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How EMS Can Address Social Inequity

Daniel is a nonprofit executive director, Texas first responder, and has participated in three Texas legislative sessions.

Emergency medical services can play an important role in addressing social inequality. Read on to learn how.

Emergency medical services can play an important role in addressing social inequality. Read on to learn how.

The Impact of Emergency Medical Services (EMS)

The conversation surrounding public safety is changing.

Policymakers are reimagining the purpose of public safety and discussing desired public safety outcomes for their communities. Social equity is a common theme for many of these outcomes.

Although law enforcement is receiving the most scrutiny, the relationship between Emergency Medical Services (EMS) and social inequity is also a public safety domain worth examining.

This article briefly examines the relationship between social inequity and EMS and discusses four known equity gaps and their suggested solutions.

EMS is a powerful tool that can reduce equity gaps when internally motivated and properly equipped.

EMS and Social Inequity

The conversation regarding EMS and social inequity is not new.

In 2019, NHTSA published EMS Agenda 2050 as the national vision for EMS.

Social equity was established as one of the six guiding principles for shaping the future of EMS with an intent to decrease healthcare inequities.

Healthcare inequity occurs when a disparity exists between population groups and positive healthcare outcomes.

Inequities can occur due to language barriers, lack of familiarity with the patient type (ex: pediatric patients), poor distribution of resources, biases, etc.

Although inequities exist, healthcare inequities are considered avoidable.

In EMS Agenda 2050, social equity is a guiding principle to ensure these avoidable gaps are addressed within the EMS domain and is considered part of EMS' professional growth.

The following are four gaps for EMS to intentionally address social inequity within its domain.

The six guiding principles of EMS Agenda 2050

The six guiding principles of EMS Agenda 2050

The Paramedic Diversity Gap

EMS is not a diverse workforce.

In 2019, US News & World Report published Diversity Emergency, an article examining EMS diversity issues.

They found that Black paramedics only make up three percent of the EMS workforce with no sign of improvement.

In fact, all minorities were found to be underrepresented with 10% of paramedics being Hispanic and 23% female.

Poor healthcare outcomes are known to follow poor workforce diversity.

Historically, leaders have attempted to address this issue at the employer level with mixed long-term results.

A more strategic focus may be EMS education.

Increasing minority student representation at the EMT level, through intentional community programs, could provide greater long-term benefits.

An example of this would be a minority representative nonprofit providing a minority EMS scholarship in partnership with a local EMS education program.

This type of intentional program creates both community ownership and a sustainable pathway into the EMS profession. The one-semester EMT course is a low barrier to entry that increases the number of minority EMTs eligible for the workforce and completes the prerequisite to apply for paramedic school.

It provides the greatest benefit per investment.

Two truths regarding the diversity gap exist: The gap exists and it will not stop existing without intentional effort. The key to any solution is being strategically intentional.

Diversity must increase within the EMS workforce.

Diversity must increase within the EMS workforce.

The EMS Language Gap

Language barriers are known to create healthcare inequities.

It's reported that 6 out of 10 Hispanic adults have experienced difficulty communicating with a healthcare provider due to a language barrier. They most often turn to a family member or translator to convey their healthcare concerns.

This is an exceptional problem in EMS due to the unpredictable work environment.

An English-speaking family member may not be present in the 911 setting or translator services may be unavailable due to a lack of cellular service.

When translator services are used, care is sometimes delayed due to communication traveling through a third party.

Inequity would be greatly reduced by increasing bilingual professionals within the EMS workforce.

This may be best accomplished by categorizing bilingual capability as a measurable clinical skill.

In Texas, roughly 29% of the population speaks Spanish at home. Some cities, like Houston, have an even larger percentage of Spanish-speaking households (37%).

EMS agencies should consider creating a performance measurement to make their bilingual workforce reflect the percentage of their Spanish-speaking households.

If 20% of an EMS agency's population speaks Spanish at home, for example, having 20% of the staff be bilingual would be a measurement of success.

