In a way, the problem with Harford County's ambulance service, which appears to be running in the red these days, according to a recent presentation to the Harford County Council, is emblematic of the problems facing the U.S. health care system.

The short version: There's a lot of money involved and a lot of people who aren't directly involved in providing health services have a financial stake in what's going on.

The long version is complicated and mind-numbingly detailed, but worth taking the time to understand.

Until a few years ago, ambulance service in Harford County was provided by the county's volunteer fire and ambulance companies. With a single exception — Havre de Grace, which has separate and unrelated fire and ambulance companies — each community has a fire and ambulance company that has been responsible for providing this vital and important service.


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Going back many decades, the volunteers have taken this responsibility very seriously, keeping up with the increasingly detailed regimen of medical training that has evolved for emergency medical crews over the years.

State and local governments came to recognize the valuable service being provided by the volunteer fire and ambulance companies, which historically and in the eyes of the law, are private, not-for-profit organizations that technically aren't beholden to the county or state governments. Even so, as the amount of training time increased, the amount of time to raise money to pay for training and equipment decreased and governments, especially the county government, became increasingly willing to pay for a portion of the operational cost of the fire and ambulance service.

It is, after all, much cheaper to pay for training and equipment for highly-qualified volunteers than it is to pay for training, equipment, salaries and benefits for a full-time county-run ambulance service.

Similarly, state officials recognized the value of the service provided by the volunteer ambulance crews in Harford County and more than a decade ago passed a key bit of legislation that allowed ambulance bills to be sent to insurance companies when the people transported had insurance coverage. The insurance companies are obliged to pay the bills.

By contrast, if an ambulance crew transported a person with no insurance coverage, a request for a donation that has the look and feel of a bill is sent out, but the person with no medical insurance is not obliged to pay.

The insurance company money paid for ambulance service to the volunteer fire and ambulance companies, however, isn't necessarily strictly dedicated for use in providing ambulance services. It might be, but there's really no way to tell. Remember, the fire and ambulance companies are private, not-for-profit organizations and they have been reluctant to open their books for much in the way of public review. That changed about a year ago, at least to some degree, when the county government more or less demanded a level of access to fire and ambulance service books.

Not coincidentally, the change came about as a result of a festering crisis involving the ambulance side of the fire and ambulance service. Increasingly, the Abingdon, Bel Air, Joppa-Magnolia and, to some extent, Aberdeen fire and ambulance companies were burdened with a dozen or more calls a day for medical emergencies of varying severity. A few dedicated, but largely overwhelmed, volunteers were dealing with an awful lot of calls and it became clear to all involved that the situation couldn't be sustained.

The solution devised by the fire and ambulance companies was to hire paid crews to ensure ambulances were staffed at peak hours and when no volunteers were available, a so-called hybrid system. It has been in place for several years, though it's pretty clear it isn't working as expected and, as one public official said, it's time to go back to the "drawing board."

Problems could have been anticipated and, indeed, were warned against, chief among them a reality in human nature that precludes one person from doing something for free when someone else would be getting paid for the same work.

It is, however, just as predictable that there will be plenty of people saying the system is working just fine and simply needs a little tweaking, and this also comes down to the issue of getting paid. Remember the law that allows volunteer fire and ambulance companies to collect from insurance companies? It's still on the books and the private volunteer fire and ambulance companies have an interest in protecting this revenue stream.

While it's unlikely to be even whispered aloud, the financial arrangements the state and county governments have with the fire and ambulance companies are an important part of what will drive the public policy discussion on how Harford County's emergency services will be provided. Certainly, the fire and ambulance companies were founded with an altruistic purpose, one that has been proudly at the forefront, though the large sums of money associated with providing emergency medical service have distorted the picture to some extent.

It's past time for Harford County - its government and its people – to take a hard look at the future of emergency medical services and how it's going to be funded.