Emergency Medical Services: Last Week Tonight with John Oliver – Transcript

John Oliver explains how emergency medical services function in the U.S., why they can be so expensive, and what we can do to fix things.
Emergency Medical Services: Last Week Tonight with John Oliver

Last Week Tonight with John Oliver
Season 8 Episode 19
Aired on August 1, 2021

Main segment: Emergency Medical Services
Other segments: The evacuation of Afghans who helped U.S. troops during the war
Guest: George Clooney

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John: Hi, there, still welcome to the show, still only taking place here for four more shows.

Can’t come soon enough.

John: I think I liked it better when you were silent.

You know what wasn’t silent? When you fucking blew me up. You remember that?

John: I do. Barcoding Kirk scared everyone, and the house began the investigation of the in spirit insurrection. But when Jim Jordan struggled to answer a basic question.

Yes or no, did you speak to president Trump on January sixth?

Yeah, I mean, I speak — I spoke with the president last week. I speak with the president all the time, I spoke with the president on January 6th. I mean, I talk with president Trump all the time.

On January 6, did you speak with him before, during, or after the Capitol was attacked?

Uh, I’d have to go — I — I spoke with him that day after? I think after? I don’t know if I spoke with him in the morning or not. I just don’t know. I’d have to go back and — I mean, I don’t, I don’t, I don’t know when those conversations happened, but what I know is, I spoke with him all the time.

John: Oh, okay then! That sounds reasonable! You seem to be employing both the nervous energy and deeply suspicious denials normally reserved for Woody Allen. Why wouldn’t I find that reassuring? But instead of that, I’d like to briefly focus on Afghanistan. The U.S. withdrawal from there is nearly complete, ahead of the August 31 deadline set by the Biden administration. But many are concerned about who’s being left behind.

As America ends its longest war, the translators left behind are begging the Biden administration to cut through the red tape and grant them special visas to come to the U.S. Today, independent senator Angus King told reporters the president’s hair should be on fire over this situation.

John: It’s true. This is a situation Biden’s hair should be on fire about — both metaphorically and literally. It’d frankly be a huge improvement on his current look, which I’d describe as “business ghost,” also known as the “Sane Doc Brown” or “The Flat Jamie Lee Curtis.” Because the fact is, there are thousands of Afghans who helped U.S. troops during the war who badly need to be evacuated because the Taliban very much wants to kill them. Since 2014, more than 300 translators or their family members have been killed. And I will say, publicly, Biden has been sending encouraging messages.

Our message to those women and men is clear. There is a home for you in the United States if you so choose, and we will stand with you just as you stood with us.

John: Oh, well, that sounds great! Although that “if they so choose part” is doing a lot of work. Because it’s not so much their choice as ours. We’re the ones in charge of the process, so putting the choice on the applicants is basically a surgeon handing you a scalpel, saying, “there is a tumor-free pancreas in your body if you so choose, and I will stand with you.” I think you might be fundamentally confused about who has power over the outcome here. And the application process has been a mess for a long time. As we discussed on the first season of this show — presumably 40 years ago — just applying for a special immigrant visa can be a nightmare. And while 18,000 afghans have applied on behalf of themselves and their families — representing an estimated 53,000 people in total — many have been stuck waiting, in some cases for years.

Moneer Noori has been waiting on a special immigrant visa for nearly a decade. He first applied for a special immigrant visa in 2013 and said he’s been rejected four times. Moneer was told by the State Department that his documents were fraudulent but was not given any specific example to appeal.

There is more than hundreds and hundreds more special force interpreters left behind. They have the same issues. And I don’t want to be left behind.

John: Yeah, of course not. And we can’t let that happen. Because it’s practically a death sentence. Being left behind, in this context is even worse than seeing Left Behind, the 2014 Nicolas Cage faith-based thriller about the second coming that boasts — and this is true — a solid 1% on Rotten Tomatoes. Clearly, there aren’t many things worse than seeing Left Behind, but I’m going to say getting abandoned to be murdered by the Taliban is definitely one of them. And it’s not just that interpreter who’s frustrated — the U.S. soldiers he worked alongside are also appalled by the situation.

We’re filling out all the paperwork. We’re going through all the due diligence and the process to make this right. And nobody is responding with any information that would be critical to getting him out of country.

