For a list of the 15 recommendations voted on by the Advisory Committee on Ground Ambulance and Patient Billing (GAPB), and the voting history, click on the file links below:

04_GAPB_ PPT_Mtg3_D1_ Recommendations_V4_11.08.2023_508.pdf   

Ground Ambulance and Patient Billing -Third Meeting Voting Summary_V03_508.pdf

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Plan to end exorbitant ‘surprise’ ambulance bills heads to Congress

Committee to recommend patients should pay no more than $100 or 10% of a bill, depending on which is less

By Jessica Glenza

July 21, 2024

https://www.theguardian.com/us-news/article/2024/jul/21/ambulance-surprise-bills-congress

A committee chartered to find ways to stop ambulances from sending patients exorbitant bills is set to tell Congress that patients should pay no more than $100 or 10% of a bill, depending on which is less.

The recommendation, which still relies on the convoluted private insurance industry, comes as nearly half of all ambulance rides in the US result in a “surprise bill” of often hundreds of dollars.

“America has decided to use an insurance system to spread the risk among many,” said Patricia Kelmar, senior director of healthcare campaigns at US Pirg, a consumer advocacy group.

“But when it comes to ambulances, without a surprise billing protection, that risk isn’t spread – the person who needs the ambulance is paying a lot more than anyone else who has that insurance.”

Kelmar was the lone consumer spokesperson on the committee formally known as the Advisory Committee on Ground Ambulance and Patient Billing. Other committee members included emergency service providers, ambulance companies, insurance industry insiders and representatives of federal agencies.

The committee was chartered when the former president Donald Trump signed the No Surprises Act in 2020 – a bipartisan bill to stop patients from receiving “surprise bills”. Although the legislation stops an estimated 10m surprise bills a year from reaching patients, ground ambulances are conspicuously excluded.

Surprise bills are in effect a dispute between insurance companies and healthcare providers. When a person takes an ambulance that is not directly contracted with an insurance company, they can bill insurance any amount they please. The remainder of the bill is then the patient’s responsibility. Hence, surprise bills are often called “balance bills”. And they can cost thousands.

For instance, Theo is a Washington state infant who arrived earlier than expected and needed to be transferred between hospitals for specialized care. The hospital ordered the ambulance, and the family was grateful for the good care.

Then the family received a $7,000 bill.

Insurance paid only a small portion – $1,000. The family tried to negotiate with both the ambulance and insurance companies, but were rebuffed. Now, they are now on a 30-month payment plan. Theo will be nearly three years old by the time the balance is satisfied.

“The hospital arranged the transportation, we didn’t have a say,” the parents said, in a presentation by Pirg. “We are grateful for the care, but surprised that even though we have good insurance we owe so much because the ambulance was out-of-network.”

Part of the reason Congress has found it difficult to regulate ground ambulances is because there are so many parties to please. Ambulances were once considered a public good and were funded by the federal government. But in 1981, the Reagan administration transformed funding for emergency medical transportation into limited block grants which states could then spend as they wish.

With federal funding diminished and states facing varying political and budget pressures, localities closed some public facilities, contracted with private companies and both began to seek payment from health insurance companies.

Now, a hodge-podge of private and public entities provide emergency medical transport, and stick patients with surprise bills as much as half of the time, according to Pirg. Privately insured Americans paid an average of $129m in surprise ambulance bills between 2013 and 2017, according to an article examining the problem in the journal Health Affairs.

Private equity has also prospered. Two of the three largest ground and air ambulance companies are now owned by private equity, which in some places has resulted in aggressive billing and collections.

“There was no discussion of whether or not we were going to ban balance billing,” said Dr Ritu Sahni, an emergency medicine doctor and a committee member at a panel discussion on their findings. “Balance billing created a barrier to good healthcare. But it was the ‘yes and’ component – how do we ensure the safety and survival of our community by making sure the future of the EMS service was secure?”

The committee coalesced around a set of recommendations to Congress that continue to rely on private insurance. They said patients with private insurance should be covered when they call 911 or are transferred between hospitals, like Theo’s family. A patient should pay no more than the lesser of 10% of a bill or $100. And, insurance should pay ambulances in a timely manner.

Although the committee published its top-line findings, the full report will not be available until it is sent to Congress, which is expected in the coming weeks. Whether Congress will act on the recommendations is unclear. Eighteen states offer some kind of consumer protection from surprise ambulance bills.

“In many ways we’re locked into the system we have and we’re trying to solve for the system we have,” said Kelmar. “But it’s a really important public policy question to know: should we keep this system? Is this the way we want to pay for emergency transportation service? Do we want private equity running ambulance services in communities?”

EMS agency and community leaders should monitor developments like this to assure logical public policy that modernizes EMS reimbursement to include reasonable reimbursement rates and coverage for valuable Treatment in Place (TIP) and Transport to Alternate Destinations (TAD) remain in place.

It's also a good reminder that during legislative processes, all stakeholders should be engaged in the process.

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Health insurance advocacy group seeks to block ambulance reimbursement bill
By Anthony Warren
Jul. 12, 2024
 
https://www.wlbt.com/2024/07/12/health-insurance-advocacy-group-seeks-block-ambulance-reimbursement-bill/
 
JACKSON, Miss. (WLBT) - An advocacy group for health insurance providers in the state wants to block a new law that would increase how much its members would have to pay ambulance companies for certain services.
 
The Mississippi Association of Health Plans (MAHP) recently filed for an injunction to block the State Insurance Commissioner from implementing H.B. 1489.
 
The petition was filed on June 28 in U.S. District Court for the Southern District of Mississippi, just days before the new law was set to take effect.
 
The bill, which was signed by Gov. Tate Reeves on May 2 after passing both the House and Senate on unanimous votes, requires insurance providers to compensate ambulance companies for certain services they previously were not paid for.
 
That compensation would be what is charged under the ambulance’s contract with a city or county, or 350 percent of the reimbursement rate of Medicare, whichever is larger.
 
Among concerns, MAHP argues the law is too vague to understand, and that provisions of the measure could drive up healthcare costs for customers. Additionally, the group is concerned about what impact the new law has on health insurance policies already in place.
 
“The vague language will create uncertainty for MAHP’s member plans, leaving plans without direction as to what claims may require coverage and what claims may not,” the suit states. “Furthermore, the significant lack of clarity will leave the interpretation and enforcement of these provisions to the sole discretion of the Commissioner [of Insurance]... or to courts deciding whether a denied claim is required to be covered as a matter of law.”
 
H.B. 1489, the “Mississippi Triage, Treat and Transport to Alternate Destination Act,” was passed during the 2024 legislative session and signed into law by Gov. Tate Reeves. The measure took effect on July 1.
 
The bill, in part, increases how much insurance companies must pay ambulance firms for services provided.
 
H.B. 1489
 
The measure also mandates insurance providers reimburse EMTs for services that they were previously not reimbursable, such as instances where individuals are treated in place or are transported to “alternative destinations” other than emergency rooms.
 
