James J. Augustine, MD, FACEP, director
of clinical operations at Emergency Medicine
Physicians (EMP) in Canton, Ohio, says this
is a chance for EMS to help design a better
system of emergency care outside the tra-
ditional role of transporting patients from
site to site. “EMS has a very important role
as a provider of unscheduled care,” he says.
“This really is our opportunity to identify the
issues and parts of our practice that need to
He notes that healthcare can benefit from
the experience of both fire and EMS in the
area of prevention measures. “Preventing
premature deaths has been the mark of the
prehospital emergency system for the past
40 years,” he says. He believes that EMS
should promulgate its successes in preven-
tion and allow those lessons learned to be
used in the design of new healthcare preven-
tion efforts, improving the overall delivery of
healthcare. “I’m a big supporter of our emer-
gency system, and there are opportunities
ahead to demonstrate our expertise,” he says.
One thing is certain: The number of people with healthcare insurance will dramatically increase. The U.S. Census Bureau
estimates that currently, nearly 50 million
Americans—including nearly one in four
working-age adults—are without insurance.
Many lost their healthcare coverage when
they lost their jobs. Those who kept their
insurance have been faced with rising premiums that put a strain on employers and
employees alike. According to the Kaiser
Family Foundation, a nonprofit organization
that focuses on healthcare policy and issues,
the average health insurance premium for
family coverage has more than doubled during the past decade to $13,770 a year.
To provide health insurance for those
who can’t afford it, the PPACA calls for the
expansion of the Medicaid program. After
2013, individuals who earn up to 133% of the
Federal Poverty Level (approximately $14,856
annually) will become eligible for Medicaid, a
state-run program that uses matching funds
from the federal government.
Currently, the federal government pays
57% of the cost of Medicaid to the states.
Under the new law, the federal government
will fully fund Medicaid for the first three
years, decreasing its support to 95% by
2017, then 90% by 2020. Twenty-six states
have publicly balked at the idea of taking on
that kind of debt. In the ruling, the Supreme
Court said that the portion of PPACA allowing Congress to penalize states that opt
out by withholding all or part of the state’s
Medicaid funds was unconstitutional. It’s
nearly certain that some states won’t add
these additional Medicaid recipients to
their rolls, although it’s unclear at this time
which ones will participate and which ones
will not—a factor that will certainly affect
EMS. Providers operating in these states will
face higher uncompensated care due to a
larger uninsured population.
“For EMS leaders who are politically active,
this is the time to start asking what your state
plans to do,” says Bourn. As stakeholders,
EMS has a say in whether the state accepts
Individuals not covered by the Medicaid
expansion will be required by law to maintain “minimum essential” healthcare coverage beginning in January 2014, or they will
pay a penalty when filing their income taxes
in 2015. Because the penalty is expected to be
lower than the cost of insurance, some people may simply choose to pay the penalty.
For those who aren’t covered by employer
policies, the PPACA provides for health insurance exchanges. These exchanges, set to go
into effect no later than Jan. 1, 2013, should
drive down the cost of healthcare policies by
allowing individuals, who previously had to
purchase policies at a higher rate, to buy into
a cheaper “group rate” policy.
However, many states have held off on
implementing of these exchanges in anticipation of the Supreme Court ruling and
may not meet the deadline. The U.S. General
Accounting Office has estimated that the net
result of PPACA could be that approximately
30 million Americans currently without health
insurance will be insured under the new law.
The EMS leaders interviewed for this article
all agreed that although Medicaid reim-
burses below the cost of providing the ser-
vice—6% below according to a 2007 report
by the American Ambulance Association,
based on 2004 data—some reimbursement
is better than nothing. In Minnesota, Aaron
Reinert, executive director of Lakes Region
EMS, says the added revenue could mean an
additional $2 billion in healthcare coverage
to his state. He sees this as a huge advantage
to begin to receive reimbursement for ser-
vices his agency already provides.
EMS was hardly mentioned in the more than
2,600 pages of the healthcare reform act;
however, the ability to test new payment
and care delivery models through demonstration projects funded by the Center for
Medicare and Medicaid Innovation does exist.
Enterprising providers ought to be seeking
demonstration projects to authorize system
changes that allow for treat-and-release, alternate destinations and in-home care.
“It isn’t the bill I would’ve written … but
it provides needed access to insurance, especially for chronically ill patients,” says Bourn.
That, he says, will change the dynamics of
patient care for EMS. With increased primary
care, these patients’ conditions will be less
likely to deteriorate to the point where they
need EMS. The bill also creates an opportunity
for EMS to become integrated into the healthcare system in a way it never has been. “Right