The American Ambulance Association has submitted comments to the Senate Committee on Health, Education, Labor, and Pensions (HELP) in response to their request for input on crafting legislation to address the health care workforce shortage.
Ground ambulance service organizations are facing a severe shortage of paramedics and EMTs which is placing a significant strain on an emergency medical system already in financial distress. We greatly appreciate the opportunity to provide our legislative solutions to the committee to help address the ongoing workforce crisis.
Please see the document linked below, which was sent to the HELP Committee Chairman, Senator Bernie Sanders, and the Ranking Member, Senator Bill Cassidy.
STATEMENT OF ADMINISTRATION POLICY H.R. 382 – A bill to terminate the public health emergency declared with respect to COVID-19
(Rep. Guthrie, R-KY, and 19 cosponsors)
H.J. Res. 7 – A joint resolution relating to a national emergency declared by the President on March 13, 2020
(Rep. Gosar, R-AZ, and 51 cosponsors)
The COVID-19 national emergency and public health emergency (PHE) were declared by the Trump Administration in 2020. They are currently set to expire on March 1 and April 11, respectively. At present, the Administration’s plan is to extend the emergency declarations to May 11, and then end both emergencies on that date. This wind-down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE.
To be clear, continuation of these emergency declarations until May 11 does not impose any restriction at all on individual conduct with regard to COVID-19. They do not impose mask mandates or vaccine mandates. They do not restrict school or business operations. They do not require the use of any medicines or tests in response to cases of COVID-19.
However, ending these emergency declarations in the manner contemplated by H.R. 382 and H.J. Res. 7 would have two highly significant impacts on our nation’s health system and government operations.
First, an abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans. During the PHE, the Medicaid program has operated under special rules to provide extra funding to states to ensure that tens of millions of vulnerable Americans kept their Medicaid coverage during a global pandemic. In December, Congress enacted an orderly wind-down of these rules to ensure that patients did not lose access to care unpredictably and that state budgets don’t face a radical cliff. If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down. Due to this uncertainty, tens of millions of Americans could be at risk of abruptly losing their health insurance, and states could be at risk of losing billions of dollars in funding. Additionally, hospitals and nursing homes that have relied on flexibilities enabled by the emergency declarations will be plunged into chaos without adequate time to retrain staff and establish new billing processes, likely leading to disruptions in care and payment delays, and many facilities around the country will experience revenue losses. Finally, millions of patients, including many of our nation’s veterans, who rely on telehealth would suddenly be unable to access critical clinical services and medications. The most acutely impacted would be individuals with behavioral health needs and rural patients.
Second, the end of the public health emergency will end the Title 42 policy at the border. While the Administration has attempted to terminate the Title 42 policy and continues to support an orderly lifting of those restrictions, Title 42 remains in place because of orders issued by the Supreme Court and a district court in Louisiana. Enactment of H.R. 382 would lift Title 42 immediately, and result in a substantial additional inflow of migrants at the Southwest border. The number of migrants crossing the border has been cut in half, approximately, since the Administration put in place a plan in early January to deter irregular migration from Venezuela, Cuba, Nicaragua, and Haiti. The Administration supports an orderly, predictable wind-down of Title 42, with sufficient time to put alternative policies in place. But if H.R. 382 becomes law and the Title 42 restrictions end precipitously, Congress will effectively be requiring the Administration to allow thousands of migrants per day into the country immediately without the necessary policies in place.
The Administration strongly opposes enactment of H.R. 382 and H.J. Res. 7, which would be a grave disservice to the American people.
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The Centers for Medicare & Medicaid Services (CMS) today appointed American Ambulance Association President Shawn Baird to the Ground Ambulance and Patient Billing Advisory Committee (GAPBAC), established by the Congress under “The No Surprises Act.” Shawn will represent the ground ambulance service provider and field personnel community.
“I am honored to have the opportunity to serve,” stated Baird. “I look forward to representing the interests of EMS providers and professionals as they care for our communities.
The Congress recognizes that the one-size-fits all approach to addressing surprise medical bills would not work for EMS. State and local governments regulate EMS agencies services and rates, as both first responders and medical care providers, which adds another level of complexity. As a result, the Congress established GAPBAC so the unique characteristics of ground ambulance services could be taken into consideration when evaluating private insurer billing policies to protect access to EMS, respect state and local government regulation, and protect patients.
Patients with private insurance should not be caught in the middle when their insurers do not adequately reimburse for vital ground ambulance services,” said Baird. “EMS must receive fair reimbursement by insurance companies for providing critical medical services to patients.”