 
1489 defines those destinations as federally qualified health centers, urgent care centers, physician’s offices or medical clinics, and behavioral health facilities.
 
Currently, EMTs can transport individuals to those locations but are not reimbursed by insurance companies for doing so.
 
Rep. Stacey Hobgood-Wilkes rejects the lawsuit, saying ambulances shouldn’t have to provide services for free. “If you provide a service, you should be compensated for it,” she said. “Without adequate reimbursement for these services, the citizens of Mississippi will not receive the reliable, high-quality care they deserve and pay for.”
 
Figures provided by the Ambulance Alliance show EMS providers in the state charge between $988 and $1,224.82 for a basic life support emergency response in urban areas. Medicare reimburses those companies just $398.56.
 
MAHP takes issue with the bill’s use of the phrase, “including but not limited to” endlessly expands the list of destinations insurance companies now must pay for.
 
“As written, it is substantially unclear what constitutes an ‘alternative destination’ and if an ‘alternative destination’ includes medical providers who do not provide any degree of emergency medical services, such as a dermatologist, pharmacist, chiropractor, and the like,” the suit states.
 
MAHP members include Amerigroup, CareSource, Cigna Healthcare, CVS Health, Magnolia Health, Molina Healthcare, TrueCare, United Healthcare, and others. A list of members can be found here.
 
The group also takes umbrage with the bill’s requirement that insurance providers reimburse ambulances for “encounters” between EMTs and those seeking medical help.
 
Under the act, third-party payers would be required to pay for treatment in place when a patient is not transported to an emergency room. Before the passage of the bill, EMTs were only reimbursed if a patient was taken to the hospital.
 
That amount of the reimbursements would be the local fees set by a city or county contract or 325 percent of Medicare, whichever is greater. In the absence of a local rate, the ambulance provider would be paid their billed charges or 325 percent of Medicare, whichever is greater, the bill states.
 
However, MAHP says the law does not say what level of service would have to be provided, only that the service must be initiated by a 911 call.
 
The group also is unsure whether companies are required to pay the reimbursements under current insurance plans, or if they would only be required to do so under plans issued after the law took effect.
 
“These unintelligible provisions create no standard at all and/or cause House Bill 1489, Section 1 to be substantially incomprehensible,” the suit states. “Section 1 does not give a person of ordinary intelligence a reasonable opportunity to know what is prohibited, and increases the risk of arbitrary application and enforcement.”
 
MAHP is asking the court for a summary judgment ruling that Section 1 of H.B. 1489 violates the due process clause of the Fourteenth Amendment to the Constitution; it also is asking the court to void Section 2 of the bill, saying it violates the Constitution’s Contract Clause.
 
The group is also asking the court to prevent the state to implement or take any action to enforce provisions of the bill being challenged.

Special thanks to Rep. Carey for introducing H.R. 8977 the 'Improving Access to Emergency Medical Services Act of 2024' yesterday.  This marks the 3rd active bill in Congress to change the economic model for EMS from a transport-based reimbursement model to a 'response-based' model; in essence, reimbursing for the CARE we provide vs. the transport we supply. The 2 other bills are S. 3236 & H.R. 6257, the Emergency Medical Services Reimbursement for On-scene Care and Support Act (EMS ROCS). Congress has been very engaged with the EMS economic model for the past year. In March, 2024, the House Ways and Means Committee recently held a field hearing on access to emergency care with Dr. Ed Racht and Matt Zavadsky as invited experts to provide testimony and participate in a 3-hour Q & A session with the committee members.  You can watch the EMS-related testimony and the Q & A with the Committee members here. Carey Leads Effort to Expand Emergency Medical Treatment Options for Seniors  July 11, 2024   WASHINGTON, D.C. - Today, Representatives Mike Carey (OH-15), Lloyd Doggett (TX-35), Carol Miller (WV-01), Pat Ryan (NY-18) and Debbie Dingell (MI-12) introduced the bipartisan Improving Access to Emergency Medical Services for Seniors Act. The bill would allow seniors on Medicare to receive at-home emergency medical services to treat minor medical incidents.   “Not every patient is best served by an emergency room visit,” said Congressman Carey. “In fact, for many seniors, a trip to the hospital can mean long wait times, increased costs and potentially life-threatening complications. We’re proud to lead this bill to give our seniors access to the highest caliber of care.”  Treatment-in-place options for emergency medical reduces costs, increases convenience and protects seniors from potentially life-threatening infections.   Adults aged 65 and older account for nearly 20 percent of all ER visits. This population contributes to the backlog in waiting rooms, even when they might not have an issue requiring inpatient treatment. In a 2021 study, patients who received at-home care had a lower risk for readmission by 26 percent and a lower risk for long-term care admission as compared to patients who received in-hospital treatment.   “Treating patients immediately at home and preventing an emergency room trip is sometimes both the best way to help the patient and the taxpayer. Our legislation to establish a Medicare pilot program is designed to show the effectiveness of fair pay to first responders for such services. Thereby we hope to encourage a permanent payment system for treatment in place,” said Rep. Doggett.   Emergency Medical Services (EMS) providers are at the frontline of delivering care and transportation in rural America. In West Virginia, many patients live hours from a hospital and must consistently rely on EMS for treatment. Our EMS personnel are equipped to provide care to patients that may not be in a dire medical situation, rather than spend precious time and resources on transporting non-emergency patients to a hospital emergency department. This commonsense legislation builds upon the Treatment-in-Place Model to provide timely care to our rural patients and empower EMS providers, and I will continue to work to improve access to quality health care for patients in West Virginia and across the U.S.” said Congresswoman Miller.   “Our grandparents, neighbors, and friends are safer and healthier because of the dedicated care paramedics and EMTs provide to our community,” said Congressman Pat Ryan. “They deserve to be compensated – no matter where they administer care. That’s why I’m proud to co-lead the Improving Access to Emergency Medical Services Act to ensure that our highly trained first responders are fully supported in continuing to save lives and serve our seniors. I will keep fighting for the resources that our first responders need and deserve.”   Rep Dingell said, “We should be making it easier for seniors to live and receive the care they need at home and in their communities. The Improving Access to Emergency Ambulance Services Act will allow seniors to receive this care that can easily be provided at home by EMT professionals rather than paying for a hospital visit. Allowing EMTs to be reimbursed for this care and preventing unnecessary hospital visits would be an immense cost-saver for Medicare, free up emergency room space for those who really need critical care, and improve quality of life for our seniors.”   The bill has received support from the National Rural Health Association, International Association of Fire Chiefs, International Association of Firefighters, American Ambulance Association, Congressional Fire Service Institute, National Association of Towns and Townships and the National Association of Emergency Medical Technicians.    Randy Strozyk, President of the American Ambulance Association said, "We greatly appreciate the leadership of Representatives Mike Carey, Lloyd Doggett, Carol Miller, Debbie Dingell and Pat Ryan in laying the foundation for future Medicare reimbursement of vital ambulance services provided at the scene of a patient in need of medical care but doesn't require a transport to a health care facility. The Improving Access to Emergency Ambulance Services Act will establish a pilot project that will demonstrate the financial and medical benefits to the Medicare program of reimbursing for treatment in place of patients by paramedics and emergency medical technicians."   Susan Bailey, MSEM, NRP, President of NAEMT, remarked: "EMS is an integral part of our nation’s healthcare system and has been proven effective in the health continuum. EMS Practitioners are now providing medical care in a variety of settings. Our role has become much broader than ambulance transport. NAEMT has long advocated for providing EMS agencies the flexibility to navigate patients to the right care in the right setting through federal and state reimbursement of Treatment in Place (TIP). We applaud Rep. Mike Carey, Rep. Lloyd Doggett, Rep. Carol Miller, Rep. Pat Ryan and Rep. Debbie Dingell for their leadership and introduction of the Improving Access to Emergency Medical Services Act of 2024.   Reimbursing EMS agencies for TIP will save Medicare billions of dollars on unnecessary emergency department visits, enhance patient experience, shorten task times for EMS agencies struggling with workforce shortages, help decompress overcrowded hospitals and emergency departments, and meet patients’ needs without long waits at the hospital.”   “EMS is a fundamental, core service that fire departments provide in their communities. Fire fighters are among the most skilled and experienced pre-hospital emergency care providers in the nation, and it is long past time that we reimburse them for the full range of care that they give to ill and injured patients. Updating Medicare’s reimbursement policies is a common-sense way to drive EMS innovation and improve the patients’ experiences during medical emergencies. The IAFF applauds Reps. Carey, Doggett, Miller, Ryan, and Dingell for their bipartisan leadership in developing this bill, and we urge Congress to answer our call to bring EMS into the 21st century,” said IAFF General President Edward A. Kelly   “I thank Representatives Carey, Doggett, Miller, Ryan, and Dingell for introducing this legislation to reimburse fire and EMS departments for treating Medicare patients in places like their homes,” said Fire Chief John S. Butler, Fairfax County, VA and International Association of Fire Chiefs President and Board Chair. “This legislation will allow some of our nation’s most vulnerable citizens to receive necessary care without the trauma and expense of being transported to the hospital. It also ensures that fire and EMS departments only must transport patients if it is medically necessary, which frees up vital EMS and hospital resources. This program will be a win-win for both Medicare patients and emergency response agencies.”   Full text of the bill is available here.

