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Back during World War Two, a young doctor named R Adams Cowley spent his deployment

on the battlefields of Europe, treating patients on the precipice between life and death.

He observed, through this experience, that those suffering the medical state of “shock”

following a traumatic injury were placed on an often certain, but not immediate, path

towards death.

This exposure to those patients developed his life's goal: he sought to take those

on that certain path towards death, and nurse them back to life.

He wanted to be able to treat then-untreatable major traumatic injuries.

Some years later, in 1960, he neared closer to this goal by opening, in some corner of

the sprawling University of Maryland Medical Center, a two-bed unit dedicated to treating

major trauma patients—the first such department in the country.

Cowley started with about a 40% survival rate, but as his experience accumulated, and his

techniques refined, more and more patients survived.

It turned out that the certain path towards death for major trauma patients was not so

certain.

However, he also observed that even his reliable techniques couldn't reverse the course of

death if a patient took too long to get to him.

He posited that once someone experienced major trauma, they had a roughly 60-minute window

to reach him, or else it was too late.

The problem was that, by the time other doctors transferred a patient to Cowley, that window

had often passed.

The system just wasn't suited for this sort of speed.

Therefore, he reinvented the system.

First, he lobbied for ambulances to bring trauma patients directly to him—or, eventually,

other trauma units—rather than just to the nearest, potentially unequipped hospital,

as was standard protocol at the time.

Second, he convinced the Maryland State Police to use their helicopters to bring trauma patients

to his unit—dramatically reducing the average time to care.

Cowley dubbed this 60-minute window the Golden Hour and the principles behind it are now

the central, guiding light of the Emergency Medical Service system—its purpose is to

stabilize, triage, and transport as fast as possible because, according to this Golden

Hour principle, faster is always better in trauma medicine.

The vast majority of the American population can reach their nearest hospital within the

Golden Hour with a traditional, ground-based ambulance system, but not all.

This is a map of the US, and these are the areas more than a sixty-minute round-trip

drive to the nearest hospital.

There are vast swaths of the sparsely-populated American west where ground ambulances cannot

fulfill the golden hour principle, especially given the recent spate of closures of unprofitable

rural hospitals.

In fact, it's not even very difficult to run into this problem.

If you were to drive from Denver to Las Vegas—two major American cities—most of your trip

would take place on Interstate 70, which would lead you through the desolate area of the

San Rafael Swell.

If your car were to crash here, your nearest hospital would be over ninety minutes away

in Moab, and this is just on the interstate—the central circulatory system of the US.

It's plenty possible to get much, much further from medical care and so, to plug these gaps,

to get patients in the most rural areas and dire circumstances to care as fast as possible,

that's where the country's air ambulance system steps in.

Across the nation, there are some 900 air ambulances stationed at hundreds of bases,

each of which expands the number of people able to reach hospital within an hour.

Each of these aircraft have the potential to change lives each and every day, and play

a big part in many people's worst days.

When your life is on the line, every minute counts, so these aircraft save life and limb

with every flight… right?

Well, to a certain person, maybe an executive at an air ambulance company, for example,

the 702 words up until now probably all sound correct, but are they really?

Everything up until now covered one simple principle: more trauma patients brought to

the hospital within sixty minutes equals more lives saved?

It can't possibly be that the central tenant of emergency medicine, the Golden Hour principle,

is just… wrong… right?

Well, in 2001, an academic review posed that exact question and found, “no large, well-controlled

studies in the civilian population that either strongly support or refute the idea that faster

is universally better in trauma care.”

Essentially, it said that the Golden Hour principle could be true, but despite the fact

that the entire EMS system operates on the collective assumption that it is true, we

just didn't know for sure.

So, in response, researchers sought an answer.

Plenty found that the answer was yes—as one would expect, faster transport to the

hospital does improve survival outcomes—but plenty others… didn't.

This one found that, “the time factor involved in managing and transporting hypotensive penetrating

injury victims directly to a regional trauma center does not appear to be related to an

adverse outcome.”

This one concluded with, “no prehospital time less than 90 minutes exerted a significant

adverse effect upon survival,” while this one found, “no significant difference in

survival after traumatic injury when the 8 minute ambulance response time criteria was

exceeded.”

Similar results, failing to find a statistically significant link between total pre-hospital

time and survival outcomes, were found in this study, and this one, and this one, and

this one, and countless more.

Twenty years onwards from that academic review, the only certainty here is uncertainty: there

is no scientific consensus on whether the Golden Hour is truly relevant today.

Uncertainty is fine—it's part of the scientific process—but the entire American air ambulance

industry is built on a collective, unverified assumption that the Golden Hour principle

is indeed true.

However, since we're dealing with assumptions, let's tackle another one.

When you think of air ambulances, you probably imagine a flight from here to here: scene

to hospital.

Of course, that's what you see in the movies, but these sorts of flights only account for

about a third of air ambulance trips.

The vast majority of their business involves hospital to hospital transfers.

You see, the trauma care system that Doctor Cowley innovated evolved into a nationwide,

hierarchical network.

Essentially, there are five levels of trauma centers—hospitals certified to treat patients

with major traumatic injuries—and as you go up in the levels, the centers become more

advanced, and less widespread.

Levels V and IV mainly deal with stabilization and initial evaluation prior to transport

to a higher level center, while Level III centers will have on-call surgeons who could

start to resolve simpler trauma cases.

