Crisis in EMS: Fewer EMTs, tight budgets leave volunteer services searching for solutions

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By Audrey Posten, North Iowa Times

Life can change in an instant—an elderly parent falls at home, a wife or husband suffers a heart attack or stroke, a child is involved in a car accident. But what if, when someone calls 911, no ambulance arrives to assist them?

Unfortunately, that’s become a reality for many people across rural Iowa, as volunteer emergency medical services (EMS) struggle with tight budgets and a shrinking pool of EMTs.

Kip Ladage, Bremer County Emergency Management Coordinator, addressed this “crisis in EMS” earlier this month, during a program attended by EMS providers and community leaders from Clayton and surrounding counties.

“Where you live should not determine if you live when a medical emergency arises,” he said.

Ladage noted part of the problem is that, unlike law enforcement and fire services, EMS is not identified as an essential service in the state of Iowa. That represents an issue, he said, because often there are more calls for EMS than fire. In fact, for every fire call, there are 10 or 20 requesting EMS.

“But communities are not required to provide EMS,” he explained. “They’re doing so out of a moral obligation and a desire to help fellow mankind.”

Most of these EMS services are volunteer-based, with EMTs leaving their jobs, families and other commitments to aid fellow residents. This volunteer aspect, said Ladage, is critical both functionally and financially.

However, many volunteers are aging. Ladage cited an Iowa EMS Association survey that showed a majority of the state’s volunteers have served 20 years or more. Some have chosen to drop back on the level of care they provide, or even retire altogether.

“If you think there’s a crisis tonight, what happens when they all decide to retire?” he asked those in attendance.

Despite pleas for help, the demand for additional volunteers has not been met by younger generations. More advanced classes, clinical times and tests sometimes eliminate candidates from progressing to becoming EMTs, Ladage added.

“I’m not suggesting we drop the bar or decrease expectations,” he said, “but it makes it hard.”

Becoming an EMT isn’t cheap, either, with initial expenses ranging from $2,000 to $2,500, Ladage shared. Ambulance services are already strapped financially, with expenses like equipment purchases, repairs and fuel; medications and supplies; insurance; training; the cost of readiness; and labor subsidies (hiring paid staff to fill gaps).

Revenue is often derived from billing for service; county, city and township contributions; donations and fundraisers; and labor subsidies, the donation of time and labor by volunteers. Billing for service is tricky, he said, because not all calls result in income. Reimbursements from Medicare, Medicaid, Wellmark and other insurers don’t always match the cost of providing service.

“We’re not doing EMS to make a profit,” he said, “but we’re still trying to stay solvent.”

The financial aspect, paired with the need for more volunteers, will affect quality of life, productivity and long-term costs, Ladage stated. 

He offered several solutions, one of which included creating county-wide services or supplementing volunteers with paid EMTs. Pros, Ladage explained, would be a more stable service, a reduction in overtime costs and greater flexibility. However, it could also mean a massive increase in labor expenses, potentially smaller rosters to call on when multiple crews are needed and the loss of volunteer EMS identity, which is important in small, rural communities.

Jim Schutte, Bremer County EMS Association President, who facilitated the meeting with Ladage, said Bremer County contemplated forming a county-wide service. They discovered, though, that creating such an entity would result in a $480,000 loss for the county. Several other Iowa counties have moved forward with similar plans, he added, all resulting in annual losses of between $200,000 and $500,000.

Since increasing revenue through standard ambulance calls is “virtually impossible,” Ladage said other options could include billing for non-transports or standby, like at fairs or sporting events. Raising taxes, although anathema to many, is another possibility, he said.

“What if citizens said they’re willing to pay?” he wondered.

The best option, Ladage said, is to have the state designate EMS as an essential service, then fund it as such. He urged EMS providers and other community members to speak with their legislators, advocating for this option.

“Elected officials need to hear from us. If the elected officials start twisting the screws, maybe we’ll see some changes,” he said. “This is not a partisan issue. We have to get the word out, get organized and keep pushing.”

At this point, time is crucial, Ladage noted.

“Without changes, EMS as we know it will cease to exist. Morbidity and mortality will increase. Citizens need to hear it, and they need to know, if they dial 911, the ambulance might not come,” he said. “We’re worried someone of fame is going to have to die before something is done about this.”

This article is part one in a two-part series on the crisis in rural Iowa EMS. To learn more about how the crisis is impacting EMS providers in Clayton County, please see next week’s issue.

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