals, related rural EMS organizations, success stories, news and others. The main RAC site, www.raconline.org, contains a number of rural-related links; its EMS page is at www.raconline.org/info_guides/ems.

     Rural Domestic Preparedness Consortium—The RDPC, www.ruraltraining.org, is funded through the Department of Homeland Security. The RDPC mission is to create rural-relevant courses for rural first responders, have them certified as training courses by DHS, then deliver them in rural communities or through distance learning, many free of charge. The website contains a course catalog and training schedule and a mechanism to request training.

     Other Aids—There are a host of nonfederal websites with helpful information as well. Some of these include projects aimed at using rural EMTs and paramedics in new ways (e.g., the International Roundtable on Community Paramedicine, www.ircp.info, and the Community Paramedic curriculum project, www.communityparamedic.org), while others discuss rural EMS grants and grant-writing and related resources (www.grantcentralstation.info). For a comprehensive list, see www.emsresponder.com/ruralemsresources. If you know of Web pages that should be added to the list, please e-mail nancy.perry@cygnusb2b.com.

     Gary Wingrove is responsible for strategic affairs at Mayo Clinic Medical Transport in Rochester, MN, and chairs the rural EMS issue group for the National Rural Health Association and the advisory board of the Rural Domestic Preparedness Consortium.

     Aarron Reinert, NREMT-P, BA, is executive director for Lakes Region EMS, a rural ambulance service in Minnesota that covers a 450-square-mile service area.