A related concern is that the priority currently given to certain programs could shift, resulting in less support for existing programs. EMS advocates have expressed concern that hospital-based emergency and trauma care issues would dominate the agenda of a new unified agency. The pediatric community is worried about getting lost in a new agency, and has fought hard to establish and maintain strong categorical programs supported by historically steady funding streams. There is concern that under the proposed structure, the current focus of the EMS-C program could get lost or diminished or simply lose visibility in the multitude of programs addressed by the new agency.

There is also the potential for administrative and funding disruptions. Combining similar agencies, particularly those that reside within the same department, may be straightforward. But combining agencies with different missions across departments with different cultures may prove highly difficult. The problems experienced during the consolidation of programs in DHS increase anxiety about this proposal.

Another concern is that removing medical-related functions from DHS and DOT could exacerbate rather than reduce fragmentation. Operationally, nearly half of EMS services are fire department–based. Thus, there is concern that separating EMS and fire responsibilities at the federal level could splinter rather than strengthen relationships.

Despite the concerns outlined above, the committee believes the potential benefits of consolidation outweigh the potential risks. A lead federal agency is required to fully realize the committee’s vision of a coordinated, regionalized, and accountable emergency and trauma care system. The committee recognizes that a number of challenges are associated with the establishment of a new lead agency, though it believes these concerns can be mitigated through appropriate planning. The committee therefore recommends that Congress establish a lead agency for emergency and trauma care within 2 years of the release of this report. The lead agency should be housed in the Department of Health and Human Services, and should have primary programmatic responsibility for the full continuum of emergency medical services and emergency and trauma care for adults and children, including medical 9-1-1 and emergency medical dispatch, prehospital emergency medical services (both ground and air), hospital-based emergency and trauma care, and medical-related disaster preparedness. Congress should establish a working group to make recommendations regarding the structure, funding, and responsibilities of the new agency, and develop and monitor the transition. The working group should have representation from federal and state agencies and professional disciplines involved in emergency care (3.6).