April 27, 2021

Rural Ambulance Crews Have Run Out of Money and Volunteers

WORLAND, Wyo. — For three years, Luke Sypherd has run the small volunteer ambulance crew…

WORLAND, Wyo. — For three years, Luke Sypherd has run the small volunteer ambulance crew that services Washakie County, Wyo., caring for the county’s 7,800 residents and, when necessary, transporting them 162 miles north to the nearest major trauma center, in Billings, Mont.

In May, though, the volunteer Washakie County Ambulance Service will be no more.

“It’s just steadily going downhill,” Mr. Sypherd said. The work is hard, demanding and almost entirely volunteer-based, and the meager revenue from bringing patients in small cities like Worland to medical centers was steeply eroded during much of 2020 when all but the sickest coronavirus patients avoided hospitals.

Washakie County’s conundrum is reflective of a troubling trend in Wyoming and states like it: The ambulance crews that service much of rural America have run out of money and volunteers, a crisis exacerbated by the demands of the pandemic and a neglected, patchwork 911 system. The problem transcends geography: In rural, upstate New York, crews are struggling to pay bills. In Wisconsin, older volunteers are retiring, and no one is taking their place.

The situation is particularly acute in Wyoming, where nearly half of the population lives in territory so empty it is still considered the frontier. At least 10 localities in the state are in danger of losing ambulance service, some imminently, according to an analysis reviewed by The New York Times.

Many of the disappearing ambulances are staffed by volunteers, and some are for-profit ambulance providers that say they are losing money. Still others are local contractors hired by municipalities that, strained by the budget crisis of the pandemic, can no longer afford to pay them. Thousands of Wyoming residents could soon be in a position where there is no one nearby to answer a call for help.

“Nobody can figure out a solution,” said Andy Gienapp, the recent administrator for emergency medical services at the Wyoming Department of Health. “Communities are faced with confronting the very real crisis of, ‘We don’t know how we’re going to do this tomorrow, because nobody’s doing it for free.’”

About 230 miles southwest of Washakie County, Ron Gatti is preparing to close up Sweetwater Medics, a small ambulance provider in Sweetwater County, where 42,000 people are spread across 10,000 square miles. Facing a budget crisis, the county is expected to end its contract with Mr. Gatti’s ambulance service in June.

The situation is a direct result of the pandemic, Mr. Gatti and county officials said. Rock Springs, the town that Sweetwater Medics serves, was looking for budget cuts; the ambulance contract was one of them. Mr. Gatti’s company proposed transitioning to a public, tax-supported service, funded by the county, he said, but the money was not there.

“Everybody wants it and nobody wants to pay for it,” said Jeff Smith, a commissioner in Sweetwater County.

Instead, after June 30, the regional hospital will have to respond on its own to emergency calls.

Mr. Sypherd, who is also president of the Wyoming E.M.S. Association, keeps a list in his head of ambulance companies, large and small, in imminent danger of closing. There is Sweetwater Medics, which could be gone by autumn. Sublette County’s service was recently saved after voters approved a small tax increase, which will fund a new hospital and the affiliated ambulance. Albin, near Cheyenne, no longer has enough volunteers to fill its crew.

“The ambulance at Albin is fiscally healthy. There’s just nobody to give it to,” said Carrie Deselms, who helps direct the program.

Fremont County, home to the state’s Wind River Indian Reservation, is set to lose its only ambulance service, American Medical Response, a national for-profit company that merged recently with the company that has handled the county’s ambulance service since 2016.

Now, American Medical Response says its profit margins cannot justify remaining there. The company has informed county officials that it will not rebid when its contract runs out this summer.

“The call volume in Fremont County plummeted, making it impossible to cover increasing operational costs without a subsidy” said Randy Lyman, the Northwest regional president for Global Medical Response, the parent company of American Medical Response. “The revenue alone simply wasn’t sufficient.”