A very well done summary of the public policy issues related to ambulance deserts, looming system failures, and the challenges with 'essential service' designation. Note the wages quoted in the article, likely related to the funding challenge, which leads to the staffing crisis.

Although this report focuses on rural challenges, the same issues are occurring in urban and suburban communities all across the country!

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Wyoming’s Emergency Medical Services ‘in limbo’

By Marit Gookin

July 9, 2024

https://www.wyomingnews.com/laramieboomerang/news/wyoming-s-emergency-medical-services-in-limbo/article_e099fe14-3d58-11ef-97ea-579add73226c.html

LANDER — In Wyoming, emergency medical care is non-essential. While people may feel that the ability to reach the hospital after a heart attack or a life-threatening car crash is vital to the health and well-being of themselves and their loved ones, legally speaking, the state of Wyoming does not consider it essential.

No one — at any level of Wyoming government — is required to provide ambulance service.

That leaves one glaring question: Who should provide ambulance service, and how should it be paid for?

After struggles with ambulance service last year, the Fremont County Commission appointed an ambulance task force including Commissioner Mike Jones to consider future funding options.

This task force met once, Jones said, and decided it had a variety of potential options to explore.

“We figured we had a couple of good options on the table,” he commented. “Things are kind of in limbo.”

Among the options considered are a sales tax, forming a special EMS district, and repurposing part of the existing half-percent economic development tax.

Some Fremont County commissioners are opposed to this last option, Commissioner Jenny McCarty explained, because they feel it stands on dubious legal ground: How does an ambulance constitute economic development?

Some Wyoming counties have no ambulance service at all — but McCarty said those counties are much smaller than Fremont County.

“We’re bigger than eight states,” she pointed out. “That’s a lot of dirt — and people are spread out all across it.”

A $2M price tag

Ambulance service in Fremont County has evolved over the years, at various points being entirely private-run, all-volunteer, fully county-operated and eventually winding up where it is today: a service provided through the county via a contract with a private company.

The county contracts with Frontier Ambulance to provide its emergency medical services.

But after its union workers voted to strike last fall, Frontier Ambulance and its parent company, Priority Ambulance, asked the county commissioners for an additional $386,796 to help cover the cost of the increased wages the workers were asking for.

In September, United Steelworkers Wyoming Union leader Will Wilkinson told this paper that low wages were leaving ambulance services short-staffed, leading to slower response times and EMTs working longer and longer shifts. The workers asked for an increase from a base rate of $12.58 an hour (for the lowest-paid EMTs) to $15 an hour.

The commissioners eventually voted in favor of the increase, bringing the county’s total ambulance expenditure up to about $1.8 million annually.

“It’s paid for this year out of the budget — but it’s unsustainable,” McCarty said.

She explained that the county had to dip into emergency reserve funds to cover the cost increase; with the county facing budget difficulties this year, that isn’t a long-term solution.

Unlike some of the other services provided through the county, Frontier Ambulance doesn’t necessarily bring the commission information about its budget or operations; as a private entity that the county contracts with, it is under no legal obligation to do so.

It used to provide periodic reports to the commissioners on how many people it had transported, but, said McCarty, it hasn’t done so for some time now.

And even if the county wanted to, shopping around isn’t much of an option.

There aren’t many organizations providing ground ambulance service in Wyoming, and if it intends to continue contracting for private ambulance service, the county doesn’t have a wealth of other companies from which to choose.

“They can walk away today; they can walk away tomorrow,” McCarty pointed out.

Although the county owns the ambulances and medical equipment and has worked out a memorandum of understanding that allows it to use these to provide services in emergencies, long term “there is no back up.”

Property tax, sales tax

The 2023 bill that allows for the formation of emergency medical districts, sponsored by Sen. Cale Case, R-Lander, and co-sponsored by Rep. Lloyd Larsen, R-Lander, outlines a specific process by which such a district can be formed.

The county commission must create a board of directors, which will then be responsible for evaluating the financial needs of emergency medical service and collecting payment from private insurance, Medicare and Medicaid.

The county can then levy a tax of up to two mills if the district was formed by a group petitioning the commission, and up to four mills if established directly by the county commission via a resolution, based on the assessed funding needs of the district after it has collected payment.

Districts are a more sustainable source of funding than sales taxes, which have to be reapproved by voters every few years.

But property taxes are often unpopular, and some feel unfair; Jones and McCarty said that several members of the public have communicated to the commission that they feel that funding the ambulance with a mill levy wouldn’t be equitable, not least because some of the areas that the ambulance currently provides service to don’t pay county property taxes.

