- The piece discusses the issues surrounding ambulance services in the United States.
- It highlights the different structures and lack of consistency in EMS providers across the country.
- The lack of federal oversight and funding for EMS is a major problem.
- EMS is not considered an essential service in many states, leading to funding deficiencies and difficulties in providing adequate care.
- EMS workers are underpaid and face high rates of injury and mental health issues.
- Rural EMS services are particularly at risk of closing down due to funding shortages.
- Even in big cities like Chicago, there are ambulance shortages and delays in response times.
- The current healthcare system and lack of government support for EMS need to be addressed and improved.

- A study found that in 19% of medical 911 calls, it took more than 7 minutes for an ambulance to arrive at the scene.
- Emergency medical services in America are underfunded and not supported by federal programs and local dollars like police and fire departments.
- EMS providers often rely on billing patients to recoup their costs, but they are only reimbursed for transporting patients to the hospital.
- This can lead to unnecessary hospital transports and surprise bills for patients.
- Some private ambulance providers are owned by private equity firms, which can lead to cost-cutting measures and negative impacts on employees and services.
- The No Surprises Act has been passed to address surprise billing, making it illegal to send patients steep medical bills when an out-of-network provider is unexpectedly involved in their care.

- Congress passed the No Surprises Act to prevent steep medical bills for out-of-network care, but it excluded ground ambulances.
- There should be a federal agency dedicated to EMS providers and they should be labeled an essential service with funding.
- EMTs boycotted a parade due to low wages and lack of hazard pay during the pandemic.
- It is time to make significant changes to support EMTs and prove our support for them.

The text discusses the issues surrounding ambulance services in the United States, highlighting the lack of consistency and funding. EMS workers face low wages, high rates of injury and mental health issues. Rural EMS services are at risk of closing down due to funding shortages. Even in big cities like Chicago, there are ambulance shortages and delays in response times. The current healthcare system and lack of government support for EMS need to be improved. A study found that in 19% of medical 911 calls, it took more than 7 minutes for an ambulance to arrive. EMS providers rely on billing patients, leading to unnecessary hospital transports and surprise bills. The No Surprises Act addresses surprise billing but excludes ground ambulances. There should be a federal agency dedicated to EMS providers, and they should be labeled an essential service with funding. EMTs have boycotted events due to low wages and lack of hazard pay during the pandemic. Changes need to be made to better support EMTs.

John Oliver explains how emergency medical services function in the U.S., why they can be so expensive, and what we can do to fix things. 

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Our main story tonight concerns ambulances.

You know, big ouchie trucks that go whoop-whoop.

Ambulances can be an annoyance to city dwellers with their shrieking sirens, although, Not if you live in Brussels, where that siren sounds very different.

-♪♪ Okay, that is just an objectively better siren.

It sounds like Mickey Mouse getting fucked on a washing machine.

And I do know that that is hard to picture, so please, let me help.

-♪ SIREN WAILING ♪ -♪ SIREN WAILING ♪ Oh boy!

I'd far rather be woken up by the sound of America's rat getting railed on the spin cycle because I'd immediately laugh, then remember that someone was having a medical emergency and feel bad, then hear the siren and laugh myself to sleep again.

Anyway, ambulance crews clearly play a critically important role across the country.

So it is no wonder that during the height of the pandemic last year, they were among those who got an outpouring of gratitude and nightly applause, with New York's mayor even making this pledge.

That when that day comes, that we can restart the vibrant, beautiful life of this city again, the first thing we will do is we will have a ticker tape parade down the Canyon of Heroes for our healthcare workers and our first responders.

Okay, first, I don't know if a parade is quite the dangling carrot de Blasio seems to think it is, because parades, and this is true, suck.

They are loud, crowded, and go on approximately 4 hours too long.

The only good thing about the Thanksgiving Day parade is seeing which country singer gets to lip sync next to the Jolly Green Giant's dick.

But second, there was a small irony in all the vocal appreciation that took place last year, as this EMT that we featured pointed out.

Right now, I'm doing all of this with no health insurance.

The job doesn't offer it, and our affordable marketplaces aren't very affordable.

If I get sick, and okay, I go get tested positive, I can't go to the hospital.

You know, people come out and they show us their support, and I love it, I love...

I've eaten so much pizza in the last 2 weeks, it's been great.

People clapping and giving pizza in appreciation was very nice, but it wasn't a substitute for the things that they actually needed, like a living wage and health benefits.