There is a misconception, fueled by stories of astronomical bills and post facto charges, that ambulance service is a sustainable — even lucrative — business model. The truth, medical professionals say, is that those bills are rarely paid in full, by Medicare, private insurance or otherwise. Even in New York City, which operates ambulance services alongside its Fire Department, ambulances do not make enough money on their own to survive.

“Revenue does not come close to covering the full cost of operating E.M.S.,” said Frank Dwyer, a Fire Department spokesman.

For years, paramedics and emergency technicians have warned that these unreliable revenue streams put the country’s emergency medical systems in danger of collapse. The current crisis in rural service, experts say, was almost certain to arrive at some point, but the pandemic expedited it.

“It is a universal issue,” said Tristan North, a senior vice president with the American Ambulance Association, which represents crews in rural and urban areas. “If you have a pretty steady volume, then you can get some efficiencies of scale and have a better idea as far as budgeting, whereas in a rural area, it’s far less predictable because you have a smaller population.”

Critical to an ambulance’s survival is its ability to transport patients to hospitals, which allows it to bill for a transport. That limited revenue stream dried up during the pandemic, according to workers across the country, when crews were discouraged from transporting all but the sickest of patients.

Instead of transporting patients to hospitals, crews were being directed to provide care on scene, Mr. Gienapp, of the Wyoming health department, said. “E.M.S. doesn’t get paid for any of that,” he said.

At the same time, many of the standard sorts of medical emergencies that helped keep ambulances afloat disappeared, either because people were moving around less, or were fearful of going to a hospital and exposing themselves to the coronavirus.

“There is not sufficient E.M.S. volume in this entire service area to make this a profitable, break-even venture,” Mr. Gatti, of Rock Springs, said. “This is an essential service that doesn’t pay for itself.”

In dense urban areas like New York or Los Angeles, there are enough people and everyday maladies that an ambulance service can come closer to sustaining itself, and enough of a tax base that cities can support it. But in places like Wyoming, the least populous state and one notoriously averse to tax increases, each missed transport in 2020 was critically lost revenue.

Unlike fire and police departments, many states do not consider ambulances to be “essential services.” Only a handful of states require local governments to provide them.

For most of the country, access to an ambulance is a lottery. Some municipalities provide them as a public service, funded by taxpayers, while some contract with for-profit ambulance companies. Most rely on the willingness of volunteer companies, like Mr. Sypherd’s in Washakie County, which are buoyed by a patchwork system of public and private funding streams.

But across the country, E.M.S. professionals say fewer and fewer people are willing to volunteer for the job, a phenomenon accelerated by the stress of the pandemic. Many municipalities expect volunteers to take time away from work, something few people can now afford to do.

“The donated labor is not there anymore,” Mr. Gienapp said.

On May 1, Mr. Sypherd will put on a new uniform.

For more than a year, he had known Washakie County’s system was unsustainable. In an effort to ensure an ambulance remained in Worland, Mr. Sypherd reached out to Cody Regional Health, a hospital system based near Yellowstone National Park, and began exploring whether the agency would take over his ambulance company.

It is a trend that is gaining traction in rural states like Wyoming: In the absence of volunteer ambulance crews or sustainable funding from local governments, some struggling ambulance services are accepting takeovers from local hospitals and health care systems.

The system is not ideal, experts acknowledge, and it could leave large swaths of rural America disconcertingly far from ambulance service. Still, faced with the alternative, many crews like Mr. Sypherd’s are grudgingly accepting the help. In May, Washakie County Ambulance Service will become a Cody Regional Health ambulance company, and will keep many of Mr. Sypherd’s original crew on staff.

“It’s the right thing to do,” said Phillip Franklin, the director of Cody Regional Health’s ambulance program.

So far, Mr. Franklin and his team have taken over two struggling ambulance companies in northwest Wyoming, and they are trying to help others with their workload.

The reality, he says, is that without help from systems like Cody’s, many of the ambulances in rural Wyoming will fail.

“Someone is always going to have to subsidize rural America,” he said.