On the other hand, the EMS district — and therefore the area it services — doesn’t necessarily have to correlate with the county’s boundaries.

An EMS district does have to consist of a specific, bounded geographic area, but the group forming the district, whether it’s a group of citizens or the county commissioners, can select any area that they want to within the county.

The idea of changing the memorandum of understanding (MOU) regarding the current half-percent sales tax has been strongly supported by some and met with opposition from others.

The half-percent tax cannot pay for the full nearly $2 million cost of the county’s contract; across the various entities that receive half-percent funding in the county, a total of $854,376 would be repurposed to help cover ambulance costs under the new MOU.

Opponents of the changes have included those who feel their legality is questionable and those who wonder what would happen to ambulance service if the half-percent tax failed to pass the ballots this November.

Lander City Council’s lone “no” vote on the new MOU, Missy White, objected to the altered MOU because she said the percentages of funds being taken from municipalities versus the county were out of balance. The question isn’t whether there’s a plan B, said White. She’s sure the county has a plan B, C and D — but she wants to know what those plans are.

“Bottom line, there has to be a funding mechanism — and it should be the people who use it who pay for it,” Larsen said.

Statewide challenges

“Our system is not working. We’ve got challenges, and people are falling through the cracks,” Gov. Mark Gordon remarked during the Wyoming Press Association convention this past January.

Around the state, he said, ambulance services are struggling; when you call 911, he pointed out, people have a reasonable expectation that someone will show up. But when it comes to medical emergencies, there are parts of Wyoming where that simply isn’t the case.

Fremont County isn’t alone in its ambulance woes — and part of the problem, Gordon said, comes back to whether it is legally considered essential.

“How do we make it an essential service?” he asked.

Some people believe the state of Wyoming should play a larger role in helping counties and municipalities fund ambulance services.

“Ultimately the question is … whose responsibility is ambulance service?” Larsen remarked. “Is it the responsibility of the state, or should it be more local?”

The county commission may be under no legal obligation to provide emergency medical services — but, McCarty said, she at least feels a moral and ethical obligation to make sure the people of Fremont County have access to life-saving health care when they need it.

“My number one job is to make sure that everybody is safe and sound in this county,” she commented.

For now, the county commission’s ambulance task force has made no reportable further progress since its first meeting. If it’s hoping to add a new potential tax to the ballot, it still has a little time to put it together; the deadline for adding measures to the November ballot is Aug. 25.

Another example of EMS agencies struggling under the current economic model. Skyrocketing costs and stagnant revenues are taxing current service levels. Municipal funding could be key to keeping the McCandless-Franklin Park Ambulance Authority afloat 2022 was the first year the authority didn't operate in the red, due to contributions from McCandless LAURA ESPOSITO AND CIARA MCENEANY June 30, 2024   https://www.post-gazette.com/news/social-services/2024/06/30/ems-mccandless-franklin-park-ambulance/stories/202406270110   Fiscally, the sole ambulance authority that covers five municipalities and 64 square miles of Allegheny County walks on soft cement.   At least, that's how Chief Chris Dell describes it. He took the helm at McCandless-Franklin Park Ambulance Authority, or MFPAA, in 2022, when the threat of disbandment was looming even more prominently over the EMS system than it is now.    Since then, Chief Dell has implemented cost-cutting measures, applied for numerous grants, and the ambulance authority has even earned national accreditation, the gold standard for first responders that less than 1% of EMS agencies earn nationwide.   From the outside, it all seems to be paying off for the MFPAA — 2022 was the first year in roughly half a decade it operated above the red line, making a modest gain of less than $5,000. While they've yet to receive their 2023 audit, Chief Dell said that internal reports indicate another year of financial gain for the organization.   But there's another factor, one out of Chief Dell's control, that now determines both profitability and the capabilities of the ambulance authority: municipal funding.    Like a growing number of EMS systems nationwide, the MFPAA, which answers about 9,000 calls annually, now relies on leaders from the areas it serves to keep it afloat. And while local municipalities acknowledge the need for ambulances, they don't necessarily want to pay for them.    "You can't blame them. They were able to get the service for free for so many years," Chief Dell said. "But municipalities are going to have to support their EMS agencies as they expect them to survive."   According to the Center for Rural Pennsylvania's 2022 survey of Pennsylvania EMS agencies, 32% of urban and mixed EMS agencies that serve urban and rural counties said they did not receive municipal funding.   And nearly two-thirds of urban and mixed EMS agencies also reported one or more budget deficits from 2018 to 2022.   Chief Dell said community members are often surprised to know that, unlike police departments, many EMS agencies, such as the MFPAA, aren’t funded by their municipalities.    Since its creation four decades ago, the ambulance authority's revenue has accrued from three sources: fees for services, a subscription program and community donations.    "[But now] everything that we do costs a lot more money than it used to," Chief Dell said.    For example, Chief Dell said, the recent purchase of an ambulance without equipment costs upward of $300,000 — more than double what it was a decade ago. The EMS system has five ambulances, and because of their robust volume of calls, they are on pace to purchase a new one every year, he said.   This year, McCandless officials set aside a $110,000 contribution to the MFPAA, the first time money for EMS was included in the town's budget. McCandless spokesman John Bojarski wrote in an email to the Post-Gazette that the town allocated the funds to "ensure that this crucial service continues to be provided to our residents."   "The town is aware of recent funding challenges facing the McCandless-Franklin Park Ambulance Authority and other ambulance providers throughout the region,” he wrote.    "We acknowledge the importance of providing professional ambulance coverage for our residents."  Franklin Park was already making contributions to the MFPAA but increased its funding, according to council meeting minutes from March.   However, the remaining municipalities — Pine, Marshall, and Bradford Woods — weren’t as quick to dole out funding.   “Pine has requested additional information regarding the cost of idle time before they make any further commitment. Marshall and Bradford Woods do not have any interest in paying or having a board seat,” according to council minutes.   After lengthy debate, $277,000 was allocated to the MFPAA for 2024 from all five towns. The agency originally asked for $350,000, but Chief Dell said he could work with that number.    "Had we not had the municipal support fund that we've gotten so far for the year, we would be operating at a loss or right around break-even," he said.   While the three municipalities committed to making only a one-time contribution, Chief Dell said he’s optimistic that once MPFAA leadership is modified, that will change.    The board consists of five representatives from McCandless and two from Franklin Park.    "The one-time contribution is dependent on having representation and having a say in the municipal MFPAA budgeting process in 2024, which makes sense," he said. "We believe that's a fair thing."   He's optimistic the one-time contributions will turn into annual payments as the MFPAA continues to meet and address concerns from unrepresented municipalities.    Nationwide Problem While disbandment and consolidation of EMS services are common nationwide, they have hit the Pittsburgh region especially hard.    Last July, Jeannette EMS shut down all operations primarily due to "financial issues," according to a Facebook post.   It urged people throughout the region to contact their government representatives to work to save EMS services, cautioning that more emergency services are also at risk of disbandment.   "We are sadly not the first service to have this happen to us, and we will unfortunately not be the last," the statement reads.   "The biggest hit to not only us but to any ambulance service is the poor reimbursement rates the insurance companies pay out, and with that, we can unfortunately no longer provide services to the City of Jeannette."    Aside from municipal funding, advocates have argued that additional funding from the state could curb the closures.   But many organizations have trouble securing funding because they are trained to provide emergency care, not fundraise, said Ralph Serphe, president and CEO of the Adams County Community Foundation, which created the WellSpan Emergency Services Fund to support Adams County nonprofit EMS agencies with professional services, start-up funding and project developments.   And a lack of secure funding ripples throughout an organization, leading to high employee turnover.   According to the National EMS Advisory Council 2023 report, EMT’s are paid almost a third less than most working Americans, with agencies seeing turnover rates of 20% to 30% annually.    Agencies that participated in the Center for Rural Pennsylvania’s 2022 survey said that pay and benefits, combined with the demands of the job, were major reasons providers left their posts.   “EMS services are a public good, and they should be supported by tax dollars,” Mr. Serphe said. “The business model of small, independent, all-volunteer EMS providers just doesn’t work anymore. We’re asking a shrinking pool of dedicated volunteers to do more and more.    “That time pressure, along with the increased cost of regulation, training and equipment, demands a workable solution.”   Chief Dell echoed his concern and said there are only so many grants ambulance authorities are eligible for and have time to apply for. Nearly 90% of a $30 million grant program from the state is allocated for fire departments, the rest is reserved for EMS.   "They get a much larger share of all grant money, but when you look at actual call volume, ambulance services do a lot more calls than fire departments," Chief Dell said.   Nationally, the EMS Advisory Council urged federal departments in its 2023 report to address pay gaps and limited funding opportunities that exist among the EMS industry compared to other public services, such as law enforcement and fire services.    The council wrote in the report that it is essential that EMS agencies have their own grant and funding opportunities that are available to “all EMS service delivery models,” along with being considered essential services on a national, state and local level.    "In reality, agencies have worked hard to do everything they can to reduce costs and to come up with unique or better funding streams and we're coming up with a shortfall — we're asking for municipal support,” Chief Dell said.

