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What happens to EMS when Trump, Congress repeal Obamacare?

Dramatic changes for EMS reimbursement are destined to happen regardless of the Republican repeal or replacement efforts targeting the Affordable Care Act


President-elect Donald Trump speaks during a news conference in the lobby of Trump Tower in New York.

AP Photo/Evan Vucci

By Stephen Hatez

President Barack Obama began meeting with prominent Democrats in early January to develop a strategy to keep his signature domestic policy, the Affordable Care Act, intact in the hands of a new administration. Vice President-elect Mike Pence and Republican Congressional leaders have been strategizing and meeting since the election to develop an alternative to the ACA. With both parties gearing up for a political showdown after President-elect Donald Trump’s inauguration, where does this leave the innovative population health projects many EMS agencies have been developing since the passage of the ACA?

The ACA gave prominence to two concepts: the Patient-Centered Medical Home and the Accountable Care Organization (ACO). It additionally made the Institute for Healthcare Improvement’s Triple Aim framework an urgent reality for EMS leaders. In short, the ACA promoted the concept of population-based health care: the notion that health care could be managed closely in the home and community setting, both improving outcomes and reducing costs [1].

After the passage of the ACA, community paramedicine began emerging within the EMS industry. To many, these programs were the realization of common-sense thinking. Utilizing trained paramedics to prevent emergencies is a far better approach than using them only to respond to emergencies. Momentum began building for a fundamental shift in the way paramedics were utilized.

Inadequate EMS reimbursement continues

However, one large problem still remained: how does EMS get reimbursed for providing community paramedicine and mobile integrated health care services? EMS has been perpetually plagued by under-funding and a reimbursement structure which pays largely on the distance a patient is transported. EMS has also shouldered the responsibility to be integral to the nation’s health care safety net by responding to every emergency call for the service. Much like hospitals, which under the EMTALA law can’t refuse a patient needing care in emergent situations regardless of ability to pay, EMS agencies respond to all requests for service.

First responder agencies and ambulance services are responsible for large numbers of uninsured or underinsured patients. Private businesses and local governments (and occasionally state governments) underwrite the cost of those unable to pay for EMS and hospital care they receive. For those patients without insurance, the large-scale Medicaid expansions under the ACA were a key part in assisting with the costs of providing EMS service, however these expansions weren’t implemented in all 50 states. If the ACA is repealed or restricted, it could have a significant impact on the agencies operating in states which implemented the expansion unless the state government steps up to increase funding for under- or uninsured patients.

In the post-ACA age of population health, EMS leaders have been looking toward sharing a percentage of payments being paid by insurance companies to hospitals, sharing in the reduction of the hospital’s expenses by providing care in the community, or sharing in the reduction of readmission penalties that Medicare has begun imposing on the hospitals in an effort to improve care and control costs. Readmission penalties created under the ACA could possibly face extinction despite proof that they work [2].

Softening rhetoric on ACA repeal

The Republican Party and the incoming Trump administration vowed to completely repeal Obamacare, creating uncertainly that this would strip insurance away from millions of Americans and slow the momentum of community paramedicine initiatives. The hardline stance seems to be softening, however, as the reality of overturning the law approaches.

‘Replace’ is used more frequently than ‘repeal,’ though both are likely to be very difficult. On January 4, the first day of the talks regarding ACA repeal, Republicans announced that even under a total repeal those currently insured under the law would be grandfathered in so that their coverage would continue. In this vein, it’s likely even that in a total repeal situation, many key provisions of the law may continue [3].

EMS reimbursement change is inevitable

Despite the outcome of the ACA, it is a certainty that the reimbursement methods of our health care system must, and will, change. Regardless if it happens under the Trump administration or in the future, the current EMS fee-for-service model will eventually be replaced. When this change happens, it will impact the EMS industry a great deal, since fee-for-service is at the roots of our current reimbursement-per-mile system.

That’s worth saying again. Regardless of what happens to the ACA, the reimbursement system for health care, and EMS, will ultimately be overhauled. That’s good news for both the transport side of the industry and the community paramedicine side. Ideas being floated as replacements still center around the concept of population health and are exactly where community paramedicine plays a crucial role.

In these proposed changes, bonuses and penalties, such as those implemented under the ACA, play a key role in helping the system transition from fee-per-service to the so-called value-based reimbursement. It’s still possible that community paramedicine programs will be integral to helping hospitals achieve bonuses and reduce penalties.

When reimbursement is ultimately overhauled and reimbursement is based on the health of a given population, community paramedicine might achieve its full potential. When the outcome of the patient takes priority over the amount of turns an ambulance’s wheel makes on the way to the hospital, we’ll see widespread utilization of preventative care by paramedics. This is destined to happen eventually (read decades), regardless of changes a repeal or replacement of the ACA might bring [4].

1. Walker, Tracey. Population Health. Accessed 1/4/17.

2. Commins, James. Readmission Penalties Work. Accessed 1/4/17.

3. Belvedere, Matthew. Trump transition. Accessed 1/4/17.

4. How to Pay for Healthcare. Harvard Business Review. Accessed 1/4/17.

About the author
Stephen Hatez is a paramedic, writer and MBA/MA Candidate at Johns Hopkins University. To learn more, please visit