A well-researched news report.
It’s interesting that the EMS levies in IA cannot be used for salaries, only training, equipment and supplies. States looking at essential service designation may want to assure that salaries can be part of the funding eligibility.
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‘Broken system’: Iowa’s rural ambulance services strained
In some parts of Iowa, 911 callers can’t be assured an ambulance will arrive
Liam Hala with Emily Andersen
Nov. 5, 2023
https://www.thegazette.com/health-care-medicine/broken-system-iowas-rural-ambulance-services-strained/
Radu Denghel always had been interested in medicine, but when it came time to decide what to study in college, he picked engineering — which also interested him but would require less time in school.
While going to engineering school in Romania, where he is from, Denghel also attended some classes at the local medical school and volunteered at the local emergency room.
Now, more than 20 years later, Denghel is in Iowa and still working in both fields — computer engineering in a full-time job with Collins Aerospace in Cedar Rapids, and medicine as a volunteer emergency medical technician for the Olin Ambulance service.
“I got to a point where my work pays my bills, so I don’t have to look for additional income and spend my time that way. And I really do believe that time is much better spent serving the community instead of just watching TV or whatever,” Denghel said.
But volunteer EMTs like Denghel are dwindling across the state, where emergency medical services are not considered an essential service statewide, meaning the Iowa Legislature does not regulate the service or provide funding for it. Two years ago, lawmakers passed a bill, Senate File 615, allowing voters in counties to declare EMS an essential service within their county and agree to pay taxes to support it.
But the availability of ambulances still is inconsistent across the state — especially in rural areas — and providers say more needs to be done to support a waning EMS force.
Even when EMS workers are paid and not serving as volunteers, ambulance providers struggle to maintain services due to high turnover, likely a result of low wages and increasing burnout. Pay for paramedics and EMTs in Iowa falls short of the state’s average wage of $25.73, with their mean wages falling at $23.31 and $17.74 respectively, according to the U.S. Department of Labor.
Low wages, combined with an average cost of more than $12,000 to obtain a paramedic’s license, mean filling the physically demanding job is increasingly difficult despite a growing need. A 2022 survey by the American Ambulance Association found that, nationwide, paramedic and emergency medical technician turnover can range from 25 to 45 percent annually — resulting in 100 percent turnover every four years or less.
Stresses on EMS providers
Emergency medicine can be physically taxing — carrying injured patients down tight stairways or out of the woods, for example EMS providers face some of the highest rates of on-the-job injuries. In 2020, almost 17,000 EMS providers in the United States were treated in the emergency room for injuries sustained on the job, according to the national Centers for Disease Control and Prevention. Many of the sprains and strains seen in the emergency department — 56 percent — were from overexertion, typically from carrying patients much larger than the provider.
Mark McCullough, legislative chair for the Iowa EMS Association, said technologies like stair-chairs and automatic gurneys help reduce injuries, but the equipment is expensive and some services — especially those relying on volunteers — don’t have them.
He also pointed to the high rates of burnout and suicide in health care workers as reasons many providers are leaving the field or moving to urban services that pay more.
Volunteer services struggle more than paid services to keep and retain providers, McCullough said. This is due to the massive time and financial commitment volunteer services require.
While Denghel was studying to get his EMT certification earlier this year, for example, he said he was working about 60 hours per week at his job and attending about eight hours per week of EMT training. Now he often has to plan his schedule around the availability of the other volunteers, so someone is always reachable in an emergency.
Kevin Stoolman, fire chief of Eastern Iowa’s West Branch, said rising costs leave many volunteer services like West Branch Fire stretched thin. The department provides fire and emergency medical services the town of 2,500, providing lifesaving care until a transport team from Tipton, West Liberty or sometimes Davenport arrives to take the patient to a hospital.
“Our goal is to have them packaged up and ready to go by the time the ambulance gets there,” Stoolman said.
But Stoolman said a rise in the number of calls the department has to answer is stressing the team and diverting money traditionally budgeted for fire protection and fire fighting to emergency medical services instead.
Minutes can matter
According to data from the Iowa Department of Health and Human Services, 75 percent of Iowa’s EMS services are entirely volunteer, though those volunteers respond to only about 10 percent of EMS calls in the state.