What’s most interesting about this report is that it uses response times as a measure of system performance. The reality is that according to recently published, peer-reviewed study of over 1.7 million EMS patient encounters, only 6% involved a time-critical EMS intervention.

Additionally, virtually every peer-reviewed study since 2002 evaluating response times and patient outcomes has demonstrated that any response time greater than 5 minutes, has no impact on patient outcomes; and only about 5% of 911 EMS calls could be impacted by a response time 5 minutes or less.

There are much more important, evidence-based measures that can be used to evaluate the performance of an EMS system; such as, compliance with medical director approved clinical bundles of care, EMS vehicle crashes, and patient experience scores. 

Domains for system performance and potential metrics, approved by 16 national and international EMS, Fire, city manager, and patient safety associations can be found here:

Kupas - Zavadsky - with Logos - Joint Statement on EMS Performance Measures Beyond Response Times - FINAL Approved by Named Associations CLEAN 4-30-24.pdf

A compendium of research related to response times and patient outcomes used to develop these potential metrics can be found here: 

References-Resources on EMS Performance Measures _ Beyond Response Times FINAL 2-15-24.pdf   

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Ambulance response times in NYC hit pandemic-era highs

By Linda Schmidt and edited by Amanda Geffner

July 1, 2024

https://www.fox5ny.com/news/ambulance-response-times-nyc-hit-pandemic-era-highs

New data shows it's taking longer for ambulances to arrive at the scene of emergencies here in the city.

The union president says city records show the city is on pace to break last year's record number of emergency calls. 

Last year it was 1.6 million, and the union says response times to those emergencies are putting the public in danger.

During the week of Memorial Day, the union says it took an average of nearly 13 minutes for ambulances to respond to life-threatening emergencies and an average of 28 minutes for non-life-threatening emergencies.  

These are the longest response times since the beginning of the pandemic.

"We're talking about people's lives here.  We're not talking about making an appointment with a plumber, or an electrician. We're talking about somebody's loved one who stopped breathing has to wait 11 to 16 minutes for an ambulance to get to their house," Barzilary said.

The union president says the city is equipped to handle about 4,000 calls a day but is receiving about 5,000. In addition to needing more ambulances, the union explains other factors contributing to the slower response times.

"With the lowering of the speed limits in New York City, lowering the lanes that are available for traffic to go through.  All the bike lanes that are added. All the street closures that are added. It's impossible to get through," Barzilay said.

The FDNY responded with a statement apparently agreeing with the union that more ambulances are needed:

"We saw a spike in EMS activity during the pandemic where we required additional resources. We have returned to pre-pandemic levels for our ambulances, but calls have not declined."

NPR's Marketplace profiles Terlingua (TX) EMS' efforts at improving community health in a rural community. The reporter also highlights the growing challenges for rural EMS agencies in an increasingly challenging economic and staffing environment.

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Rural paramedics are making routine house calls to avoid costly emergency room visits

Travis Bubenik

Jun 28, 2024

https://www.marketplace.org/2024/06/28/community-paramedicine-visits-west-texas-ems-paramedics/

In some rural parts of the U.S., where hospitals and doctors’ offices are in short supply, people often turn to calling 911 just for basic medical care.

Experts say that’s a problem for patients and hospitals, but a growing model called community paramedicine aims to address it by having paramedics regularly check in on people before a health issue turns into an emergency.

One of those programs is playing out in the tiny desert town of Terlingua, Texas, where Susan Martin is chief of the local emergency medical services department. Her small crew, fewer than 10 people, responds to 911 calls across a dusty, 3,000-square-mile range of rural West Texas.

“A lot of what we’re seeing now with the heat is environmental: some dehydration, some heat exhaustion, things like that,” she said.

Martin said they also get calls from people with chronic health issues.

“Some patients don’t understand their medications,” she said. “[As in] ‘They don’t make me feel good so I don’t want to take them, so I don’t take them, then I end up being a 911 call.'”

The closest hospital is more than an hour away, so the local EMS team’s single ambulance can be tied up for a good chunk of the day on an emergency call.

That’s a big part of why Martin’s team has launched a “community paramedicine” program, where paramedics regularly check in on people with known health issues — patients who might not get to the doctor as often as they should.

“A lot of people out here, they’re very like, reclusive,” said Alexandria Hollenbeck, one of the local paramedics. “It tends to be older people, or people with chronic illnesses, such as hypertension, COPD.”

A 2023 survey from a national paramedics trade group counted more than 150 of these kinds of community paramedicine programs across the country. It’s a growing health care model championed by EMS agencies and hospitals at a time when some advocates say rural health care is facing a crisis.

