By Abigail Ham
The Keene Sentinel
CHESHIRE COUNTY, N.H. — After losing more than $1.3 million in its first year of operation, the EMS service run by Cheshire County is still in the red, per financials the county released Friday. But county officials say Cheshire EMS could be on the path to sustainability within the next couple years.
In 2024, the service faced another significant gap between expenses and revenue — about $1.9 million, according to financial documents. However, the county offset that with about $1.12 million from other funding sources, leaving the EMS fund with a loss of about $527,000, financials show.
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That fund’s balance now sits at a loss of about $1.4 million, the documents say.
But there’s some good news — according to County Administrator Chris Coates, the first two quarters of 2025 have seen the EMS service in the black.
If that keeps up, he said, Cheshire EMS could break even for the first time this year, and use any extra funds to start paying down the past deficit.
A learning curve
In 2022, Cheshire County became the first in New England to attempt to operate its own EMS service.
EMS services are difficult to run and notoriously unprofitable.
It was a steep learning curve, Coates and Finance Director Sheryl Trombly said. They joke that it gave them both gray hair.
The county has always maintained that the move was meant to address a crisis in local ambulance capacity when Diluzio Ambulance was going out of business.
But it was met with criticism from fire and EMS departments and other people, in part because it relied heavily on finite COVID-era funding to get off the ground.
American Rescue Plan Act funding covered the cost of building a station, ordering vehicles and acquiring other big equipment needed. The leftover money from that project has been used to offset some operating expenses in the years since.
Expanding operations
From an operational standpoint, Coates said the service is seeing success.
EMS call volumes grew rapidly in 2024, from less than 160 in January to more than 220 in December, according to Cheshire EMS documents. The service is now providing more interfacility transfers, too, and SmartRide, a partner organization supported by the county, is on track to provide 16-17,000 transports in 2025, Coates said.
Cheshire EMS has formal contracts with 19 communities, some for full service and others as backup to local fire departments.
Coates said the intent was not to be a competitor with those services, but to support them where they didn’t have capacity.
He said Friday that means Cheshire EMS provides a lot of support to towns like Fitzwilliam, Troy and Winchester, where available EMS staff is limited, and doesn’t venture as often into towns like Walpole and Jaffrey, where local services are able to handle the bulk of the call volume.
“We have a good working relationship with everyone now,” Coates said.
In a letter to The Sentinel earlier this year, Coates, Keene City Manager Elizabeth Ferland and Keene Fire leaders said they collaborate heavily on EMS now.
“Chief [ Jason] Martin of the Keene Fire Department and Chief [ Mark] Kreamer of CCEMS meet monthly to discuss system needs, challenges, and future opportunities for collaboration. These meetings help to ensure timely, high-quality emergency care for the people of this region,” the letter read.
Finances
From a financial standpoint, the service is still growing into its boots.
In July 2026, the money from ARPA that has partially subsidized the cost of Cheshire EMS services will run out, according to Coates.
In 2024, $379,000 from those funds was used to reduce the impact of net losses on the county’s EMS fund, according to county financials.
Cheshire EMS budget documents for 2025 show the county expects to expend $1.4 million of the ARPA funds this year and has already transferred about half that.
Looking ahead
The end of the ARPA funds will mean towns contracted with Cheshire EMS will see increases in what they’re charged, which is a function of both population and a base rate.
County representatives have met with about 10 towns already to discuss those changes, according to Coates. He said the response has been largely positive, since most town leaders understood that the increase was coming.
A document shared with those towns breaks down the county’s portion of the tax rate, which increased an average 1 percent over the past seven years, but went up 3.4 percent in 2025.
About 86 percent of county services are required by state law, according to that document.
The N.H. Department of Revenue Administration found that in Keene , county taxes make up just 9.3 percent of the total taxes property owners face per $1,000 valuation. The bulk of the remainder is made up of education taxes.
Trombly said locals concerned about their taxes shouldn’t panic when they see the negative fund balance in the EMS fund.
The $1.4 million that the service is in the hole for isn’t something taxpayers are going to see affecting their bill, she said. Instead, it’s incorporated into the overall budget as an open receivable in the general fund.
You can picture that as the EMS service having written a check for the county that just hasn’t been cashed yet, but in this case the service doesn’t actually have the money to back it up yet.
But Trombly and Coates said they’re optimistic about the service being able to have a neutral or even positive fund balance within the next couple of years.
That’s dependent on many things, however, including the policy landscape.
Changes to Medicare and Medicaid billing and enrollment requirements could take a chunk out of the county’s revenue streams, Coates said.
On the other hand, N.H. Senate Bill 245 could give the service a boost.
The new law requires private insurers to reimburse providers at a rate of 325 percent what Medicare would be, at least for the next two years.
Trombly said that could help the county shrink the gap between what it bills and the payments it’s able to collect. In 2024, that gap averaged around $450,000 per month.
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