$56K+ in local donations keeps Ala. county EMS in business

Greene County community members said they will not lose the service, but experts said the agency's problems are typical for rural ambulance services

Amy Yurkanin

GREENE COUNTY, Ala. — Almost two weeks ago, Jamie Gray, the director of Alabama State Emergency Medical Services, received a letter saying there would be no more ambulance service in Greene County.

The letter came from the acting director of the EMS in Greene County, a rural county just south of Tuscaloosa near the Mississippi state line.

“The letter said Greene County EMS on Friday at 8 p.m. would cease operations due to financial constraints and payroll, et cetera,” Gray said.

After a flurry of calls with county officials, Gray learned that the EMS director wasn’t authorized to send the letter and had subsequently resigned. Contributions poured in from local businesses, totaling at least $56,000. Local law enforcement officers organized a charity basketball tournament during Memorial Day weekend.

“We have had people to come forward and they have assured us that we will not lose the service at this time,” said Joe Powell, chair of the Greene County EMS board.

But Powell acknowledged the service had run into financial trouble. The system’s crisis echoes problems in rural ambulance services across the state and country, experts say.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said failures to find sustainable funding sources have caused trouble across rural America. Unlike fire departments and law enforcement, ambulance services are usually not considered essential services that should be supported by taxes. Instead, they earn money from insurance and patient reimbursements when they transport people to the hospital.

Emergency Medical Services in small communities might not make enough of these trips to support the costs of buying, maintaining and staffing even a small number of ambulances. EMS services in Smith’s Station in east Alabama and in Livingston near Greene County closed earlier this year, according to Alabama Rep. Ed Oliver in 1819 News.

“We’ve always made assumptions about EMS, about what it is, about how it exists and the assumption that it’s always going to be there in the future,” Gienapp said. “That somebody is planning for this. And what rural America, all of America is now realizing, is that we’ve all been operating on the wrong assumption.”

In the more remote rural areas, ambulances often provide much of the high-level medical care, Gienapp said. When they close down, it can create longer waits for people who need urgent medical attention.

Most communities have spent decades running law enforcement and fire departments, but pay little to no attention to ambulance services, Gienapp said.

“It’s not until you have something like what happened in Greene County, suddenly there’s now a crisis,” he said. “There’s a sense of urgency because we’re going to call 911 and nobody’s going to come. That’s what driving it home.”

Gray said all counties in Alabama have ambulance service, although it may be sparse in some communities. If Greene County EMS had shut down, it would have left the county without an ambulance service.

“We do our best to keep a county served,” Gray said. “If Greene County had closed, we would have gotten someone to come in and cover it while we help set up another system.”

Gray said many systems statewide are struggling. Staffing rates are at about 65 percent of pre-pandemic levels. Rural systems in particular struggle to keep the drivers and medical technicians needed to operate ambulances.

Gov. Kay Ivey awarded $10 million in COVID relief funding for emergency service providers. A bill passed this year designates EMS an essential service, which would make ambulance services eligible for more federal funding.

Powell said Greene County EMS is seeking state and federal grants to support the service. He said there has been no discussion yet of raising taxes. Gray also said he did not know whether taxes could be used to support ambulances in Alabama. His department regulates and certifies systems but does not oversee funding.

Many rural counties have lost medical services in recent years as hospitals downsized or closed completely. Gienapp said EMS services struggle with similar stresses caused by shrinking populations, but also have fewer options to change their business model. The most expensive part of operating an ambulance system in rural America is having the vehicle staffed and ready to go.

“An ambulance service is a one-trick pony,” Gienapp said. “It only can bill when it provides a transport. So an ambulance service only can bill for the time and services while they have a patient in the back and they are going to a hospital.”

Hospital administrators might be able to reduce hours for certain services, but an ambulance can’t do that, Gienapp said.

“If a community decides that it wants an ambulance service, then it has to recognize that a majority of those costs come from when the ambulance service is sitting there and not generating revenue,” he said. “That’s the big gap. If it’s important to you, you have to find a way to pay for it.”


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