Adrian Billings is a longtime West Texas doctor and rural health expert at Texas Tech University.

“This area is one of the most under-resourced health care areas in our state,” he said.

For patients, Billings said, routine paramedicine check-ins at home can avoid expensive emergency room visits. Hospitals want to avoid that too, as they can face penalties when too many patients come back to the emergency room soon after release. That’s called a readmission.

“From a financial standpoint, community paramedicine programs do help cut down on readmissions that can be very costly for hospitals,” Billings said.

One KFF Health News analysis from 2022 tallied $320 million in hospital readmission penalties nationwide. 

But even though paramedicine programs can save big on costs, preventative care like this requires an upfront investment.

“The economic model for EMS-based community paramedicine is very challenging.” said Matt Zavadsky, a longtime emergency medicine professional in Texas who now works for a national consulting firm for EMS operations. 

He said insurance providers — Medicare, Medicaid and private insurers — mostly don’t cover paramedics making house calls. 

“So we’ve got EMTs and paramedics all over the country who are doing the right thing by trying to work with patients to prevent unnecessary emergency department visits, but yet they’re not eligible for reimbursement,” he said.

The new paramedicine program in small-town Terlingua is being funded as part of a broader $5 million  U.S. Department of Agriculture rural development grant, with no guarantees for long-term funding. 

“Being able to prove to the payers that these programs are economically more efficient than a 911 call to the emergency department is going to be crucial for those rural communities to sustain these outstanding programs,” Zavadsky said.

He hopes that with time and data, community paramedicine programs will be able to prove their worth to health care insurers.

EMS and public safety have done a great job for decades educating people about using 9-1-1 for emergencies. But we haven’t done a great job educating them about what constitutes an ‘emergency’.

We often say that there may be no such thing as an inappropriate 9-1-1 request, but there is such a thing as an inappropriate response to that request.

Communities should evaluate options for matching the right response to each 9-1-1 call. Often, as Kern County is finding, and as any EMS provider can tell you from personal experience, most 9-1-1 EMS calls are NOT for true emergencies.

Effective Emergency Medical Dispatch programs, paired with alternate response options such as dispatch triage, 2-1-1 integrations, community paramedicine responses, and even partnering with Lyft or Uber to provide non-medical transport services for low/no-acuity 9-1-1 calls, can be effective options to preserve scarce EMS response resources.

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Kern residents continue to abuse 911 system, officials say

BY JOHN DONEGAN

Jun 24, 2024

https://www.bakersfield.com/news/kern-residents-continue-to-abuse-911-system-officials-say/article_a209a9a0-3273-11ef-be57-6b95ffa41612.html

Facilities of the 911 emergency system are being drowned in a flood of trivial calls, officials said at a news conference Monday.

Held at Kern County Public Health’s Mt. Vernon Avenue headquarters in Bakersfield, leaders from the 911 system continuum — from firefighters to dispatchers to medical workers — urged the public not to dial 911 unless there is a genuine emergency.

The call to “not call” came as authorities are seeing a steady rise in 911 reports — about a third more since 2019 and a slight bump from the year prior. As of Monday, EMS Program Manager Jeff Fariss with Kern Public Health said the county expects to exceed 13,000 911 calls for the month of June.

“That exceeds any month during the pandemic,” Fariss said.

More than 40% of those incoming calls, however, prove to be bogus and don’t merit a response. These are calls about a cough, a headache or other non-emergency best solved at home or at your local doctor’s office, officials said.

This comes at the detriment of callers trying to report serious crimes or victims of heart attack, stroke or other life-threatening conditions who are forced to wait before their query can get through.

It’s a frustration felt among the rank-and-file dispatchers who answer half a million calls each year — which averages to nearly one every minute every day. The frustration, officials said, lies in not knowing which will prove to save a life or hinder another.

Kern County Fire Department spokesman Andrew Freeborn and others believe the issue, at its core, is a cultural one, spurred by isolationism that worsened during the pandemic. COVID-19 also revealed a misunderstanding with what role first responders play in people’s everyday lives.

“We see a lot of people that are by themselves that don’t have that caretaker there,” Freeborn said. “And instead of calling that caretaker to say they don’t feel well, instead of bothering a friend or family member, they’ll just burden the 911 system for something that’s not a true emergency. Now, we just see a lot of people throwing up their hands and saying, ‘I don’t feel well, I guess I’ll just call 911.’”

Asked for an example, Freeborn recalled a 911 call they received from a woman who, upon running vitals, simply wanted a free ride to Santa Clarita.

“And I said, ‘but we’re in Bakersfield,’” Freeborn recalled. “And they said, ‘yeah, but I’m coming from Northern California, I’m trying to get down to San Diego… The system isn’t Uber.”

For non-emergencies, Kern Public Health Director Brynn Carrigan urged people to see their primary care doctor.

It’s also vital, she added, to prioritize preventive care such as annual exams and check-ups that, in tandem with a healthy diet and exercise, can reduce the reliance on first responders.

And the irony is that an ambulance ride rarely guarantees priority in hospital care. Unless someone is dying, many — more than a third in Kern County — who arrive by ambulance often have to wait with everyone else.

“We all know injuries and medical issues can be overwhelming and frightening,” Fariss said. “But we also want to ensure that we are responsibly using our 911 services.”

Quick thought on costs....

Using existing resources that must be on-duty anyway for fire responses to respond to an ADDITIONAL call is generally a bargain for the taxpayer. The marginal cost of sending that unit to a medical call vs. sitting around waiting for a fire call is the cost of a pint or 2 of fuel, maybe some medical supplies/equipment depreciation, and maybe some costs for premium pay for EMS certs.

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Colorado Springs Mayor exploring three paths for ambulance services after CSFD proposal was voted down

By Rebecca Gvozden

Jun. 24, 2024

https://www.kktv.com/2024/06/25/colorado-springs-mayor-exploring-three-paths-ambulance-services-after-csfd-proposal-was-voted-down/

COLORADO SPRINGS, Colo. (KKTV) - Colorado Springs, Mayor Mobolade, held another monthly briefing on Monday, to discuss public safety and highlight the 2024 Paris Summer Olympics.

One key topic brought to the table was the next steps in ambulance services. This comes after a proposal with Colorado Springs Fire Department (CSFD) to take over EMS services was voted down by city council earlier this month. Mobolade says he’s looking at three paths moving forward.

“One is to renegotiate and extend the AMR contract,” Mayor Mobolade said to the media. “Two is to open up a full request for proposal process, we call it also RFP. And then three, is to continue to work with my fellow council members to explore different alternative solutions, and those conversations are happening already.”

Mobolade says he’s in many conversations with the council members that voted ‘no’.

“A couple of them have said we still want to explore what it looks like for the fire department to take this on,” Mobolade said. “So that work is still ahead of us.”

Mobolade says he and city council members still have work to do with exploring their options but still believes this is the right time for the city to adapt to ever-changing public safety demands. What’s most important to him is delivering that promise of efficient public safety to the community.

