by Open Markets’ Health Care Researcher and Reporter Olivia Webb
On July 2, 2018, a Boston woman fell into the gap between a subway car and the platform. Passengers rocked the train back and forth, eventually extricating her. Her leg was cut down to the bone. Still, she begged her rescuers not to call an ambulance. “Do you know how much an ambulance costs?” she sobbed. Because there was no choice but to call an ambulance, though, one eventually arrived.
Ambulance services used to be covered by local taxpayers, volunteers, or nonprofit hospitals, part of a suite of services akin to firefighting, which many people took for granted. This remained the status quo for emergency medical services for decades. Then, following the 2008 recession, private equity firms began to buy up ambulance companies. Quality has declined, and prices have shot up. Within ten years, from the recession to the Boston woman falling on the platform, the transformation of ambulance services from community service to luxury good was complete. Under the new paradigm of private equity, poorly maintained ambulance services siphon profit from vulnerable patients.
During the early 19th century, emergency triage occurred only on the battlefield. In the Napoleonic era, when standard war strategy involved lining masses of troops up against one another directly, retaining a critical number of men on the field was of the highest importance. Soldiers who were the least injured received priority under the contemporary triage system, as they could be bandaged quickly and sent back onto the field. Mortally wounded troops were left to die where they fell. Napoleon’s surgeon, Baron Dominique-Jean Larrey, is speculated to have been the first to reverse this order of triage. Under his system, the heavily injured were extracted first to undergo then-new amputation operations that would save their lives.
The Civil War saw the first iteration of the Napoleonic triage system on American soil, as the first battlefield ambulance wagons prioritized the severely wounded. Civil War servicemen were subjected to approximately 60,000 amputations, an estimated 75 percent of all surgeries performed during the war. Immediately following the war, the first civilian ambulance corps were formed. Medical treatment still being somewhat primitive, one service carried a quart of brandy for each patient it picked up.
Although civilian ambulance services grew over the next 100 years, a survey of 900 cities in 1965 found that fewer than a quarter had a regulated emergency transport system. The Highway Safety Act of 1966, passed as part of an attempt to stem growing traffic deaths, required states to form emergency medical services and standardize equipment and training. The newly formed Department of Transportation offered matching grants and demonstration projects. Yet despite the new law, ambulance services continued to languish behind what could be achieved in emergency care.
In the early 1970s, a cadre of senators began pushing for improvements. Recent shootings of prominent individuals (Martin Luther King Jr., Robert Kennedy, Governor Wallace of Alabama, and Senator Stennis of Mississippi) were fresh on the minds of those testifying, as was the “substandard” ambulance care that had been provided to those shot. The resulting EMS Services Development Act of 1973 provided more grants and highlighted the need for helicopter transportation to cover large swaths of the country.
Over the subsequent decades, states and local regions took increasing control of their ambulance services, with municipalities and nonprofit hospitals providing the services. But the Great Recession created an opportunity to financialize the practice of lifesaving emergency transport.
After 2008, a number of private equity firms moved to take over ambulance and air ambulance providers. Of the three air medical transport companies that have since captured 67 percent of the U.S. market, two are private equity–owned. American Medical Response, the largest provider of ground ambulance services in the U.S., was purchased by Kohlberg Kravis Roberts & Co. Known as KKR, this firm also owns one of the largest air transport companies, Air Medical Group Holdings. Priority Ambulance, LLC, which operates 400 medical transport vehicles, is a portfolio company of Enhanced Equity Funds.
Because private equity firms seek to recoup their investment rapidly rather than putting capital back into the businesses, PE-owned infrastructure has a reputation for being shoddy. Indeed, there have been numerous reports of ambulances in disrepair, slow response times, failing equipment, and low-paid, overwhelmed staff. In a 2016 investigation, The New York Times uncovered at least two lawsuits alleging that the poor quality of service led to patient deaths. One study found that nearly 85 percent of air ambulance crashes between 1998 and 2012 were operated by for-profit companies.