Baird will bring to the Committee his years of firsthand experience and expertise as a paramedic and operator of an ambulance service in both urban and rural areas. He will also share knowledge gained from his years of volunteer leadership at the American Ambulance Association and the Oregon State Ambulance Association, as well as his term as an appointee to the National EMS Advisory Committee.
The GAPBAC is charged with “reviewing options to improve the disclosure of charges and fees for ground ambulance services, better inform consumers of insurance options for such services, and protect consumers from balance billing.” The Committee will submit a report that includes recommendations with respect to disclosure of charges and fees for ground ambulance services and insurance coverage, consumer protection and enforcement authorities of the Departments of Labor, Health and Human Services, and the Treasury and State authorities, and the prevention of balance billing to consumers. The report must be received no later than 180 days after the date of its first meeting.
About the American Ambulance Association
The American Ambulance Association safeguards the future of mobile healthcare through advocacy, thought leadership, and education. AAA advances sustainable EMS policy, empowering our members to serve their communities with high-quality on-demand healthcare. For more than 40 years, we have proudly represented those who care for people first.
On Wednesday evening, Representative Andy Kim (D-NJ) along with Representatives Markwayne Mullin (R-OK), Cynthia Axne (D-IA), Mike Carey (R-OH), Marc Veasey (D-TX), Al Larson (D-FL), and Bruce Westerman (R-AR) introduced the Supporting our First Responders Act (H.R. 8994). H.R. 8994 would establish the “EMS Grant Program” with funding at $50 million a year. Grants could be used for the training and retention of paramedics and EMTs, equipment, and facility modifications as well as additional purposes as seen fit by the HHS Secretary.
Of significant importance, private sector ambulance service organizations would be eligible for grants under the program. While the total amount available to private EMS would be capped at 2% or $1 million of the funding per year, H.R. 8994 is the first piece of legislation to explicitly state that private for-profit ambulance service organizations would be eligible to apply directly for such grant funding. The AAA worked closely with the sponsors of H.R. 8994 as well as Boundtree and the National Association of Emergency Medical Technicians (NAEMT) on the introduction of the bill.
The temporary Medicare ambulance increases are scheduled to expire at the end of the year at a time when our industry is facing unprecedented financial challenges. In addition to extending the Medicare add-on payments for five years, the AAA is asking Congress to increase the 2% urban rate to 3.4%; the 3% rural rate to 4.3%; and the super rural 22.6% rate to 26.7% to help address the crisis.
The Protecting Access to Ground Ambulance Medical Services Act of 2021 (S. 2037, H.R. 2454) by Senators Catherine Cortez Masto (D-NV), Susan Collins (R-ME), Bill Cassidy (R-LA), Debbie Stabenow (D-MI) and Patrick Leahy (D-VT) and Congresswoman Terri Sewell (D-AL), Congressman Markwayne Mullin (R-OK) and Congressman Peter Welch (D-VT) would extend the temporary Medicare ground ambulance increases of 2% urban, 3% rural and the super rural bonus payment for five years and help ensure that rural zip codes remain rural under the Medicare fee schedule following the upcoming zip code reclassification based on 2020 Census data.
These bills are essential to ensuring access for all patients to vital emergency and non-emergency care, but they still do not bring payment rates up to a level that covers the increased cost of labor and other expenditures. We ask that you write to your members of Congress to cosponsor S. 2037 or H.R. 2454 and support increasing the percentages to 3.4% urban, 4.3% rural and 26.7% for the super rural bonus payment.
The paramedic and EMT shortage has become a top policy priority of the AAA as we pursue several short and long-term initiatives to address this unprecedented crisis. Over the last several months, the AAA has been working closely with Members of the Senate Appropriations Problem Committee and the Office of the Assistant Secretary for Preparedness and Response (ASPR) to secure a grant program that would assist ground ambulance service organizations in hiring and retaining paramedics and EMTs. I am extremely pleased to report that the Fiscal Year 2023 Senate HHS appropriations package includes the program language for which the AAA has been advocating.
The language in the Senate Report reads:
EMS Preparedness and Response Workforce Shortage Program.— The Committee recognizes that our Nation is facing a crippling EMS workforce shortage which threatens public health and jeopardizes our ability to respond to healthcare emergencies on a timely basis. ASPR should prioritize ensuring a well-trained and adequate ground ambulance services workforce in underserved, rural, and Tribal areas and/or addressing health disparities related to accessing prehospital ground ambulance healthcare services, including critical care transport.