Like, this is, like, both a huge leadership failure for me, like, personally, and the military. The — the fact that I haven’t been able to get my — my guy out.

John: That does sound maddening. Particularly because “getting my guy out” is basically what we’ve been conditioned to think the military does. It’s supposed to be Saving Private Ryan, not “filing paperwork on private Ryan’s behalf, waiting a few months, filing requisition paperwork to track down the initial paperwork, and then learning private Ryan was shot in the head by a Nazi last month.” And there is real urgency here, as the Taliban currently controls about half of Afghanistan’s 419 district centers, and while they’ve yet to capture any of the provincial capitals, they are pressuring about half of them. This is basically the Bill Cosby comeback tour of political crises: we can all see where it’s going, and if we don’t act quickly, something terrible is going to happen. And incredibly, there are some — like supercuts superfan Rand Paul — who have questioned whether we should be evacuating all these people at all.

I would encourage them rather to stay and fight. I think it would be good to have many English speakers in Afghanistan. The future of Afghanistan could be a bright future, but they’re going to have to fight for it and, ultimately, it is their fight.

John: Okay, first — fuck all the way off. And second — fight with fucking what, exactly? Their working knowledge of the difference between there, their and they’re? Also, telling translators to “stay and fight the Taliban” is pretty rich coming from a guy who couldn’t even win a fight against his neighbor on his own front lawn. And the administration may point to the fact that, this month, 2500 Afghans are being flown in stages to an army base in Virginia. And that they’re negotiating with third countries like Qatar and Kuwait to house Afghans at military bases while they await visa approval. But so far a tiny percentage of the people in the pipeline have been evacuated. And the fact that we’re just scrambling for a plan now is inexcusable when we’ve had 20 years to develop one, and for around half that time, Biden was in the white house. If we really want to make sure these applicants are safe, we could bring them to the U.S. for processing. Guam has been suggested. And we should do that right now because the clock is ticking, and the translators in Afghanistan are well aware of that fact.

While evacuation plans to a third country may still be uncertain, the Taliban death threats here are crystal clear.

Yeah, I receive a lot of phone calls from them.

Phone calls?

Yes. And they told me, “soon we will come to Kabul, and we will find you and we will kill you.”

The Taliban have said interpreters will not be in danger, as long as they show remorse for their treason.

Would anyone believe that?

You’re almost laughing, you wouldn’t believe them.

No, I will never believe them.

John: Yeah, of course he doesn’t believe the Taliban. A “Taliban promise” sounds inherently like bullshit. It also sounds like a pretty racist soft-core romance paperback written by a white woman who’s never met anyone from there. But mostly it sounds like bullshit. There is no reason to believe things will end well for anyone we leave behind. These people helped us at great risk to themselves and their families. And if you don’t think we should give them a safe home here in return, then all I have to say is this: actually, can I get a translator for that?

He said, “fuck you.”

John: I did. Thank you. And now this.

* * *

Announcer: And now, and now, Jim Cramer loves chipotle.

The worst restaurants are going up and not the best ones. But chipotle is the best. I love them. I would eat chipotle all the way. They are back and they seem to love chipotle as I do. I still love chipotle it was awesome. I had a burrito. Oh, boy, when it comes to chipotle. To be fair, no one looks good — everyone goes to chipotle. Chipotle last week. I had chipotle yesterday. Why? You were able to sit down and have your cilantro lime roasted — it is unbelievably good. Have you ever had chipotle?

Yeah, I have. I have had it. Yeah. He enjoys it a great deal. It’s got cheese. A lot of cheese, right? Is that what queso is?

Have you ever had a bowl?

I had a ball. I’ve had a burrito?

You get the box?

I don’t go there that often.

♪ ♪

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John: Moving on. Our main story tonight concerns ambulances. Y’know, big ouchie trucks that go woop-woop. Ambulances can be an annoyance to city dwellers with their shrieking sirens. Although, not if you live in brussels, where that siren sounds very different. [Warbling siren] okay, that’s just an objectively better siren. It sounds like mickey mouse getting fucked on a washing machine — in a good way. And I know that’s hard to picture, so let me help: [warbling siren]

Oh, boy.