If you had a heart attack, and paramedics showed up with a pepperoni pie and some garlic knots, you'd be grateful, sure, but you'd also be justified in pointing out that that's not everything that the situation demanded.

And that man's story is by no means a one-off.

EMS workers around the country are shockingly underpaid, which is kind of amazing, especially when you consider how prohibitively expensive taking an ambulance can be.

So much so, you'll often see local news stories like this.

It was rush hour at the Mass Avenue station when this passenger stepped off the crowded train.

Surveillance video shows the moment her leg dropped into the gap, trapping her between the train and the platform.

As other commuters rocked the train to dislodge the woman's leg, a Boston Globe reporter tweeted from the scene.

It is a pretty strong indictment of our current healthcare system that that woman's main concern was getting crushed financially, even while she was getting crushed physically.

So given that, we have injured people begging bystanders not to call ambulances, and the EMTs who work inside them forced to live off pizza donations.

Tonight, let's take a look at our emergency medical services, specifically how they function, why they can be so expensive, and what we can do to fix things.

And the first thing to know is, there is absolutely no consistency when it comes to EMS in this country.

When you talk about emergency medical services, you're actually talking about 19,000 locally run EMS providers with wildly different structures.

To give you an idea of just how much variance exists, in Houston, EMS is provided by firefighters, cross-trained as paramedics or EMTs.

In New York City, it's under the fire department umbrella, but it's a separate division and supplemented by private companies.

In Pittsburgh, it's a freestanding municipal department of its own.

And in rural Wyoming, EMS is mostly provided by volunteer-based organizations.

And frustratingly, in no part of the country does EMS have ambulances that sound like this.

♪ The very fact our sirens could sound like a Puccini aria performed by a flustered parakeet, and yet we choose for that not to be the case, makes us a bunch of fucking idiots.

But all of this is to say, if you have seen 1 EMS setup, you've seen exactly 1 EMS setup.

And 1 reason for this is that there is no single federal agency overseeing and supporting EMS in the same way that, For instance, fire departments have the U.S.

And the frustrating thing is, it didn't have to be this way.

Back in 1973, Congress enacted the EMS Systems Act, which created a new program to help develop regional EMS systems, something that was badly needed.

Prior to that, ambulance services were frequently provided by hearses simply because they were long enough to transport a human body.

Now, unfortunately, under the Reagan administration, budget cuts eliminated direct federal funding and oversight, shifting the responsibility onto the states, many of which opted to direct their money away from EMS and into other public health services instead.

Which brings us to an absolutely incredible fact.

Unlike other first responders, such as police and fire departments.

Right now, in all 39 of these states, EMS is not considered an essential service.

Meaning local governments don't have to provide it to their citizens, which as a practical matter, means EMS generally has much less access to government funding.

And if this is surprising news to you, you are not alone.

Just listen to this Utah State Representative.

I became aware of the fact that this issue existed when I asked the question to Chief Brad Hanek.

And he said, he started explaining to me this issue, and I was like, really?

I thought this was an essential service, too.

Finding out that EMS is not deemed essential is like finding out that most states don't consider geese to be birds.

They have beaks, wings, feathers, they rain shit from the sky.

Sully Sullenberger is their Jeffrey Dahmer.

I didn't realize anyone was even disputing that!

EMS providers can be so strapped for cash, especially in rural areas, that they have to fundraise for themselves.

Do a quick search on GoFundMe right now, and you will find multiple outfits trying to raise money for equipment, gear, and updated ambulances.

And you know our healthcare system is fucked up when patients and providers are relying on the same crowdfunding platform.

Some people even do fundraising stunts for their local EMS, whether it's this guy doing a polar bear plunge for a thousand bucks, or this DJ doing a three-hour livestream that raised money for EMS workers in New York.

And I have to say, My admiration for that man's generosity is almost enough to overcome my horror at the idea of a three-hour live stream DJ set.

It's like someone donating a million dollars to cancer research by writing out a check in turtle blood.

And these massive funding deficiencies start to explain why it is that EMS workers, like that guy you saw earlier, are so terribly paid.

The median annual wage is just over $36,000, well below what police officers and firefighters make, and for a dangerous and stressful job.

EMTs and paramedics have an injury rate about 3 times the national average, and they're roughly 10 times more likely to have suicidal thoughts or behaviors.