Level II centers have surgeons with 24-hour immediate availability, rather than just on-call,

in addition to certain specialists.

Then, those most advanced, Level I centers have everything conceivably necessary for

any trauma case including specialists across all fields, and the ability to treat a case

all the way from initial presentation through rehabilitation—which can be a multi-year

process.

Level I trauma centers are incredibly expensive to run, and therefore need a critical mass

of patients to cover costs.

Consequently, it's very possible to be more than 600 miles or 950 kilometers from one

while in the lower 48, or 2,000 miles or 3,200 kilometers from one while in Alaska.

Due to this potential distance, a major trauma case outside a major city would typically

go first to a Level III, IV, or V trauma center, which are far more commonplace, where they'd

be stabilized and evaluated to determine whether they need to be transferred to a more advanced

facility.

So, someone in a vehicle crash in the San Rafael Swell on I-70 in Utah would likely

first go to the Moab Regional Hospital, which is a Level IV center.

If the doctors and nurses there determined the patient needed a higher level of care,

they would be transferred—in this case to St. Mary's Hospital in Grand Junction, Colorado,

which is a Level II center.

Then, if that hospital determined the patient had such complex and specialized injuries

that even they couldn't handle it, the patient would likely be transferred to Denver Health's

Level I trauma center.

Since each of these transfers would take hours by ground, the decision would almost certainly

be made, for major trauma cases, to use an air ambulance.

This is the bread and butter of the air ambulance business and surely this saves lives, right?

Well, yes and no.

In one study of major trauma patients suffering from certain high-mortality injuries, patients

admitted to Level II centers had a 29.7% mortality rate, while those admitted to a Level I center

only died 25.4 % of the time.

More advanced trauma centers do save more lives, and therefore conventional wisdom would

assume that transfers to higher level centers save lives, but conventional wisdom almost

always misses the nuance of a situation.

According to another study, some quarter of adults and half of children transferred to

Level I trauma centers are brought there unnecessarily—in other words, they've been subject to “secondary

overtriage” where the more advanced center ends up discharging them after completing

treatment that a less advanced center would have been plenty capable of.

Now, a certain level of secondary overtriage is to be expected and even encouraged—after

all, it's better to be safe than sorry—but again, we need that nuance.

For an overtriaged patient, they would have survived if they had stayed in a Level III

center, for example, and they did survive when they ended up in a Level I center, so

the health outcome was the same, but for those patients transferred by an air ambulance,

they received something else: an absolutely massive bill.

A conservative estimate puts the average price of an air ambulance flight in the US at $27,900.

Others put that figure even higher, well into the 30 or 40 thousands, meaning it's very

possible and even common for someone to be charged more for a quick helicopter ride to

or from the hospital than they make in a year.

Another counterargument, though: a human life, to the holder of that life, is essentially

invaluable—any cost to save it is worth it—but the problem is not the cost, it's

the price.

The cost for air ambulance companies to operate a given flight, according to the companies

themselves, is somewhere between $6,000 and $13,000.

That shouldn't be possible—as in, quite literally, the rules of economics say that

that gap between cost and price shouldn't be possible, because in a normal free market,

for normal products, competition would drive down prices far closer to costs since lower

prices increase demand, and companies can increase profits with greater market share,

but the American air ambulance market is very far from normal.

Every product in the world can be mapped onto a graph that looks like this: price on the

y axis, quantity purchased on the x.

This is what a normal product looks like—as price goes down, quantity purchased goes up.

There are some exceptions to this—for example, certainly luxury goods plot like this on the

graph, where higher prices actually stimulate higher demand, to an extent—although almost

no product will look like this.

This, however, is the relationship between price and demand for air ambulances—as price

increases, it has zero impact on demand.

It's easy to understand why: the people purchasing and paying for air ambulance flights

have no agency over whether or not to do so.

The decision to use an air ambulance is made by first responders or doctors, not the often-unconscious

patient, and so there is a complete lack of market forces working to lower the price.

When the free market isn't working to regulate the allocation of goods and services into

the most societally advantageous configuration—which is this case would be the greatest possible

availability of air ambulances at the lowest possible prices—economists would describe

that as a market failure.

In cases of market failure, even the most staunchly libertarian economist would tend

to agree that the only solution, at that point, would be external intervention—typically,

by the government—and so this massive, critical industry charging vulnerable people massive,

crippling prices can't possibly be completely unregulated, right?

Wrong: in fact, not only is the air ambulance industry not regulated, but it seemingly can't

be.

You see, back in 1978, Congress passed the Airline Deregulation Act, ending the government's

ability to regulate the fares of airlines.

This led to a dramatic decrease in airfares and a dramatic increase in flights—essentially,

it paved the way for the US to become the world's largest aviation market—but when

it sought to deregulate airlines, that truly meant all airlines.

Through the years, as various states have attempted to fix the market failure of the

air ambulance industry, providers have successfully argued in court time and time again that because

they are technically airlines, and because the Airline Deregulation Act prevents states

from regulating airfares, states therefore cannot regulate the prices air ambulances

charge.

There is truly no limit to what they can charge.

But, wait.

There is another, unique market force in the American healthcare industry that could solve

this problem: that of insurance, right?

You see, most insurers in the US have a network of providers that they cover and, if a patient

uses an out-of-network provider, they are charged a far higher rate, or are subject

to an annual spending cap.

In non-emergency circumstances, it's often possible to find an in-network provider, and