EMS Waste, DOGE Edition

The destruction of the “Firemen First Principal.” With a bonus: the Firemen First Principal inside the Firemen First Principal.

Editor’s Note: Today’s guest post is offered by a New York City paramedic with three decades of service, and who endured the brunt of the COVID epidemic’s reality.

Boggling the media-verse is DOGE uncovering vast waste and abuse (and likely, fraud). Yet, there is nothing new to boggle over: the Pauls, father (Ron) and son (Rand), have been all over it for practically two generations. The abstract waste we have been in denial about (partly because it is so mind-boggling) has at last become concrete and teeth are a-gnash. And not a moment too soon: the USA is unique in the developed world in not having a political party for fiscal responsibility. We are also the most indebted nation in the history of debt. Those facts are related.

Whenever our government is forced to address waste/fraud/abuse, the “Firemen First Principle” (FFP) is duly grifted. That’s where the government does not pry out waste/ineffective policies but sabotages its essential roles to gin up a clamor to get “its” funding back (quotes because all government monies belong to the taxpayers).

Want to stop paying 6 million bucks [to promote tourism to a Jihad-prone country with a taste for murdering tourists?

"…then say goodbye to your house when we cut firemen, because that gets cut along with it.

Complicit in the con is the legacy media doing the clamor-ginning, both because of their political bias and biases in favor of the status quo.

The FFP is a useful metaphor for our entire approach to budgeting: waste is built into the skeleton of a monster of “omnibus” spending (thereby making it abstract). If waste/fraud/abuse is cut, that will cause the whole thing to collapse, by design. It became normal to pass the whole incomprehensible Jenga in an all-or-nothing blackmail to keep the government from collapsing into chaos:

Don’t want to extol the virtues of tourism to a country murderous of tourists?

Then Grandma will have to eat cat food!

This disincentive to adapt is a major factor making government less effectual over time. A science thing that leftists refuse to accept is that all systems are in tension between stability and adaptation. The imperative for stable evolutionary adaptation goes for government just as much as it does for nature (libertarians argue that the ethical framework for that is banning coercion).

But policies/monies that are evolutionarily unstable are only rarely clawed back from the government. That’s because the ability of the government to get (and keep) funding grows out of political power, not the importance of what is being funded. The tendency is for more spending to be heaped on top of the unstable approach, which makes the system fail increasingly. Few Americans would agree that our government has been more effective over the last generation, despite being much more expensive. BTW: this will not improve anytime soon: spending on just interest for the debt is now more than we spend on defense and Medicare: because of wasteful spending in the past, our ability to use the resources we have left will be stunted into the future as far as the eye can see. And, my God, are there ever important things that need doing!

Read on.

We are seeing this play out in real time: in a recent Congressional address President Trump got a laff-riot over said mind-boggling examples of waste/abuse. We will leave off, for now, the question of how any incumbent member of Congress could dare show their faces to yuck over the system that they preside over. Human beings with intact souls fear being smote by righteous lightning for such a level of hypocrisy.

The basic question here: how are big-laffs in waste/fraud/abuse made real after our politicians grind the sausage into applied policy? “Billions in essential Medicaid cuts!” Congress has the ability (and an electoral imperative) to cooperate with necessary culling. Never mind that, even if successful, waste culling will only get back a fraction of the spending reform we need. Instead, the Democrats made moves to shut down the very government they claim is the only thing that stands between the poor and the dying (libertarians say a functional economy better serves that purpose). Congress can move resources from the non-essential things into the essential ones. But they won’t. It’s that disincentive to adapt (a flat-out refusal to, really). That’s because what is wasteful to human beings with souls intact is essential to them. And that is because these things are prioritized by the calculus of their political power, not by what is objectively the most important.

The intersection of objective importance and funding by political sausage grinding is something I know a lot about. For this next part let me reintroduce myself: I was a longtime contributor here at the Roots of Liberty and I’m back with this guest essay. I have been a 911 paramedic with the New York City Emergency Medical Services (NYC EMS) for some thirty years (retiring soon). The EMS is at the foundational level of what people think of when they think of the services the government should be providing. Like police and fire service, paramedic capability is foundational to any basic public health system, as are immunizations and clean water. EMS is the public health systems’ bulwark against preventable death and disability because they usually happen out of the reach of the clinicians in the hospital who could prevent them.