“It’s trying to be smart, trying to create efficiencies, understand that every time that 911 call comes, and we have to deploy our firefighters we’re still the first on the scene and then an AMR any other private ambulances also shows up,” Mobolade said. “So, we’re paying twice for one service. That’s not, that’s not good stewardship.”

Other topics discussed pertained to violent crimes, motorcycle crashes, and staffing of the Colorado Springs Police Department (CSPD).

Mayor Mobolade says violent crimes have increased, and around this time last year there were about fourteen homicide investigations, however today, we’re at about twenty-one. He plans to have a meeting with the district attorney and his team, to try and understand the data around these increases.

With an increase in motorcycle crashes in the Springs, the mayor said he was told... with the city growing, they’re going to see a natural increase in this department of crashes.

Mayor Mobolade says CSPD is short about twenty people. They’re expecting to be fully staffed by early next year or in the middle.

Overall, he says public safety is at the forefront of his responsibilities.

“Public safety is at the top of my mind all the time, and in large part because it’s, no one else has that responsibility, but your government,” Mobolade said.

Special thanks to our colleague, Steve Wirth, for finding and sharing this Washington Post report!

Too many old people’: A rural Pa. town reckons with population loss

There is a deepening sense of fear as population loss accelerates in rural America. The decline of small-town life is expected to be a looming topic in the presidential election.

By Tim Craig

June 23, 2024 at 5:00 a.m. EDT

https://www.washingtonpost.com/nation/2024/06/23/rural-america-shrinking-population-pennsylvania/

SHEFFIELD, Pa. — Lee Goldthwaite might have the most stable job in this remote corner of northwestern Pennsylvania.

The caretaker of Sheffield Cemetery is busier than ever directing crews clearing trees to make space for more graves as deaths dramatically outpace births here and in other vast stretches of rural America.

Each time he buries a newly deceased resident he wonders how the town that once drew scores of young families will survive.

“We already lost our bank,” Goldthwaite said as he took a break from trimming the grass around headstones. “We lost our liquor store, and we may be about to lose our high school.”

Across rural Pennsylvania, there is a deepening sense of fear about the future as population loss accelerates. The sharp decline has put the state at the forefront of a national discussion on the viability of the small towns that have long been a pillar of American culture.

America’s rural population began contracting about a decade ago, according to statistics drawn from the U.S. Census Bureau.

A whopping 81 percent of rural counties had more deaths than births between 2019 and 2023, according to an analysis by a University of New Hampshire demographer. Experts who study the phenomena say the shrinking baby boomer population and younger residents having smaller families and moving elsewhere for jobs are fueling the trend.

According to a recent Agriculture Department estimate, the rural population did rebound by 0.25 percent from 2020 to 2022 as some families decamped from urban areas during the pandemic. But demographers say they are still evaluating whether that trend will continue, and if so, where.

Pennsylvania has been particularly afflicted. Job losses in the manufacturing and energy industries that began in the 1980s prompted many younger families to relocate to Sun Belt states. The relocations helped fuel population surges in places like Texas and Georgia. But here, two-thirds of the state’s 67 counties have experienced a drop in population in recent years.

The Center for Rural Pennsylvania, an agency overseen by the state legislature, estimates that Pennsylvania will lose another 6 percent of its rural population by 2050. Some counties, including Warren County, where Sheffield is located, will experience double-digit population declines.

State lawmakers and other leaders now consider the population loss a crisis and are drawing up plans to try to reverse the trend. They say neither Pennsylvania nor the nation can afford to lose small towns and the institutions that power them. Not only are they a touchstone of American life, but they are also key to driving certain sectors of the economy, like agriculture.

Already, the demographic shift is affecting where students attend school, how long residents have to wait for an ambulance and whether they can quickly see a doctor. In some cases, local governments themselves are on the verge of collapse as they struggle to fill open jobs and leadership positions.

The decline of small-town life is expected to be a looming topic in the presidential election as both President Biden and former president Donald Trump vie for votes in this critically important battleground state. Trump won many rural voters during his last two presidential campaigns with his populist economic message. Biden, meanwhile, is highlighting his administration’s investments in broadband and major public works projects.

“It’s kind of like building blocks. You pull one block and the wall gets weaker,” said state Rep. Eddie Day Pashinski (D), a lawmaker driving the conversation on solutions to population loss. “You pull another block out, and it collapses and that is kind of where our rural communities are.”

‘Too many old people’

Sheffield hugs the Allegheny National Forest and is about 75 miles southeast of Erie, the nearest big city. In the early 20th century, it was known for having the largest sawmill east of the Mississippi River. Back then, it was a hub for timber and oil exploration.

The town’s decline started decades ago as the lumber mills and tannery shops started closing. But it’s been only in the last decade or so that the full weight of the community’s future challenges began to be felt in intimate ways.

Sheffield’s only ambulance was taken out of service about two years ago, around the same time the community’s only day care closed due to low enrollment. Starting this school year, teens are being bused to a distant high school because there are not enough teachers to staff the local one.

Residents are peeved that the local bank branch and liquor store have closed. The organizers of the town’s beloved Johnny Appleseed Festival recently announced they don’t have enough volunteers or money to continue. And many of Sheffield’s churches no longer have full-time priests or pastors, deepening residents’ sense of malaise.

“I wish I had an idea to say, ‘If you do this,’ this place can be turned around,” said Jack Cashmere, 86, a lifelong Sheffield resident. “But I guess you just have too many old people like myself.”

In Warren County, nearly twice as many people died as were born in recent years, according to the Pennsylvania State Data Center at Pennsylvania State University. Sheffield Township, which includes a broader swath of land outside the town center, had one of the sharpest population declines in Warren County, according to census data. It is now home to 1,805 residents, a 23 percent decline compared with 20 years ago.

During its heyday, Sheffield was packed with commercial and recreational businesses that gave residents here just about everything they needed to maintain an active, middle-class lifestyle. There was a bowling alley, auto dealerships, doctors offices and pool halls.

High school football games as recently as the 1980s attracted 1,000 spectators, said Dennis Sturdevant, the self-described historian for the township.

Today, downtown Sheffield consists primarily of a small grocery store, a 150-year-old bar, one restaurant, two convenience stores, an antique shop and a small video-gambling room.

After most businesses closed or moved elsewhere, today one of the township’s biggest employers, Sheffield Container, employs just 25 people, said Lonny Connolly, the manager of the industrial packing company. The average salary is $18 an hour.

“I don’t know why the industry is not coming in,” Connolly said. “But I do know that is why people are moving out.”

A small class

The absence of children has Sheffield leaders on edge as they ponder how to keep the town afloat.

In 1980, Sheffield Area Middle-Senior High School had about 600 students. The current enrollment is just 224. The broader Warren County School District — encompassing most of the county — also saw its school enrollment decline by more than half since 1980.

Statewide, the Pennsylvania Department of Education estimates, there will be 60,000 fewer public school students by the 2027-2028 school year.