In the House, the AAA’s efforts contributed to House appropriators increasing the ASPR account funding for the Hospital Preparedness Program (HPP) (more than $30 million). We anticipate that ASPR would focus its efforts to address the ground ambulance workforce shortage through the HPP, so this increase in funding is also a critical component of the AAA’s efforts.
Although the appropriations process has many more steps to go through before final passage, having the EMS workforce shortage highlighted in the Senate report is a critical step toward achieving our goal to provide ground ambulance services across the country with the help they need during this unprecedent time.
The AAA will continue to work closely with Congressional champions and the ASPR team as they shepherd this language through the next steps in the process. I would like to thank Chairman Patrick Leahy (D-VT), Chair Patty Murray (D-WA), Senators Bill Cassidy (R-LA), Susan Collins (R-ME), Shelly Moore Capito (R-WV), Cindy Hyde-Smith (R-MS), Jeff Merkley (D-OR) and Ranking Members Richard Shelby (R-AL) and Roy Blunt (R-MO) for championing and supporting the effort.
This week, Senator Sheldon Whitehouse (D-RI) along with Senator Alex Padilla (D-CA), introduced the Student Loan Forgiveness for Frontline Health Workers Act (S. 3828), which provides loan forgiveness to individuals working in frontline healthcare responding to the Covid-19 pandemic. The legislation broadly defines healthcare workers and includes those who work in both public and private EMS. It provides relief to those who participate in both Federal student loans and private loans. We are very pleased to see the introduction of this legislation as it represents the kind of broad-based coverage for both governmental and non-governmental EMS that we have been advocating for. The legislation specifically covers paramedic certification programs that are accredited as part of CoAEMSP which requires college affiliation and makes them eligible for relief as federal student loans. The bill has broader standards than the current Public Safety Loan Forgiveness program. S. 3828 covers front-line healthcare workers regardless of their length of service as long as they are providing Covid healthcare-related services and specifically covers “an emergency medical services worker who responds to health emergencies or transports patients to hospitals or other medical facilities”. In addition, the student loan forgiveness for those working in EMS, would be exempt from inclusion in that individual’s taxable income.
The AAA supports this legislation and applauds Senator Whitehouse and Senator Padilla for their efforts to assist our frontline healthcare workers.
Last night, the United States Senate passed language as part of the FY 2022 Omnibus Appropriations Package that would delay the due date of the Medicare Payment Advisory Committee (MedPAC) report analyzing ambulance cost data. The U.S. House of Representatives had passed the package on Wednesday. The delay in the MedPAC report is a victory for the AAA and our members as we spearheaded efforts for the delay.
We thank Senators Chuck Schumer, Catherine Cortez Masto, Ron Wyden, Mike Crapo and Debbie Stabenow and Representatives Richard Neal, Kevin Brady, Frank Pallone and Catherine McMorris Rogers for championing and assisting with passage of the provision.
The delay in the timing of the MedPAC report was necessary due to CMS postponing the beginning of ambulance cost data collection by two years to account for the COVID-19 pandemic. Even though data collection had been delayed, MedPAC indicated that they were compelled to stick to the statutory deadline of issuing a report – with very little or no new ambulance data – to Congress by March 15, 2023.
With little to no new data, MedPAC would have likely reinstated their recommendations from their 2002 ambulance report which did support most of the temporary ambulance increases but at the cost of cutting BLS non-emergency services by 5.75%. MedPAC had also recommended doing away with rural and super rural increases in favor of a low volume adjuster which would disrupt reimbursement levels for rural providers without having more detailed data if indeed the proper approach.
The language from the FY2022 Omnibus Appropriations Package is as follows:
SEC. 311. REVISION OF THE TIMING OF MEDPAC REPORT ON AMBULANCE COST DATA.
Section 1834(l)(17)(F)(i) of the Social Security Act (42 U.S.C. 1395m(l)(17)(F)(i)) is amended by striking ‘‘Not later than March 15, 2023, and as determined necessary by the Medicare Payment Advisory Commission thereafter’’ and inserting ‘‘Not later than the second June 15th following the date on which the Secretary transmits data for the first representative sample of providers and suppliers of ground ambulance services to the Medicare Payment Advisory Commission, and as determined necessary by such Commission thereafter,’’.