John: I mean, that’s fantastic. I’d far rather be woken up by the sounds of America’s rat getting railed on the spin cycle, because I’d immediately laugh, then remember that someone was having a medical emergency and feel bad, then hear the siren and laugh myself to sleep again. What a siren! Anyway, ambulance crews clearly play a critically important role across the country. So it’s no wonder that during the height of the pandemic last year, they were among those who got an outpouring of gratitude and nightly applause, with New York’s mayor even making this pledge:

I want to guarantee you one thing: that when that day comes that we can restart the beautiful, vibrant life of this city again, the first thing we will do is we will have a ticker-tape parade down the canyon of heroes for our health care workers and our first responders. We will honor those who saved us.

John: Okay, first: I don’t know if a parade is quite the dangling carrot de Blasio seems to think it is. Because parades — and this is true — suck. They’re loud, crowded, and go on approximately four hours too long. The only good thing about the Thanksgiving day parade is seeing which country singer gets to lip sync next to the jolly green giant’s dick. But second, there was a small irony in all the vocal appreciation that took place last year, as this EMT we featured pointed out.

Right now, I’m doing all of this with no health insurance. The job doesn’t offer it. And our affordable marketplaces aren’t very affordable. If I get sick and, okay, I go get tested positive, I can’t go to the hospital. And, you know, people come out, and they show us their support. And I love it. I love — I have eaten so much pizza in the last two weeks. It’s been great. I don’t need pizza. I need to be able to pay my bills.

John: Right. People clapping and giving pizza in appreciation was very nice but wasn’t a substitute for the things they actually needed, like a living wage and health benefits. Think about it like this: if you had a heart attack and paramedics showed up with a pepperoni pie and some garlic knots, you’d grateful, sure, but you’d be also justified in pointing out that’s not everything that the situation demanded. And that man’s story is by no means a one-off. EMS workers around the country are shockingly underpaid, which is kind of amazing, especially when you consider how prohibitively expensive taking an ambulance can be — so much so that you’ll often see local news stories like this:

It was rush hour at the Mass Avenue station when this passenger stepped off the crowded train. Surveillance video shows the moment her leg dropped into the gap, trapping her between the train and the platform.

As other commuters rocked the train to dislodge the woman’s leg, a Boston Globe reporter tweeted from the scene, “she begged ‘no one call an ambulance. It’s $3,000. I can’t afford that.'”

John: Wow. It’s a pretty strong indictment of our current healthcare system that that woman’s main concern was getting crushed financially, even while she was getting crushed physically. So given that we have injured people begging bystanders not to call ambulances and the EMTs who work inside them forced to live off pizza donations, tonight, let’s take a look at our emergency medical services: specifically, how they function, why they can be so expensive, and what we can do to fix things. And the first thing to know is, there is absolutely no consistency when it comes to EMS in this country. When you talk about “emergency medical services,” you’re actually talking about 19,000 locally run EMS providers with wildly different structures. To give you an idea of just how much variance exists: in Houston, EMS is provided by firefighters cross-trained as paramedics or EMTs. In New York city, it’s under the fire department umbrella, but it’s a separate division and supplemented by private companies. In Pittsburgh, it’s a free-standing municipal department of its own. And in rural Wyoming, EMS is mostly provided by volunteer-based organizations. And frustratingly, in no parts of the country does EMS have ambulances that sound like this: [warbling siren] the very fact our sirens could sound like a Puccini aria performed by a flustered parakeet, and yet, we choose for that not to be the case, makes us a bunch of fucking idiots. But all of this is to say: if you’ve seen one EMS setup, you’ve seen exactly one EMS setup. And one reason for this is that there is no single federal agency overseeing and supporting EMS in the same the way that, for instance, fire departments have the U.S. Fire Administration. And the frustrating thing is, it didn’t have to be this way. Back in 1973, congress enacted the EMS systems act, which created a new program to help develop regional EMS systems, something that was badly needed. Prior to that, ambulance services were frequently provided by hearses, simply because they were long enough to transport a human body. Unfortunately, under the Reagan administration, budget cuts eliminated direct federal funding and oversight, shifting the responsibility onto the states — many of which opted to direct their money away from EMS and into other public health services instead. Which brings us to an incredible fact: unlike other first responders, such as police and fire departments, right now, in all 39 of these states, EMS is not considered an essential service, meaning local governments don’t have to provide it to their citizens. Which, as a practical matter, means EMS generally has less access to government funding. This is a huge deal. And if this is surprising news to you, you’re not alone. Just listen to this Utah state representative.