So it is no wonder that ambulance services can have real trouble finding or retaining workers and volunteers, especially in rural communities.

Experts now warn that close to one-third of all rural emergency medical services are in immediate danger of closing down.

In rural Marmoth, North Dakota, no 1 remembers the last time the town had a doctor.

The ambulance is the community safety net.

We are literally 1 person away from closing.

If we lose 1 of our EMTs, 1 of our care providers, we will have to look at shutting down and closing our doors.

No workplace should be in danger of shutting down because it loses 1 person.

Unless, that is, that workplace is the Sex and the City reboot.

It's never gonna work without Kim Cattrall.

It's not that any of you are bad, it's that you only work together.

I can't appreciate my Puritan Charlotte if I don't have my naughty Samantha.

I know I live for Miranda Hobbs, but if she's not serving side-eye while Samantha uses penne pasta to describe her new Italian lover's dick, What is the point?

And to be clear, this isn't just a rural problem.

Some big city services are stretched to breaking point, too.

Take Chicago, where its EMS is operated by the fire department.

Both workers and city officials have complained for years that not enough resources have been allocated to EMS, leading to an ambulance shortage.

And while the fire department says its fleet meets the needs of residents, a local news investigation found some pretty harrowing stories.

1 analysis of 700,000 medical 911 calls found in 19% of them, it took an ambulance more than 7 minutes to get to the scene.

That is just not something you want to hear.

I think we all know, when you call an ambulance, you want it to show up like that.

You know, I got the power to just clap my hands and summon Kermit the Frog anytime I want.

-♪♪ Well, I thought that went very well.

Emergency medical services in America are underfunded because in most places, they're not supported by federal programs and local dollars the way that police and fire departments are.

And the fact they are so underfunded starts to explain why they can cost so much.

Because for many, the way they recoup their costs is by billing patients.

Although, interestingly, if they don't physically transport those patients to a hospital, they could be out of luck.

You're reimbursed based on the number of patients that you transport to a hospital.

So you could get called a thousand times a year and only transport 750 patients.

Those other 250 calls, you made no money on.

And policies like that can not only put EMS providers even further into a financial hole, It can also incentivize them to take patients to the hospital even if it is not totally necessary.

It's a practice known throughout the EMS industry as, you call, we haul.

Although to be honest, nowhere near as fun as the fire department's motto, you hurt, we squirt.

And EMS's funding structure doesn't just serve providers poorly, it serves patients poorly too.

Because right now, patients and their insurance reimbursements are most EMS outfits' primary funding sources, which is just not a good situation for either side.

Some patients have Medicare and Medicaid, and by law, EMS providers are required to accept their reimbursement rate, despite Many saying that they are set too low.

But for patients with private insurance, the fact is, EMSs are not required to accept that at all.

In fact, many choose to keep themselves out of network for most insurers, meaning that they can generally set their rates wherever they want.

This situation can often leave patients facing so-called surprise bills, some of which can be absolutely ridiculous.

Baby Sawyer just couldn't wait to enter the world.

Katie Marietta's water broke a week before he was due.

She and husband Daniel raced to Sutter-Roseville.

With the emergency room inside, Katie screamed for him

Roseville PD called the paramedics, who cut the umbilical cord and drove Katie and Sawyer a matter of a few hundred yards to the hospital door.

But later, it would come into focus when 2 equal AMR ambulance bills showed up, 1 for Katie, 1 for baby Sawyer, totaling more than 3,500 bucks.

Not even a full minute worth of an ambulance ride.

We delivered our child in the front seat of our car.

Because from what I just heard, you did some driving and then sat back while your wife, in your words, popped out a human.

So, I'm not sure you really did the hard part so much as you were just sort of there.

And there can be absolutely crazy examples of surprise billing, even when EMS is run by the city.

In Houston, literally all city-run ambulance services are out of network for all insurers.

And a study of 1 large national insurance plan found that 71 percent of ambulance rides had the potential to generate a surprise bill.

And when you know that, is it any wonder that that woman begged people not to call her an ambulance?

Or that this incredibly grim trend has emerged?

That's now the choice, as more Americans are using Uber and other car services to get to the emergency room.

42 year old Tech Magazine writer, Shandra Steele, did it.

Emergency room doctor Robert Glatter of Lenox Hill Hospital in New York says Uber ER, as it's been nicknamed, is not a smart idea in a crisis.