During the pandemic the EMTs and paramedics of NYC EMS where the most important governmental function in the worst-affected pandemic city in the world: our entire healthcare system was at risk of drowning under too many patients. To keep swimming we had to “bend the curve,” which was spreading out the caseload of sick people over time. That meant patients had to be triaged out in the field for the severity of the problem. My colleagues and I in the NYC EMS did that all through the pandemic. I did not see anyone else doing it (and there was nobody from the Egyptian Ministry of Tourism out there with us).

The pandemic also threatened the economy at the foundational level. I don’t need to revisit the sacrifices made here. Suffice it to say: the pandemic was the greatest challenge our civilization faced since World War 2. Governments everywhere in the developed world tried to mitigate the threat to the globalized economy with stimulus funding. The USA passed two enormous stimulus packages, and the prevailing economic theory is that the second one (at least) unleashed the inflation that steals some fifth of our wealth to this day. Inflation was likely the pivotal issue of the 2024 Presidential election. Another Def Trump Comedy Jam could be done on all the ways this stimulus money was thrown at political fetishes of every imaginable kind. If you want to really make yourself apoplectic, Google some of it, there is no end to the march of this folly. Be particularly enraged by spending in the “mere” tens of millions of dollars range, we’ll get back to that.

Stimulus that went seemingly everywhere except the foundational EMS service that saved the most-affected pandemic city on earth. Because, only five years later, NYC EMS, the institution, is drowning. Our commissioner is warning of the imminent collapse of EMS. Working conditions are as bad now as they were at the height of the pandemic, as testified to by your scribbler being chased out of the profession by our constant dysfunction.

Much of the reason for that dysfunction is because, like Russian nesting dolls of politically-motivated funding fuckery, EMS’ money is way too thin because it is deep inside the general budget of the FDNY, which prefers red stuff. They get away with that because no politician can be elected dogcatcher by supporting the politically pipsqueak EMS over the interests of the firefighters, the behemoths of Mayor-making.

But, by objective importance, fewer than 100 New Yorkers die from fire-related causes a year. These are vanishingly rare because of modern building fire codes (especially smoke detectors). And humans need little encouragement moving themselves away from something burning, unless something very unusual has happened. By contrast, my guesstimate is that your average practicing NYC paramedic not only sees, but treats to the same standard of care of a doctor in an Emergency Department, some 2 cardiac arrests a month. Many of us see a good bit more than that. Which means 4 active 911 medics will have not only seen, but definitively treated, more mortality than the entire 2.3 billion dollar fire department. This is consistent with my empirical experience: in my more than 30 years of full time 911 service I have seen only 1 fire-related death (something unusual went wrong). While all of us will die one day (sorry), and the thing that does us in will very likely be the kind of medical emergency we paramedics were made to treat. The contrast between the two is political calculus, vs objective importance. But NYC, with a deficit spending crisis, is moving monies from EMS into, you guessed it, yet more red stuff. $400K was cut from a $380M dollar budget).

So, just the amount of money our government spent to encourage Americans to accept more risk of being murdered touring Egypt would buy back EMS’ budget cuts many, many times over (while Egypt also features in State Department advisories of elevated risks for tourist violence, LOL). A minute’s worth of Federal spending would not only prevent EMS’s imminent collapse but go far to reform this cornerstone of public health of the most advanced medical city in the developed world; which serves as the bulwark against preventable death and disability; which served as NYC’s equivalent of the RAF in the Battle of Britain. About a third of the Navy’s rinse/repeat annual yeet of advanced missiles at Yemen would be NYC EMS’ entire budget… sigh and so on.

But, in our system of funding-by-political-calculus, for EMS to get “our” funding back, the only option would be to continue to fund EMS as run-off from other bloated projects (hell, nonsensical, even). And when people die because of it (and they will, that’s a promise)? EMS will then magically gain a lion’s roar of attention. “Budget cuts killed…!!!” Will be ginned and clamored. Which, if we go by what has been true for FDNY decades, will mean more money for fighting fires that never happen and crumbs from the funding feast for EMS. Just as we will cut Medicaid before we cut our own tourist-murder program. Adaptation, no matter the importance, is contingent on furthering the waste, and at 37 trillion dollars in debt, we cannot afford any more. That’s the destruction of the FFP.

You will know we are adapting when the roar is for “evolutionarily stable adaptation, and ONLY for what’s objectively important!” This paramedic advises readers not to hold their breath.