COMMENTARY ON TRAUMA CARE : The Future Could Bring Us an Emergency-Room Emergency : Fund strictures may mean fees for medical--and other--public services that we now take for granted.

Recent events in the Middle East should have taught us how quickly peace can change to war and neighborhood calm can degenerate to chaos. The decision to close many of our lifesaving trauma units because the community is unwilling to fund them is a tragedy whose loss most citizens may now only vaguely regret.

However, it is a decision with dire future implications we may yet have to face.

In a peaceful environment in which far fewer people need trauma care than need garbage collection, the loss is not yet loudly and publicly lamented, except by that unfortunate minority who may have lost a friend or loved one because of the lack of adequate emergency medical service. But, then, in recent weeks, the citizens of Tel Aviv and Riyadh and Riga and Vilnius probably did not foresee a compelling need for expensive emergency services in their communities, either.

By now we should have learned to expect the unexpected and that change if it comes may occur in the blink of an eye. Currently, for lack of adequate funding, even the familiar local emergency rooms in nearby hospitals are threatened with loss of trained staff and adequate facilities, and if they wither and disappear we will all be at very great risk.

Ellfreth’s Alley in downtown Philadelphia where I was born and raised is a single block of quaint old homes that date back to pre-Revolutionary America. They are still elegant and highly desirable residences. And on the front pillar of many of them is a brightly polished brass plaque inscribed with the name of the fire company that some early Philadelphians had hired to guard their homes from destruction.

If they had arranged protection for their homes, the fire company did its job. If a house did not display the plaque, the pumpers and the hoses and the firemen went home or at most stood by to make sure the conflagration didn’t endanger their other clients. Like so many pre-Revolutionary innovations, the plan is attributed to Benjamin Franklin.

Some of the societal infrastructure that we have assumed will always be free may have to become self-supporting. When we dial 911 we take it for granted that the responding police or fire or paramedical services we need are part of our inalienable rights as taxpaying citizens.

Maybe so, but it was not always this way and may not always be this way in the future as the cost of maintaining facilities escalates. Though we may not choose to call it a tax, it is a levy we may have to start paying.

Some cities in Orange County have developed an innovative response to the cost of self-protection. To offset the ever-increasing expense of paramedic services, Westminster has recently enacted what is essentially a modification of the old Ben Franklin fire protection plan.

For a fee of $35 every family, household or business in Westminster can buy unlimited access to paramedical service at no additional cost. Those without the coverage will pay a fee for the service every time it is requested. For non-members there will be a charge now estimated at $110 to $150 per call. Success will depend on the aggressiveness with which the city demands payment from non-subscribers, for if non-members with the means can get the same attention as those with the foresight to join, obviously no one will rush to pay the up-front fee.

As the cost of previously “free” municipal services rises and the demand increases and the “peace dividend” that seemed so invitingly near until last August evaporates, it seems likely that many other services that we have come to expect with the air we breathe may become luxuries.

Garbage pickup is an expensive and ongoing necessity that in my father’s day used to go along with street lights as a free dividend of home ownership. Now many, if not most, communities levy a surtax for it.

It is not at all fantasy to envision the day when subscription to fire protection may again be a separate fee for a householder or an apartment house owner or a business. Those who do not pay, of course, would be similarly protected but charged, and the success of an insurance plan would again depend on the determination of the community to collect from the non-subscribers who use the service.

The idea is neither radical nor reactionary. We think of the streets and highways as free, but we all pay annually for the privilege through our assessment for automobile license tags. And now in Orange County and other parts of the state, we are in the process of further increasing the cost of using the highways by adding toll roads.

The concept of buying prepaid catastrophe insurance is an old idea whose time has come and gone, which may yet again rise like the phoenix, if some basic support services are to survive.