I became aware of the fact that this issue existed when I asked the question to chief Brad Hannig, what can I do for you? He started explaining to me this issue and I was like, really? ‘Cause I thought this was an essential service too. I didn’t know any better.

John: Yeah, of course he was surprised! Finding out that EMS is not deemed essential is like finding out that most states don’t consider geese to be birds. That’s what they are. They have beaks, wings, feathers, they rain shit from the sky, Sully Sullenberger is their Jeffrey Dahmer — they’re fucking birds! I didn’t realize anyone was even disputing that. EMS providers can be so strapped for cash — especially in rural areas — that they have to fundraise for themselves. Do a quick search on GoFundMe right now, and you’ll find multiple outfits trying to raise money for equipment, gear, and updated ambulances. And you know our healthcare system is fucked up when patients and providers are relying on the same crowdfunding platform. Some people even do fundraising stunts for their local EMS, whether it’s this guy doing a polar bear plunge for a thousand bucks or this dj doing a three-hour livestream that raised money for EMS workers in New York. And I have to say — my admiration for that man’s generosity is almost enough to overcome my horror at the idea of a three-hour livestream dj set. It’s like someone donating a million dollars to cancer research by writing out a check in turtle blood. Love the end, hate the means. And these massive funding deficiencies start to explain why it is that EMS workers like that guy you saw earlier are so terribly paid. The median annual wage is just over $36,000 — well below what police officers and firefighters make — and for a dangerous and stressful job: EMTs and paramedics have an injury rate about three times the national average and they’re roughly ten times more likely to have suicidal thoughts or behaviors. So it’s no wonder that ambulance services can have real trouble finding or retaining workers and volunteers, especially in rural communities.

Experts now warn close to one third of all rural medical services are in immediate danger of closing down.

In rural Marmarth, North Dakota, no one remembers the last time the town had a doctor. The ambulance is the community safety net.

We’re literally one person away from closing if we lose one of our EMTs, one of our care providers. We will have to look at shutting down and closing our doors.

John: that’s terrible. No workplace should be in danger of shutting down because it loses one person. Unless that workplace is the “sex and the city” reboot. What are you thinking? It’s never going to work without Kim Cattrall. It’s not that any of you are bad, it’s that you only work together. I can’t appreciate my puritan Charlotte if I don’t have my naughty Samantha. And I live for Miranda Hobbes, but if she’s not serving side eye while Samantha uses penne pasta to describe her new Italian lover’s dick, what’s the point? And to be clear, this isn’t just a rural problem. Some big-city services are stretched to breaking point, too. Take Chicago, where its EMS is operated by the fire department. Both workers and city officials have complained for years that not enough resources have been allocated to EMS, leading to an ambulance shortage. And while the fire department says its fleet meets the needs of residents, a local-news of residents, a local news investigation found some pretty harrowing stories

One analysis of 700,000 medical 911 calls found in 19% of them it took an ambulance more than seven minutes to get to the scene. Sometimes there just isn’t one.

We’re out of ambulances. We’ll let you know.

John: Wow. “We’re out of ambulances.” That is not something you want to hear. I think we all know, when you call an ambulance, you want it to show up like that.

What’s wrong with you?

John: Aw, no. I’m sorry, George. I did it again. I’m sorry.

How hard is it not to snap your fingers?

John: Y’know, it turns out, it is surprisingly hard.

You know, I got the power to clap my hands and summon Kermit the frog, do you think I do it? No, I do not. Because I respect Kermit.

John: I get that. But, hey, George? Do it. Do it now. Please. [Claps]

All right.

This better be good, George.

It’s not.

John: Well, I thought that went very well. Anyway, where were we? Oh, that’s right. Emergency medical services in America are underfunded, because in most places, they’re not supported by federal programs and local dollars the way that police and fire departments are. And the fact they are so underfunded starts to explain why they can cost so much. Because for many, the way they recoup their costs is by billing patients. Although interestingly, if they don’t physically transport those patients to a hospital, they can be out of luck.

