While I was sitting in a coffee shop on New Year’s Day, the man next to me asked me what I was reading. It was An American Sickness: How Healthcare Became Big Business and How You Can Take It Back by Elisabeth Rosenthal, which I had been looking at because it is highly relevant to the conversation about American healthcare sparked by the killing of UnitedHealthcare CEO Brian Thompson. In fact, the book was directly referenced in the accused shooter Luigi Mangione’s manifesto.
Coincidentally, I had just read Rosenthal’s discussion of why ambulances are so expensive, and the man next to me turned out to be an Emergency Medical Technician (EMT). So we quickly got into a fascinating—and disturbing—conversation about his life and work, one that I think illuminates a lot about the problems with not only American healthcare but also with our economic system more broadly.
At first, the man, whom I’ll call D, told me some basic facts about his work that didn’t seem to have political implications. He was from New Orleans but had been working lately on a contract basis for a company out in Texas. He was back in town for the New Year but heading back west soon. The work in Texas paid better, he said. Then, as he progressively revealed more facts about his work to me, it became clear that his life demonstrated the fundamental brokenness of our system.
D casually mentioned that when he had worked as an EMT here in New Orleans, he had been homeless for months on end. I was shocked. How? Well, first, even though ambulances are incredibly expensive for patients, EMTs are not actually paid very much. The average hourly pay in the area is under $14, even though EMTs do crucial work saving lives and have to do a lot of what doctors and nurses do with far fewer resources and in incredibly stressful and time-sensitive conditions. D was not only being paid little, but even though he was working 7 days a week, 12 hour shifts, he was only getting paid for 3 of those nights. How could that be?
Here was what had happened: D had worked for a private ambulance company. They had made him what sounded like a good offer: they would pay to train him as a paramedic (a higher level than a basic EMT) if he committed to working for them for three years afterward. Paramedic training requires both coursework and up to 1,200 clinical hours working at a hospital. The company sent him to a community college in a different city for four months to do his coursework, then when he came back to town he needed to do his clinical hours. The clinical hours, which he did 4 nights a week, were unpaid, because they were considered part of his education. But the low salary meant he couldn’t afford rent, and he ended up living out of his car.
Now, the work of an EMT is incredibly difficult, especially in a city with a lot of violence like New Orleans. D was working long shifts, 7 days a week, seeing incredibly distressing and traumatic things. (He said seeing violence against children was the most difficult to deal with.) Eventually he burned out, and needed time off. But, he says, when he came back he was told that he needed to have his clinical hours completed by a certain date, or else none of what he had done already would count. The completion date was not possible to meet, since by the time the company had processed his paperwork the deadline had passed. As a result, D not only lost credit for all the unpaid hours he had done already, but he was told he would have to repeat the four months of coursework if he wanted to get his paramedic certification—and this time the company would not pay his tuition, so he would have to take on debt. Worst of all, the company said that because he did not complete the program, he was on the hook for the tuition and board, and had accrued a debt of $14,000. This meant that despite doing hundreds of hours of unpaid work, working seven nights a week, he actually ended up being pursued by a debt collector, and didn’t even receive his paramedic certification!
At that point, D quit to go and work in restaurants, which was better-paid work. But he missed the satisfaction of helping save people’s lives, and so he returned to being an EMT. He told me he was happy with his current life situation, saying he’d actually been very fortunate and has no complaints. But when I inquired about what was better, he said that his new job in Texas paid less by the hour than he had been earning in New Orleans, but he was able to stay in a house out there that his mother owned in exchange for helping to renovate it. In other words, he hadn’t found a job that actually paid EMTs a living wage, but he’d been able to depend on family resources to make up for what his employer wouldn’t provide!
Even though D professed himself happy with his current life situation, I couldn’t help but realize that he had been horribly exploited. The ambulance company had profited by charging a fortune for its services while underpaying him. The unpaid clinical work is classified as “education,” but I think that’s just a way of rationalizing exploitation. Even if it’s necessary training, it’s work, and it should be paid (just as internships should be paid). The only way D had finally been able to make ends meet was thanks to his family, but what about those who don’t have family resources? And why should families have to subsidize people in order for them to achieve a basic standard of living?