Next week, we will be launching a Call to Action asking AAA members to reach out to their members of Congress to cosponsor the Protecting Access to Ground Ambulance Medical Services Act (H.R. 2454, S. 2037) Medicare Ambulance which would extend the temporary Medicare ambulance increases for five years. The increases expire at the end of this year and the five-year extension is necessary to provide time for the MedPAC report and the Congress to act.
“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”
U.S. House of Representatives Hearing on “America’s Mental Health Crisis”
Statement of Shawn Baird, President, American Ambulance Association
February 2, 2022
Chairman Neal, Ranking Member Brady, and members of the Committee, on behalf of the members of the American Ambulance Association (AAA), I greatly appreciate the opportunity to provide you with a written statement on America’s Mental Health Crisis. Simply put, America’s hometown heroes who provide emergency medical services and transitional care need the Congress to recognize the significant stress and trauma paramedics and emergency medical technicians (EMTs) have experienced as a result of this pandemic. The AAA urges members of Congress not to forget these heroes and to expressly include allground ambulance service personnel in efforts to address America’s Mental Health Crisis.
Emergency medical services (EMS) professionals are ready at a moment’s notice to provide life-saving and life-sustaining treatment and medical transportation for conditions ranging from heart attack, stroke, and trauma to childbirth and overdose. These first responders proudly serve their communities with on-demand mobile healthcare around the clock. Ground ambulance service professionals have been at the forefront of our country’s response to the mental health crisis in their local communities. Often, emergency calls related to mental health services are triaged to the local ground ambulance service to address.
While paramedics and EMTs provide important emergency health care services to those individuals suffering from a mental or behavioral health crisis, these front-line workers have been struggling to access the federal assistance they need to address the mental health strain that providing 24-hour care, especially during a COVID-19 pandemic, has placed on them. We need to ensure that there is equal access to mental health funding for all EMS agencies, regardless of their form of corporate ownership so that all first responders can receive the help and support they need.
EMS’s Enhanced Role in the Pandemic
As if traditional ambulance service responsibilities were not enough, paramedics and EMTs have taken on an even greater role on the very front lines of the COVID-19 pandemic. In many areas, EMS professionals lead Coronavirus vaccination, testing, and patient navigation. As part of the federal disaster response subcontract, EMS personnel even deploy to other areas around the country to pandemic hotspots and natural disasters to bolster local healthcare resources in the face of extraordinarily challenging circumstances.
Mental & Behavioral Health Challenges Drive Staffing Shortages on the Front Line
Myriad studies show that first responders face much higher-than-average rates of post- traumatic stress disorder, burnout, and suicidal ideation. These selfless professionals work in the field every day at great risk to their personal health and safety—and under extreme stress.
Ambulance service agencies and fire departments do not keep bankers’ hours. By their very nature, EMS operations do not close during pandemic lockdowns or during extreme weather emergencies. “Working from home” is not an option for paramedics and EMTs who serve at the intersection of public health and public safety. Many communities face a greater than 25% annual turnover of EMS staff because of these factors. In fact, across the nation EMS agencies face a 20% staffing shortage compounded by near 20% of employees on sick leave from COVID-19. This crisis-level staffing is unsustainable and threatens the public safety net of our cities and towns.
Sadly, to date, too few resources have been allocated to support the mental and behavioral health of our hometown heroes. I write today to ask for Congressional assistance to help the helpers as they face the challenges of 2022 and beyond.
Equity for All Provider Types
Due to the inherently local nature of EMS, each American community chooses the ambulance service provider model that represents the best fit for its specific population, geography, and budget. From for-profit entities to municipally-funded fire departments to volunteer rescue squads, EMS professionals share the same duties and responsibilities regardless of their organizational tax structure. They face the same mental health challenges and should have equal access to available behavioral health programs and services.
Many current federal first responder grant programs and resources exclude the tens of thousands of paramedics and EMTs employed by for-profit entities from access. These individuals respond to the same 911 calls and provide the same interfacility mobile healthcare as their governmental brethren without receiving the same behavioral health support from
Federal agencies. To remedy this and ensure equitable mental healthcare access for all first responders, we recommend that:
During the current public health emergency and for at least two years thereafter, eligibility for first responder training and staffing grant programs administered by the U.S. Department of Health and Human Services (such as SAMHSA Rural EMS Training Grants and HHS Occupational Safety and Health Training Project Grants) should be expanded to include for-profit entities. Spending on training and services for mental health should also be included as eligible program
Congress should authorize the establishment of a new HHS grant program open to public and private nonprofit and for-profit ambulance service providers to fund paramedic and EMT recruitment and training, including employee education and peer-support programming to reduce and prevent suicide, burnout, mental health conditions and substance use
Any initiatives to fund hero pay or death benefits for first responders should be inclusive of all provider models—for-profit, non-profit, and
The rationale for the above requests is twofold. First, ensuring the mental health and wellness of all EMS professionals—regardless of their employer’s tax status—is the right thing to do.