You’re reimbursed based on the number of patients that you transport to a hospital. So you could get called 1,000 times a year and only transport 750 patients. Those other 250 calls, you made no money on.

John: Yeah, it’s true. And policies like that can not only put EMS providers even further into a financial hole, it can also incentivize them to take patients to the hospital, even if it’s not totally necessary. Which makes no sense. It’s a practice known throughout the EMS industry as “you call, we haul,” which is a fun phrase, although to be honest, nowhere near as fun as the fire department’s motto: “you hurt? We squirt.” And EMS’s funding structure doesn’t just serve providers poorly — it serves patients poorly too. Because right now, patients and their insurance reimbursements, are most EMS outfit’s primary funding sources, which is not a good situation for either side. Some patients have Medicare and Medicaid — and by law, EMS providers are required to accept their reimbursement rates, despite many saying they’re set too low. But for patients with private insurance, the fact is, EMSes are not required to accept that at all. In fact, many choose to keep themselves out of network for most insurers, meaning they can generally set their rates wherever they want. This situation can often leave patients facing so-called “surprise bills.” Some of which can be absolutely ridiculous.

Baby sawyer just couldn’t wait to enter the world. Katie Moraida’s water broke a week before he was due. She and husband Daniel raced to Sutter Roseville. With the emergency room in sight, Katie screams for him to stop the car.

He said, “don’t push.” And I said, “I have to push.”

She went like this.

And I pushed. And then pop! And he came out!

Roseville PD called the paramedics, who cut the umbilical cord and drove Katie and sawyer a matter of a few hundred yards to the hospital door. The entire time with a paramedic, 10 minutes.

It is such a blur.

But later it would come into focus when two equal AMR ambulance bills showed up, one for Katie, one for baby sawyer, totaling more than 3,500 bucks.

Not even a full minute worth of an ambulance ride. We had already done the hard part. We delivered our child in the front seat of our car.

John: Well, hold on there. Did “we” really do the hard part, Dan? Because from what I just heard, you did some driving, and then sat back while your wife — in your words — “popped” out a human, so I’m not sure you really “did the hard part,” so much as you were just sort of there. C’mon, Dan. Be an ally. Read a tweet. And there can be absolutely crazy examples of surprise billing, even when EMS is run by the city. In Houston, literally all city-run ambulance services are out-of-network for all insurers. And a study of one large national insurance plan found that 71% of ambulance rides had the potential to generate a surprise bill. And when you know that, is it any wonder that woman begged people not to call an ambulance? Or that this incredibly grim trend has emerged:

Ambulance or Uber? That’s now the choice as more Americans are using Uber and other car services to get to the emergency room. 42-Year-old tech magazine writer Chandra Steele did it.

What were your symptoms?

I had some internal bleeding which I already —

You had internal bleeding and you took an Uber to the hospital?

Emergency room doctor Robert Glatter of Lenox Hill Hospital in New York says Uber E.R., as it’s been nicknamed, is not a smart idea in a crisis.

They don’t have any kind of oxygen, they don’t have intravenous fluids or ivs, they don’t have paramedics. That’s the main difference. They have a driver.

John: Right! They also may not know which local hospital has a trauma, stroke, cardiac, or pediatric unit. Because they’re Uber drivers. The most they have are tiny water bottles you’re afraid to drink from and a charger for a Samsung phone you do not own. So to recap: instead of all of us paying a little bit all the time for ambulances, we have a system where some of us pay an awful lot all at once when we have a terrible emergency. And if you’re thinking, “how could this possibly get any worse?” Well, wait, it can. Because for-profit businesses are also involved here — in fact, currently, private companies represent about 25% of all ambulance providers. And many of them are owned by private equity firms who’ve been acquiring distressed local ambulance providers for decades. Remember that baby who got a bill for being born? That came from a private for-profit company, American medical response. They’re currently the largest ambulance company in the U.S. and are owned by one of the country’s largest private equity firms. And when a private equity firm swoops in to help wring profits out of ambulance services by keeping costs low and revenues high, things generally don’t change for the better. Take Transcare, an EMS company acquired out of bankruptcy by a private equity firm run by this woman, Lynn Tilton. And a few things to note about aside from serving looks that can only be described as “my style icons are Wayne Newton and a Ferrero Rocher candy,” Lynn Tilton is a self-described poet, already one of the biggest red flags imaginable. We looked, and one of the only things close to poetry we could find from her was this Instagram post: “I am a woman of strength, nothing can break my spirit, I am wild and free, I am a warrior of light, I am me.” Which feels less like real poetry and more like someone with a concussion trying to remember Kesha lyrics. Lynn Tilton was also the star of the sadly canceled reality series “diva of distressed,” where she portrayed herself as a savior of troubled companies in inspirational moments like this:

One of the things we do is we all commit. So I’m going to ask you all to commit with me that we will not stop until we’ve achieved our goal. I commit!

We commit.

Thank you. Commit, commit! No pussies in my mill!

John: She seems great. And Lynn Tilton certainly knows how to instill a sense of courage in those around her. Reminds me of that famous FDR quote: “the only thing we have to fear is pussies in my mill.” And Tilton promised to bring that uplifting leadership to Transcare. But many who worked there described rough conditions on her watch, with one former employee saying they were sent out in a vehicle where the brakes didn’t work properly and during the 2014 Ebola scare had trouble getting enough sanitary wipes to disinfect their ambulances. Former staff even said they were pressured by Transcare supervisors to go “E.R. shopping,” meaning they’d steal medical supplies from the E.R.s to restock their ambulances. And when Transcare inevitably ended up filing for bankruptcy in 2016, its employees found out that they’d lost their jobs like this.

Workers were told they had 30 days left on the job. They showed up today to find this. Transcare was shuttered.

I was in shock. We were all in shock.

It was horrible. It’s absolutely horrible.

A work emergency for dozens of paramedics.

You know, I have to find another job. I have another side job to support me right now, currently, but that doesn’t pay the bills.

Last night we were told, “see you tomorrow. Have a good night.”

John: Well, that’s fucked up. There are certain businesses you assume might disappear overnight, like a kid’s lemonade stand or any circuit city in the late 2000s. Incidentally, they all became kingdoms of optical cables and loose batteries governed by rats, and that’s absolutely fine. But it is not great when what’s disappearing is a community’s life-saving medical service. And it’s not just that Transcare folded — it’s that, in a bankruptcy court ruling last year, a judge recommended finding Tilton liable for nearly $42 million for stripping value out of the company. Which isn’t totally shocking from a woman whose employees were encouraged to strip value out of fucking emergency rooms. Now, I have to say: Tilton denies having done anything wrong and has challenged that recommendation in federal court. And the thing is, I’m not just mad with Lynn Tilton here. I’m mad that we’re operating a system where a vital service is left vulnerable to the Lynn Tiltons of the world. So what can we do about this? Well, as I’ve said before, ideally, we’d transition to a Medicare for all approach, but that doesn’t seem to be in the cards right now. And in the meantime, there are smaller things we could do. For patients, we need to put an end to surprise billing. The good news is, congress passed a bill last year called the “no surprises act,” making it illegal to send patients steep medical bills when an out-of-network provider is unexpectedly involved in their care. The bad news is, while that applies to air ambulances, the bill, for some reason, explicitly carved out ground ambulances. In other words: most fucking ambulances. As for EMS providers: we should establish a lead federal agency dedicated to them. And they should absolutely be labeled an essential service. Especially because that’s what everyone thinks they are. But for that label to mean something, it has to come with funding at the local, state, and federal levels. And there’s no better time to make those big changes than right now, when we still remember the absolute hell of what these workers went through last year. Remember that parade that Bill de Blasio promised? It actually took place last month, but you know who notably didn’t attend? EMTs, many of whom boycotted it because of stagnant wages and the fact that they worked during the pandemic without hazard pay. Look: last year, everyone was anxious to show how much they supported EMTs. Well, now’s the time to prove it and make big changes on their behalf. And if we do that, maybe we’ll collectively be worthy of a siren that sounds like this: [warbling siren] get yours, mickey, you filthy mouse.

That’s our show. Thanks so much for watching. We’ll see you next week. Good night!


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