The crazy thing, of course, is that D was often doing a lot of the same work that a doctor or nurse does, but not getting anything like the same kind of salary. Given ambulance prices, it’s not like the patients were getting the benefit of the exploitation of D. This is a system that doesn’t work for the EMTs and doesn’t work for the patients! The only people it works for are the owners of the ambulance company. D himself did not seem to feel the kind of anger that I think he’s entitled to feel, in part because his work is meaningful to him. But when I said he’s still being underpaid and the whole situation is grossly unfair, he agreed. “People ask me if I like my job,” he said. “That’s complicated. I like the work. But the ‘job’ is also the company, the pay…” And those things, he made it clear, sucked.
During the course of Joe Biden’s presidency, there has been a very frustrating public debate over how “the economy” is doing. Defenders of Biden often argue that “the economy” is now doing well, pointing to indicators like unemployment rates, GDP, or manufacturing investment. Or perhaps they will point to the statistic that most people report that they are happy with their own financial situation. But I think D’s story shows how this is a totally misleading picture. D told me he was satisfied with his own financial situation. But his situation was deeply unfair. He was being paid far less than he should have been. He was not able to afford a basic living (let alone a comfortable middle-class life) on his salary despite doing noble, stressful, traumatic work in long, consecutive shifts. He had to relocate from the city where he wanted to live in order to be paid less to work somewhere else, so he could supplement his wages with free housing from a parent. He was only “satisfied” because his baseline expectations were so low. Before he had been literally living out of his car, working seven days a week, and still accruing debt! Now he was at least not living out of his car, although he was still being pursued for unpaid debt (and has a wrecked credit score that will keep him from getting a loan, and will find it hard to ever become a paramedic).
So don’t tell me this is a “good economy.” Don’t tell me this is a functional country. A system that treats D this way is totally dysfunctional. He should be a paramedic right now, earning a middle-class salary. (I’d say around $100,000 a year would be fair, considering how difficult the work is). But our system is failing. D told me that plenty of others—those who want to be EMTs, who want to serve others—end up burning out and leaving. Low pay and long hours surely result in lower quality work, even though this work could not be more important to get right.
As EMT David Anderson explained in an article for this magazine back in 2018, a core problem here is that ambulances are being run on a for-profit model. Anderson explained that this creates incentives to underpay and overwork EMTs:
The private ownership model for ambulances is fundamentally at odds with its own purpose… They want to get the cheapest gear, the cheapest ambulances, and the cheapest workers. You will see EMS personnel make fast-food level wages, for what is ostensibly an extremely important job. Paying people by the hour in addition to having prohibitively expensive equipment means EMS corporations need to maximize the workload for a workforce that they keep as small as is feasible.
D affirmed everything Anderson explains in his article. EMTs suffer major health problems (D didn’t even have health insurance, because now he worked on contract) and their performance suffers because of overwork. How can we treat our emergency responders this way? Anderson makes it clear that the only viable model is public ambulance services that pay EMTs good wages (with health insurance!) and are free at point of use for patients. These exist. Ambulances are free to use in the U.K. In some other countries, there is a nominal call-out fee. Even Mogadishu has a (small) free ambulance service. We can fix this, but we don’t. The U.S. has the most expensive ambulances in the world.
Because we don’t fix an obviously fixable problem, we are not functioning well as a country. That much should be obvious. And it’s maddening that people are defending the American economy in 2024. This is a country where an EMT can become homeless as they strive to improve their qualifications so they can help people more! Something is very wrong. And the brokenness that affected D is just one small piece of a broken healthcare system. It makes me angry every time I think about how many people are getting rich off of the sick and off of those trying to help the sick. I am not surprised a lot of people were not sorry to see UnitedHealth’s CEO shot, and that the overwhelming majority of Americans blamed not just the perpetrator, but the healthcare system itself for the murder.
Every time I’m told that the economic statistics are good, that people’s discontent is based more on “vibes” than material reality, my reaction is the same: Go out and talk to people. And don’t just ask them superficial questions (“Are you happy?”) Get them to tell you about their lives. I don’t think D even really saw his situation as outrageous or exploitative; he seemed surprised when I told him that it sounded really fucked up, although he agreed that it was. There is something deeply wrong with many of our core institutions, which are mistreating people systemically. I did not happen to be sitting next to some strange statistical outlier with a rare kind of bad luck. D was experiencing the economic system as it functions regularly. We need to understand just how bad things out there are for people, so that we can commit ourselves to repairing them.