Second, because keeping paramedics and EMTs employed by private ambulance agencies who are on the frontlines of providing vital medical care and vaccinations during this pandemic is the smart thing to do.
Thank you for considering this request to support ALL of our nation’s frontline heroes. They are ready to answer your call for help, 24/7—two years into this devastating pandemic, will Congress answer theirs?
Please do not hesitate to contact American Ambulance Association Senior Vice President of Government Affairs, Tristan North, at email@example.com or 202-486-4888 should you have any questions.
Prevalence of PTSD and common mental disorders amongst ambulance personnel: A systematic review and meta-analysis. Soc Psychiatry Psychiatr 2018;53(9):897-909.
ALmutairi MN, El Mahalli AA. Burnout and Coping Methods among Emergency Medical Services Professionals. J Multidiscip Healthc. 2020;13:271-279. Published 2020 Mar 16. doi:10.2147/JMDH.S244303
Stanley, I. H., Hom, M. A., & Joiner, T. E. (2016). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and Clinical Psychology Review, 44, 25–44. https://doi.org/10.1016/j. cpr.2015.12.002
Doverspike D, Moore S. 2021 Ambulance Industry Employee Turnover Study. 3rd Washington, DC: American Ambulance Association; 2021.
Yesterday, the American Ambulance Association Board of Directors approved the Association’s advocacy priorities for 2022. Our key initiatives reflect the challenges we face this year, including short-sighted threats to EMS balance billing, a worsening workforce shortage, the expiration of the temporary Medicare increases, and potential sequestration cuts.
We also continue to fight for you as you care for people first on the frontlines of the COVID-19 pandemic. We will sustain our efforts at securing additional funding for ground ambulance services to help address the increased costs of providing medical care and transport during the Public Health Emergency.
Staff will be reaching out to you at key points later in the year about letter writing for specific individual policy requests. But it is important that they hear from you now on all the top issues for ground ambulance services. They are:
Top AAA Advocacy Priorities for 2022
EMS Workforce Shortage
With the persistent shortage of ground ambulance service field personnel raising to a crisis level with the COVID-19 pandemic, the AAA moved the issue to a top policy priority. The AAA is currently working with key Congressional Committees of jurisdiction to hold hearings on the EMS workforce shortage. We are also developing legislation to specifically target increasing access for ground ambulance service organizations to federal programs and funding for the retention and training of health care personnel.
The AAA successfully educated the Congress on the role of local government oversight and other unique characteristics of providing ground ambulance service organizations. As a result, the Congress directed the establishment of a Ground Ambulance and Balance Billing Advisory Committee to address the issue. The Committee is in the process of being formed and then has 180 days in which to make recommendations to the Congress. The AAA will be involved with the Committee and advocating that the Congress implement policies that meet the needs of our members.
Additional COVID-19 Financial Assistance
The AAA is advocating for additional financial assistance for ground ambulance service organizations to help address the increased costs of labor and other higher costs associated with providing health care during the COVID-19 pandemic.
Medicare Ambulance Relief
The temporary Medicare ambulance increases of 2% urban, 3% rural and the super rural bonus payment expire at the end of the year. The AAA will continue to push for passage of the provisions of the Preserving Access to Ground Ambulance Medical Services Act (S. 2037, H.R. 2454) before the provisions expire as well as for the adoption of language to ensure truly rural areas remain rural following changes to geographical designations based on the 2020 census.
The Congress delayed the additional 4% sequestration cut for only one yea. The AAA is working with other EMS and health care provider and supplier groups to permanently prevent the cut from going into effect as well as further extending the moratorium on the long-standing 2% cut.
Ambulance Cost Data Collection
With the 2-year delay of ambulance data collection due to the pandemic, the Medicare Payment Advisory Committee (MedPAC) will have little to no data to analyze in March 2023 in which to make recommendations to the Congress on Medicare ambulance payment policy and rates. The AAA is asking the Congress to push back the date of the MedPAC report and also expand the modified data collection timeline of two years to the intended four years.
On behalf of my fellow board members, I again thank you for your continued membership and participation. We look forward to serving you for many years to come.