Paid EMS services handle most calls in Iowa, but not all areas have enough paid emergency transport staff to cover the need, causing them to rely on other ambulance services to help pick up the slack. This can lead to longer wait times for care.
Katrina Altenhofen, the interim director of the Washington County Ambulance Service, said Iowa lacks a standard of operation for ambulance services and the ongoing workforce shortage strains an already stressed EMS network.
When a lack of staff causes a service to decrease the number of ambulances it runs, other nearby services may be required to pick up calls outside their normal coverage area — resulting in longer response times in both areas, Altenhofen said.
“You have communities within the state of Iowa right now that don't even have ambulance services and don't have a hospital,” Altenhofen said. “So they are at the mercy of whoever is that next closest entity to be able to come down and help.”
Cedar County Sheriff Warren Wethington said ambulances in Cedar County can take between 15 and 45 minutes to respond to an emergency call, depending on what else is going on and where in the county the call comes from.
“Just last week, we had the Clarence ambulance out of service. Tipton has two ambulances and they went to take somebody to Iowa City and somebody to Cedar Rapids, and there was another call … and there wasn’t anybody to cover it. We had to wait until the crew came back from Cedar Rapids,” Wethington said.
All the ambulance services in Cedar County currently are volunteer, but Wethington has been working with other county officials to create an EMS referendum that will be on the ballot Tuesday. If passed, the referendum would allow the county to implement an additional property tax of 75 cents per $1,000 of taxable value. The tax would be used to create two paid ambulance services and possibly an additional volunteer service.
Wethington said some people have expressed concerns about the already existing ambulance services losing out on revenue they use for upkeep of equipment and other necessary expenses. But he stressed the new ambulances would not be meant to replace the volunteer services, but provide backup.
“I want to make it very clear that we want a partnership. We don’t want to take anything away from anybody. This is purely a backup for when they’re out of service, don’t have a crew, or are out on another call,” he said.
If the referendum is approved, Wethington said it could take up to two years before the new ambulances are fully operational.
Few counties have adopted EMS tax
Only a handful of Iowa counties have voted to make EMS an essential service and levied taxes to support it — leaving much of the state hanging in the balance.
Jones County is one of the five counties where voters approved a levy in November 2022. Brenda Leonard, the Jones County emergency management coordinator, said the county’s two full-time ambulances and multiple volunteer ambulances all have been understaffed and overly busy recently. She said many of the volunteers hold fundraisers to pay for equipment and training, and she’s hoping the new levy will mean paramedics no longer have to spend as much of their time fundraising.
“I think it has brought to light in our county that it was not an essential service. When you called 911, you were not necessarily going to get an ambulance,” Leonard said.
Sheila Frink, services director of the Anamosa Area Ambulance Service — the largest service in Jones County — said that Anamosa’s service is planning to use the money they will receive from a levy approved there to buy a new ambulance.
Anamosa’s ambulance staff are not volunteer, but the tax levy cannot be used for salaries. It can go only toward training, equipment and other expenses.
Washington County has not passed a tax levy for ambulance services, but the county has been fully funding emergency medical services since 2020 when supervisors used general county funds to purchase several ambulances and the building they were kept in from a private owner, according to interim director Altenhofen.
The county previously had subsidized the ambulance service in varying amounts each year, but took over completely when a contract with the private ambulance service ended. Since buying the ambulances, the funding has come from the county general fund and also the revenue brought in from the ambulance service, Altenhofen said.
The county also developed a Washington County EMS Council in 2020 that is working to put a tax levy for the ambulance service on the ballot in coming years.
“The Board of Supervisors recognized the need to be able to offer the citizens of the county emergency care. Waiting on an ambulance to come from Iowa City, Mount Pleasant, Marengo or Fairfield just was not a viable option,” Altenhofen said.
Since EMS still is not considered an essential service statewide, there is no obligation for ambulance services to take calls from other areas. In areas where EMS is not declared an essential service, there is no guarantee an ambulance will come at all when a patient calls 911. Many counties that rely on volunteer services don’t have a hospital, and many don’t have the tax base to help support the service, Frink said.
“It's a broken system,” Frink said.
