Save Lives, Save the Bottom Line! Inequality in 911 Call Responses

A near-unique feature of the US healthcare systems among the developed nations is the absence of national healthcare coverage, resulting in a patchwork of privately insured individuals, publicly insured individuals through Medicaid and other arrangements, and uninsured individuals. Obviously, this introduces health care provision inequality – better insurance means better health and longer life. But how serious is this problem?

One way to look at this is to view healthcare providers as organizations with multiple goals – financial and social, where social means fair healthcare provision. Research on how organizations handle multiple goals usually, but not always, demonstrates that financial goals are attended to first, and all other goals afterwards. But could this be true also for responses to 911 calls for medical emergencies? This was the question addressed by Timothy Gubler, Haibo Liu, and Alexandru Roman in research just published in Strategic Management Journal. 
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What did they find? Indeed, financial goals mattered a great deal. They studied Emergency Medical Services (EMS) teams, which are the medical first-responders who stabilize a patient, provide first treatment if possible, and transport the patient to emergency room or other care. EMS teams are health care professionals motivated to help patients, and have legal duty of care, so they do not neglect patients in critical conditions regardless of insurance. They can, however, spend more time and provide more care when encountering insured patients with non-critical conditions, and a team engaged in such care will be less available for calls until they are done, so indirectly other patients suffer. 

So, do they prioritize financial goals? Yes, they do, but how much depends on some conditions. In general EMS teams will spend more time and do more procedures on privately insured patients, and this effect is stronger when their organization has lower revenue. Surprisingly, the effect is also stronger when their organization is a non-profit, so the common belief that non-profits is the cure for financial motives in healthcare and other social services simply isn’t true for EMS teams. A depressive set of findings for anyone wishing that unequal healthcare funding might produce equality in healthcare provision. The only consolation is that if the medical condition of the patient is sufficiently serious, financial factors have reduced effect on provision. Reduced, but they privately insured individuals are still favored.

Should we be impressed with this research because it is theoretically surprising? No. This is exactly what prior research on multiple goals suggests. Should we be impressed because it is counter-intuitive? No. We understand intuitively that more money means more service, even for medical conditions. Why is this research impressive, then? This is a highly politicized part of public life with many actors wishing to give the impression that what is unfair is fair, or that what is unfair is inconsequential. Facts are needed, and this research provides them. That is why it is impressive and important.
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Gubler T, Liu H, Roman A. 2025. No margin, no mission? How emergency medical service crews attend to competing financial and social goals on 9-1-1 calls. Strategic Management Journal, forthcoming.
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