This measurement would work best with EMS professionals being compensated for their bilingual skill set and completing an accredited language validation process.

At this time, no one is sure about how to measure EMS success. It's the perfect opportunity to consider bilingual capability as a clinical skill, reduce healthcare inequity, and establish a performance metric producing quality EMS.

A bilingual workforce should be considered a clinical performance metric.

A bilingual workforce should be considered a clinical performance metric.

The Formal Education Gap

Addressing social inequity requires EMS leaders to embrace formal education.

A paramedic certificate requires 45 credit hours of paramedic-specific coursework and 1,600 contact hours between labs, clinicals, and additional curriculum.

Unfortunately, this coursework does not include foundational courses, such as English, History, and Government, that can improve communication, social understanding, and critical thinking.

EMS is a public safety model interacting with numerous healthcare, social, political, racial, and cultural systems. It's also an emerging profession expected to address portions of primary care, emergency care, behavioral care, social services, and more in the coming decades.

The profession's problem solvers need more than a technical curriculum to strategically address community needs.

The first step to promoting this is to increase paramedic access to higher education.

In Texas, EMS is excluded from state-granted tuition exemption. Tuition exemption is provided to firefighters and law enforcement to meet community needs, but legislators have continually blocked this opportunity for paramedics.

EMS agencies should also consider employee tuition reimbursement with compensation available for those completing degree programs.

This could be used in conjunction with the National EMS Management Association's Seven Pillars of EMS Officer Competencies.

Overall, it's time for EMS to examine and embrace the benefits of higher education in addressing social inequity. The profession is limited in its problem-solving without a non-technical skill set.

EMS should embrace the benefits of higher education.

EMS should embrace the benefits of higher education.

The EMS Funding Gap

Inconsistent EMS funding creates community equity gaps.

The CEO of a hospital district once shared that his EMS system was exceptional for one reason: "I can afford to be ethical".

Unethical actions take place when EMS is underfunded.

Many EMS delivery models are only funded by billing people for transport services. This creates more of a private business focus than a public service focus.

Underfunded EMS systems must perform actions providing the best payment opportunity and not necessarily actions providing the best healthcare outcome. This is where inequity begins.

This is an unfortunate reality when you realize EMS is the primary point of healthcare access for many communities.

Federally, the Center for Medicare & Medicaid Services took a progressive step toward correcting this with the ET3 payment model. ET3 reimburses EMS agencies for navigating patients to appropriate healthcare destinations and not just the emergency room.

The program, however, is still in a trial phase and in need of Congressional support.

Locally, many communities treat EMS as a commodity and withhold tax funding from its services. In Texas, this can be seen with Emergency Services Districts over-funding fire suppression while allowing healthcare to be contracted by private ambulances for discounted rates.

Ultimately, there is no incentive for EMS to address equity issues within their domain because they are only funded for medical transportation.

Properly funded EMS, however, is exactly what is needed to prevent emergencies, reduce unnecessary medical debt, and create stronger opportunities for social mobility within neglected communities.

The impact of EMS on these communities can be seen by examining the work of Austin-Travis County's Community Health Paramedic Program or their Expanded Mobile Crisis Outreach Team.

Until policymakers at each level of government commit to funding EMS, funding issues will continue promoting social inequity within our communities.

It's too expensive to be ethical.

Under funding EMS at all levels of government promotes community healthcare inequities.

Under funding EMS at all levels of government promotes community healthcare inequities.

The Upshot

EMS is a public safety branch that can address social inequity or sustain it.

The national vision for EMS recognizes social equity as one of the six guiding principles for the future of EMS.

As policymakers reimagine public safety, it would be beneficial to strategically equip EMS to address equity gaps within its domain. The future of EMS coincides with reducing these gaps and can do so with intentional actions.

This content reflects the personal opinions of the author. It is accurate and true to the best of the author’s knowledge and should not be substituted for impartial fact or advice in legal, political, or personal matters.

© 2020 Daniel J Owens