They don't have any kind of oxygen, they don't have intravenous fluids or IVs.

They also may not know which local hospital has a trauma, stroke, cardiac, or pediatric unit because they're Uber drivers.

The most they have are tiny water bottles you're afraid to drink from and a charger for Samsung phone you do not own.

So, to recap, instead of all of us paying a little bit all the time for ambulances, we have a system where some of us pay an awful lot all at once when we have a terrible emergency.

And if you're thinking, How could this possibly get any worse?

Because for-profit businesses are also involved here.

In fact, currently, private companies represent about 25 percent of all ambulance providers.

And many of them are owned by private equity firms, who've been acquiring distressed local ambulance providers for decades now.

Remember that baby who got a bill for being born?

That came from a private for-profit company, American Medical Response.

They are currently the largest ambulance company in the U.S.

And are owned by 1 of the country's largest private equity firms.

And when a private equity firm swoops in to help wring profits out of ambulance services by keeping costs low and revenues high, things generally don't change for the better.

Take Transcare, an EMS company acquired out of bankruptcy by a private equity firm run by this woman, Lynn Tilton.

Aside from serving looks that can only be described as, my style icons are Wayne Newton and a Ferrero Rocher candy.

Lynn Tilton is a self-described poet, already 1 of the biggest red flags imaginable.

We looked, and 1 of the only things close to poetry we could find from her was this Instagram post.

I am a woman of strength, Nothing can break my spirit.

I am me." Which feels less like real poetry, more like someone with a concussion trying to remember Kesha lyrics.

Lynn Tilton was also the star of the sadly canceled reality series, Diva of Distress, where she portrayed herself as a savior of troubled companies in inspirational moments like this.

So I'm gonna ask you all to commit with me that we will not stop until we have achieved our goal.

And Lynn Tilton certainly knows how to instill a sense of courage in those around her.

It reminds me of that famous FDR quote, the only thing we have to fear is pussies in my mill.

And Tilton promised to bring that uplifting leadership style to Transcare.

But many who worked there described rough conditions on her watch, with 1 former employee saying...

And when Transcare inevitably ended up filing for bankruptcy in 2016, its employees found out that they'd lost their jobs like this.

Workers were told they had 30 days left on the job.

A work emergency for dozens of paramedics.

I have another side job to support me right now, currently, but that doesn't pay the bills.

Last night, we were told, see you tomorrow, have a good night.

There are certain businesses you assume might disappear overnight, like a kid's lemonade stand or any circuit city in the late 2000s.

Incidentally, they all became kingdoms of optical cables and loose batteries governed by rats.

And that's absolutely fine, but it is not great when what's disappearing is a community's life-saving medical service.

And it is not just that Transcare folded.

It's that in a bankruptcy court ruling last year, a judge recommended finding Lynn Tilton liable for nearly $42 million for stripping value out of the company, which I guess isn't totally shocking from a woman whose employees were encouraged to strip value out of fucking emergency rooms.

Now, I have to say, Tilton denies having done anything wrong and has challenged that recommendation in federal court.

And the thing is, I'm not just mad with Lynn Tilton here.

I'm mad that we're operating a system where a vital service is left vulnerable to the Lynn Tiltons of the world.

Well, as I've said before, ideally, we transition to a Medicare for all approach, but that doesn't seem to be in the cards right now.

And in the meantime, there are smaller things that we could and should do.

For patients, we need to put an end to surprise billing.

And the good news is, Congress passed a bill last year called the No Surprises Act, making it illegal to send patients steep medical bills when an out-of-network provider is unexpectedly involved in their care.

The bad news is, while that applies to air ambulances, the bill, for some reason, explicitly carved out ground ambulances, in other words, most fucking ambulances.

As for EMS providers, we should establish a lead federal agency dedicated to them.

And they should absolutely be labeled an essential service, especially because that's what everyone thinks they are.

But for that label to mean something, it has to come with funding at the local, state, and federal levels.

And there is no better time to make these changes than right now, when we still remember the absolute hell of what these workers went through last year.

Remember that parade that Bill de Blasio promised?

EMTs, many of whom boycotted it because of stagnant wages and the fact that they worked during the pandemic without hazard pay.

Look, last year, everyone was anxious to show just how much they supported EMTs.

Well, now is the time to fucking prove it and make big changes on their behalf.

And if we do do that, maybe we'll collectively be worthy of a siren that sounds like this.

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