with the effects of local tax revolts, would certainly reduce financing. As the 1980s progressed, the demand for more efficient, effective systems would become universal. Managers of EMS systems, just like their counterparts elsewhere, needed to know which components of the system were crucial and which could be deleted if funding was limited. The answers to those questions were anything but clear.
1981: The Omnibus Budget Reconciliation Act
Late in the summer of 1981, President Reagan signed comprehensive cost containment legislation that converted 25 Department of Health and Human Services (DHHS) [formerly the DHEW] funding programs into seven consolidated block grant programs [58]. EMS was included in the Preventive Health Block Grant, along with seven other programs such as rodent control and water fluoridation. Individual states were then left to determine how much money from the block grants would be distributed locally. Although existing EMS programs were temporarily guaranteed minimal support, a state could later decide to withdraw all block grant money from one or more regional EMS programs. This concept, simply a fundamental premise of conservative federal government, evolved quite differently in each state. As with decisions regarding how to implement clinician levels and assure competence, the funding process was generally quite political, with little direct input from the public or the EMS or medical communities.
The 1976 Forward Plan for the Health Services Administration made it clear that, by 1982, all federal EMS system financial support would end, and regional EMS programs would be the responsibility of the regional agencies. The federal role was to be “one of technical assistance and coordination” [59]. These changes significantly curtailed federal funding for EMS program development and evolution.
1982–1996: Changing Federal Roles
The public health initiative for developing a national EMS system came to a gradual, quiet, and unceremonious demise after the 1981 legislative changes. In most regions, the remnants of the old DHEW program were left to die off slowly under the cloud of confusion occasioned by the Preventive Health Block Grants formula. In most (but not all) states, EMS regional programs were lost in the shuffle of competing health programs while the Reagan administration systematically eliminated federal support for all such programs. In fact, in most jurisdictions the regional EMS momentum present throughout the 1970s simply evaporated. Paradoxically, some individuals involved in EMS saw the end of DHEW era as an opportunity to develop and implement alternative approaches that would not previously have been permitted [60].
Organizations such as the NREMT, the National Association of EMTs (NAEMT), and NASEMSO stepped into the vacuum and endeavored to provide some degree of national infrastructure and EMS identity. At the state level, state EMS agencies managed to keep the momentum by sponsoring well‐attended statewide conferences. At the federal level, the DOT continued its support of EMS activities.
In 1984, the Emergency Services Bureau of the National Highway Traffic Safety Administration (NHTSA) was instrumental in creating the American Society for Testing and Materials (ASTM) Committee on Emergency Medical Services (F‐30). Through the ASTM, NHTSA sought to legitimize the promulgation of standards in many areas of EMS. Through a complex consensus process, thousands of ASTM technical standards were arrived at in many different industries, including construction and building. Although these standards have no federal mandate, they were often enforced at the local level, for example, in building codes. Since a confusing but enthusiastic beginning in 1984, more than 30 EMS‐related standards have been developed, including those for the EMT‐A curriculum, rotor‐wing and fixed‐wing medical aircraft, and EMS system organization. This last document outlined the roles and responsibilities of state, regional, and local EMS agencies. The resultant standards, although mandated by no authority, were considered by several state legislatures when state EMS laws or guidelines, written to obtain federal funding in the mid‐1970s, required updating. Many of the ASTM F‐30 standards have been withdrawn in recent years.
The F‐30 Committee prospered as long as physician involvement was evident and decisive, but it was clearly NHTSA’s decision what standard to expedite and when. The NREMT, NAEMT, and other interest groups joined the physicians, each to protect themselves. Although many physicians and physician groups eventually tired of the F‐30 exercise, NHTSA preserved some semblance of a central authority at the federal level.
As early as 1983, NHTSA began assuming some roles previously associated with old DHEW programs. Many of the original evaluation staff were hired on a part‐time basis to promote use of EMS management information systems. In 1988, NHTSA attempted to organize the electronic exchange of information among surviving EMS clearing houses, but those efforts eventually failed after 3 years. Because NHTSA had no specific legislative mandate to assume many of the roles previously performed by DHEW, some states tried to assume those roles but were often unsuccessful. One area that received less attention at the federal level was trauma research and systems development. That would remain so until the passage of the Trauma Care Systems Planning and Development Act in 1990 (Public Law 101‐590). This program was funded for several years by DHHS but subsequently also lost funding.
It would be incorrect to view the period since 1982‐1996 as simply stagnant. It might be better characterized as a time when varying forces confused attempts by the federal government and national organizations to define and standardize EMS. During this time, neither an operational consensus nor a discrete EMS development philosophy emerged. Across the country, local activists battled others in pursuit of diminishing funds. By 1992, patients had clearly emerged as customers, and, by the beginning of the Clinton administration, EMS was as conceptually unified, standardized, efficient, expensive, and confused as the rest of American health care. The Clinton health care plan of 1993 barely mentioned ambulance services, and it did not address EMS systems at all.
Emergency Medical Services for Children Program
The Emergency Medical Services for Children (EMSC) program was first authorized and funded by the U.S. Congress in 1984 as a demonstration program under Public Law 98‐555. The EMSC program is administered by the DHHS Health Resources and Services Administration’s Maternal and Child Health Bureau; many of the EMSC programs are jointly funded by the Health Resources and Services Administration (HRSA) and NHTSA. This program is a national initiative designed to reduce child and youth disability and death caused by severe illness or injury [61] and serves as an example of a successful collaboration between government and academic forces.
In the late 1970s, the Hawaii Medical Association laid the groundwork for the EMSC program by urging members of the American Academy of Pediatrics to develop multifaceted EMS programs that would decrease morbidity and mortality in children. It worked with Senator Daniel Inouye (D‐HI) and his staff to write legislation for a pediatric EMS initiative.
In 1983, a particular incident demonstrated the need for these services. One of Senator Inouye’s senior staff members had an infant daughter who became critically ill. Her case showed the serious shortcomings of an average emergency department when caring for a child in crisis. A year later, Senators Orrin Hatch (Republican‐UT) and Lowell Weicker (Republican‐CT), backed by staff members with disturbing experiences of their own, joined Senator Inouye in sponsoring the first EMSC legislation.
Initial funding from the EMSC program supported four state demonstration projects. These state projects developed some of the first strategies for addressing important pediatric emergency care issues, such as disseminating educational programs for prehospital and hospital‐based clinicians, establishing data collection processes to identify significant pediatric issues in the EMS system, and developing tools for assessing critically ill and injured children. In later years, additional states were funded to develop other strategies and to implement programs developed by their predecessors. This work progressed through the 1990s when all 50 states and the territories received funding to improve EMSC and integrate it into their existing EMS systems. In response to the available money, in many areas, prehospital care of children became the focus of all EMS innovation.
After several years, with projects developing many useful and innovative approaches to taking care of children in the prehospital setting, a mechanism