When someone with a medical emergency calls 911, they expect an ambulance to show up.
But sometimes, there simply isn’t one available.
Most states don’t declare emergency medical services (EMS) to be an “essential service,” meaning the state government isn’t required to provide or fund them.
Now, though, a growing number of states are taking interest in recognizing ambulance services as essential — a long-awaited move for EMS agencies and professionals in the field, who say they hope to see more states follow through. Experts say the momentum might be driven by the pandemic, a decline in volunteerism and the rural health care shortage.
EMS professionals have been advocating for essential designation and more sustainable funding “for longer than I’ve been around — longer than I’ve been a paramedic,” said Mark McCulloch, 42, who is deputy chief of emergency medical services for West Des Moines, Iowa, and who has been a paramedic for more than two decades.
Currently, 13 states and the District of Columbia have passed laws designating or allowing local governments to deem EMS as an essential service, according to the National Conference of State Legislatures, a think tank that has been tracking legislation around the issue.
Those include Connecticut, Hawaii, Indiana, Iowa, Louisiana, Maine, Nebraska, Nevada, Oregon, Pennsylvania, South Carolina, Virginia and West Virginia.
And at least two states — Massachusetts and New York — have pending legislation.
Idaho passed a resolution in March requiring the state’s health department to draft legislation for next year’s legislative session.
Meanwhile, lawmakers in Wyoming this summer rejected a bill that would have deemed EMS essential, according to local media.
“States have the authority to determine which services are essential, required to be provided to all citizens,” said Kelsie George, a policy specialist with the National Conference of State Legislatures’ health program.
Among those states deeming EMS as essential services, laws vary widely in how they provide funding. They might provide money to EMS services, establish minimum requirements for the agencies or offer guidance on organizing and paying for EMS services at the local level, George said.
The lack of EMS services is acute in rural America, where EMS agencies and rural hospitals continue to shutter at record rates, meaning longer distances to life-saving care.
“The fact that people expect it, but yet it’s not listed as an essential service in many states, and it’s not supported as such really, is where that dissonance occurs,” said longtime paramedic Brenden Hayden, chairperson of the National EMS Advisory Council, a governmental advisory group within the U.S. Department of Transportation.
More financial support
There isn’t a sole federal agency dedicated to overseeing or funding EMS, with multiple agencies handling different regulations, and some federal dollars in the form of grants and highway safety funds from the Department of Transportation. Medicaid and Medicare offer some reimbursements, but EMS advocates argue it isn’t nearly enough.
“It forces it as a state question, because the federal government has not taken on the authority to require it,” said Dia Gainor, executive director for the National Association of State EMS Officials and a former Idaho state EMS director. “It’s the prerogative of the state to make the choice” to mandate and fund EMS.
In states that don’t provide funding, EMS agencies often must rely on Medicaid and Medicare reimbursements and money they get from local governments.
Many of the latter don’t have the budgets to pay EMS workers, forcing poorer communities to turn to volunteers. But the firefighter and EMS volunteer pool is shrinking nationally as the volunteer force ages and fewer young people sign up.
Overhead for EMS agencies is expensive: A basic new ambulance can cost $200,000 to $300,000. Then there are the medicine and equipment costs, as well as staff wages and farther driving distances to medical centers in rural areas.
The fact that people expect it, but yet it’s not listed as an essential service in many states, and it’s not supported as such really, is where that dissonance occurs.
– Paramedic Brenden Hayden, chairperson of the National EMS Advisory Council
By contrast, police departments are supported and receive funds from the U.S. Department of Justice along with local tax dollars, and fire departments are supported by the U.S. Fire Administration, although many underserved areas also rely on volunteer firefighters to fill gaps.
“We need more if we’re going to save this industry and [if] we’re going to be available to treat patients,” Hayden said. “EMS in general represents a rounding error in the federal budget.”
What’s more, reimbursements only occur if a patient is taken to an emergency room. Agencies may not receive compensation if they stabilize a patient without transporting them to a hospital.
Gary Wingrove, president of the Paramedic Foundation, an advocacy group, has co-authored studies on the lack of ambulance service and on ambulance costs in rural areas. The former Minnesota EMS state director argues that reimbursements should be adjusted on a cost-based basis, like critical-access medical centers that serve high rates of uninsured patients and underresourced communities.
A rural crisis
About 4.5 million people across the United States live in an “ambulance desert,” and more than half of those are residents of rural counties, according to a recent national study by the Maine Rural Health Research Center and the Rural Health Research & Policy Centers. The researchers define an ambulance desert as a community 25 minutes or more from an ambulance station.
Some regions are more underserved than others: States in the South and the West have the most rural residents living in ambulance deserts, according to the researchers, who studied 41 states using data from 2021 and last year.
In South Dakota, the Rosebud Sioux Reservation covers a 1,900-square-mile area in the south-central part of the state.
State Rep. Eric Emery, a Democrat, is a paramedic and EMS director of the tribe’s sole ambulance station, providing services to 11,400 residents.
Emery and his colleagues respond to a variety of critical calls, from heart attacks to overdoses. They also provide care that people living on the reservation would otherwise get in the doctor’s office — if it didn’t take the whole day to travel to one. Those services might include taking blood pressure measurements, checking vital signs or making sure that a diabetic patient is taking their medicine properly.
Nevertheless, South Dakota is one of 37 states that doesn’t designate emergency medical services as essential, so the state isn’t required to provide or fund them.
While he and his staff are paid, remote parts of the reservation are often served by their respective county volunteer EMS agencies. It would simply take Emery’s crew too long — up to an hour — to arrive to a call.
“Something I wanted to tackle this year is to really look into making EMS an essential service here in South Dakota,” Emery said. “Being from such a conservative state that’s very conservative when it comes to their pocketbook, I know that’s probably going to be a really hard hill to climb.”
Ultimately, Wingrove said, officials need to value a profession that relies on volunteers to fill funding and staffing gaps.
“We’re looking for volunteers to make decisions about whether you live or die,” he said.
“Somehow, we have placed ourselves in a situation where the people that actually make those decisions are just not valued in the way they should be valued,” he said. “They’re not valued in the city budget, the county budget, the state budget, the federal budget system. They’re just not valued at all.”
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