In a bid to account for the low enrollment and teacher shortages, the district decided to bus students in ninth through 12th grades to Warren, about a 30-minute drive away, each morning so they could learn core subjects such as a math and science. Students return to Sheffield High School in the afternoon for their electives.

But Warren County School District Superintendent Gary Weber said even more drastic steps may be needed, including possibly shuttering Sheffield’s high school altogether.

“There is no sign of growth in the future.” he said.

But to Sheffield residents, the idea that their community might soon be without a high school is alarming. If the school closes, they say, even more families could move out and the town’s problems will grow more entrenched.

Today there are 32 students in Sheffield Township’s graduating class.

Jamie O’Donnell, 33, has a second-grader enrolled in the Sheffield school system and another child entering kindergarten next year. She said having local schools gives Sheffield a “small-town atmosphere,” including the peace of mind that comes with having relatives who are also school bus drivers.

“We have to find a way to make it work,” said O’Donnell, who added that she may have to move her family if the high school closes.

“Once you close the school, your town dies,” Sturdevant, 80, said.

Ann Mitchell, the administrator at Sheffield’s Ruth M. Smith Center, said she doesn’t have much confidence that the numbers will rebound. In 2022, the center closed what Mitchell described as Sheffield Township’s only licensed day care as enrollment sank from an average of 40 children in the 1980s and 1990s to just eight children.

As she scanned an abandoned room where toy trucks, strollers and old blankets now collect dust, Mitchell said the closure is yet another sign that the once vibrant town is fading.

“I think [Sheffield] is slowly dying,” Mitchell said. “But I like to be positive and think there is still some hope.”

‘All gray hair’

Throughout Sheffield and the rest of rural Pennsylvania, the aging population has led to a crisis at one of the most fundamental small-town institutions: the local volunteer fire station.

The nation’s volunteer fire services rely on residents who leave work or home to respond to community emergencies. They have been a mainstay of life in small towns for centuries, putting out fires and transporting residents to the hospital, while also hosting bingo games, fish fries and potluck dinners.

But as the population ages and decreases, fewer people are signing up to serve as volunteers. Jerry Ozog, executive director of the Pennsylvania Fire & Emergency Services Institute, said the state had an estimated 300,000 volunteer firefighters during the 1970s. A state-commissioned study released in 2018 estimated Pennsylvania was down to 38,000 volunteer firefighters, and Ozog believes the number may have decreased further since then.

At many volunteer fire stations in Pennsylvania today, Ozog said, “it’s all gray hair and nobody under the age of 55.”

That has made it harder for fire stations to respond to emergency calls. Growing numbers of departments have also shelved their ambulance service, unable to find enough qualified volunteers who are willing to become a licensed EMT or paramedic. In some pockets of Pennsylvania, the nearest ambulance is now 40 minutes away, Ozog said.

Sheffield Township lost its ambulance in 2022.

Matthew Bell, the chief of the Sheffield Volunteer Fire Department and a township supervisor, said he made the decision to scrap the ambulance because not enough volunteers were responding to emergency calls. The township now contracts with a private ambulance service that must travel about 20 miles to get to Sheffield Township.

“We had four of us running all the ambulance calls and we said, ‘We can’t do this anymore’” Ball, 30, said.

Throughout Sheffield, there is deep concern about emergency response times. Doug Kennedy, associate director of the only funeral home in the township, said he has seen more people die in their homes since the local ambulance service ended.

But Bell said call logs show the wait time for a private ambulance is no longer now than when the township had its own service. And David Basnak, the president of EmergyCare, the private ambulance service that Sheffield contracts with, said it is more routine for paramedics to discontinue lifesaving efforts for heart attack patients at home. That’s because EMTs have more advanced resuscitation equipment on hand than they used to.

“Everything they can do in a hospital for patients, we can do in the house,” he said.

Lonely bar patrons

As the population ages and declines, Sheffield Township has struggled to operate its government and maintain activities that the community can be proud of.

For 17 years, residents looked forward to the annual three-day Johnny Appleseed Festival, when thousands of visitors would cram into town to watch professional lumberjack, horse, tractor, cornhole and pie-baking competitions.

But this spring, event organizers announced they could no longer staff the festival. As residents age, it has become harder to find the youthful volunteers needed to put on such a labor-intensive festival, said Sandy Setili, an event organizer.

“You can’t sustain a festival as big and physically demanding as ours if you don’t have volunteers,” Setili said.

Sheffield suffered another blow this year when several high-ranking township employees quit — including two of three supervisors. The township appointed one person but couldn’t find anyone to fill the second vacancy. It then took the unusual step of putting an ad in the local paper to find someone to keep the local government running.

As the presidential election approaches, many residents in this deeply Republican town say they view Trump as having a better vision for salvaging rural America, even though Biden has steered billions of dollars to initiatives that support rural America.

But at the Lee House, one of two remaining bars in Sheffield Township, many patrons were not optimistic that either Trump or Biden have the answers needed to save the community. The bar, which dates back 150 years and advertises on its front door that smoking is still allowed indoors, now routinely closes at 9 p.m. due to “fewer and fewer people,” said Carla Allen, the bar’s owner.

“I don’t want either of them for president,” said Barb Strike, 54, as she puffed on a Parliament cigarette and sipped a Bud Light. “They don’t care about us because no one in this town is rich enough for them to care.”

‘We are going to stick around’

Jim Decker, chairman of the Warren County Chamber of Business and Industry, said local leaders must figure out a way to reinvent the community. The Center for Rural Pennsylvania report said the county would lose 11 percent of its population, including 26 percent of its working-age adult population, by 2050.

Although Warren County lacks easy access to an interstate highway, Decker said the county will try to market its location near state forests and recreational areas such as the Allegheny River to draw in new residents. He even wonders whether climate change could one day force more people to seek out cooler climates such as northwestern Pennsylvania.

But Decker acknowledged the planning for Warren County’s recovery is “a daunting task.”

Kenneth M. Johnson, the demographer at the University of New Hampshire, said the deck remains stacked against most rural communities, except for those within proximity to larger metropolitan regions or those with industries that rely heavily on immigrant labor.

“Barring some outside occurrence, it’s very unusual for counties to recover,” Johnson said.

Dirt from the most recent burial in St. Michael’s Byzantine Catholic Cemetery in Sheffield sits piled up near the top of a hillside. (Justin Merriman for The Washington Post)

Goldthwaite, the caretaker of the Sheffield Township cemetery, isn’t yet ready to believe his community will wither.

Even as he laments the loss of 13 people from his church over the past three years, Goldthwaite believes younger families will eventually come. There must be other people, he says, who want to be able to look out their door and see black bears, turkeys and deer, or fish trout out of the Tionesta Creek.

“I don’t care what anyone says about it. I think it’s a great little community,” said Goldthwaite, speaking over the sound of the chain saws clearing more space in the cemetery. “I think we are going to stick around.”