TOMPKINS COUNTY, N.Y.—Emergency services, unfortunately, don’t pay for themselves.

At least not in rural areas, where the challenge of running an emergency medical service (EMS) makes clear a painful irony: a self-sustaining EMS operation depends on a high call frequency. Low population densities mean lower call frequencies, which means less potential billing revenue for an EMS service.

This isn’t anything new for rural communities where non-profit EMS models depend on fundraising drives, municipal support and the gumption of volunteers to fill in budgetary and staffing gaps. Dryden Ambulance, for example, follows this model.

But Trumansburg Deputy Mayor Ben Carver thinks this model is well worth retooling. Carver gave an overview on countywide EMS services to the Tompkins County Council of Governments (TCCOG) on Feb. 24. The presentation was based on a report co-written by Carver and four other students from the Cornell Institute of Public Affairs (CIPA), where he is a masters candidate. 

Carver made the general case that EMS services have become too expensive to be supported by the confined financial and human resources of a sparsely populated municipality, citing that the financial strain can be seen across the state’s rural EMS operations.

Carver said, financial stress is nearly universal in New York State’s rural EMS operations, but it’s also just the tip of the iceberg.

“Agencies are having difficulty recruiting staff, training staff or retaining staff, trouble keeping up with certification and equipment requirements,” Carver told The Ithaca Voice.

Call volume is also increasing, which adds stress to already thinned volunteer staff. Just between 2016 and 2021, Carver told TCCOG he found that calls had increased from 21.57 to 27 a day.

These myriad issues are what led to the closure of Slaterville Ambulance, which served the Town of Caroline in Tompkins County from 1959 to 2016.

Beth and Greg Harrington were core volunteers and organizers for Slaterville Ambulance, which operated on a budget of about $55,000 a year. Slaterville Ambulance didn’t charge for rides and was entirely staffed by volunteers. The Harringtons said that the ambulance company responded to about 400 calls a year. 

The ambulance company was also an advanced life support service (ALS), a more stringent designation than basic life support (BLS), requiring ambulances to be staffed with paramedics.

Dwindling number of volunteers is ultimately why Slaterville Ambulance shut down operations.

The requirements for volunteers were as demanding as a part-time job. EMT and paramedic training courses could range up to 18 months of commitment, requiring volunteers to log hundreds of hours of ambulance riding to get certified and attend classes twice a week. Volunteers would then sign up for 12 hour shifts at Slaterville Ambulance.

“You didn’t want to scare people away, but you also didn’t want to get them to join and bring up all these hours of training,” Greg said.

Cardiopulmonary resuscitation (CPR) certifications need yearly renewal, and in New York State, licenses for emergency medical services must be renewed every three years through testing.

Advancements in technology have moved EMS further away from a transportation service to a healthcare service, said Carver, which is a field seeing costs go up across the board in the U.S.

Carver’s report also found that the average municipal EMS spending in Tompkins County went up 79% between 2016 and 2021, which appears to track with increases in national health care spending.

Blue represents Tompkins County. Orange represents National. Credit: (Carver, McDonald, Song, Wange, Wu, 2022)

The CIPA report labeled these price increases as “regressive tax burden” on low-income households in rural communities with municipally supported EMS.

“The theory is in a fully ALS ambulance, If you’re doing the first 15 minutes of an ER visit in a crisis,” Beth said. “So you want people, whether they’re volunteers or paid, you want people capable of doing that.”

While onsite care has improved, the ability for volunteers to meet these professional demands was made more challenging, this trend met with a disappearing culture of volunteerism, Beth said.

“What we’re seeing out here in Caroline, and I think it’s everywhere else, is that whole sense of community, that whole sense of families staying in one place for a long time and investing in their community doesn’t exist anymore,” she said.

Beth Harrington added though that she sees that people are working more, sometimes up to two or three jobs, and the opportunity to volunteer is reduced. 

“It’s not just that people don’t care anymore,” she said.

At Slaterville Ambulance, the dwindling number of volunteers ultimately placed a high burden on the remaining group, leading to its closure.

The Town of Caroline opted to not expand Slaterville Ambulance’s budget in order to bulk up the volunteer staff with paid Paramedics and EMTs.

Bang’s Ambulance, a commercial company serving all of Tompkins County, is now the only EMS provider in the Town of Caroline.

Slaterville Ambulance’s closure had an impact on countywide EMS service, Carver said. The report he produced compared county wide average response times in 2017 — just after Slaterville Ambulance’s closure — to county wide average response times in 2021.

The initial effect of Slaterville Ambulance closing was a massive increase in response time to calls in Slaterville, which rose to an average of 18.4 minutes in 2017. Beth said that average response time was around five minutes for calls in the Town of Caroline while Slaterville Ambulance was in operation.

By 2021, Bang’s had filled in the gap left in Caroline EMS, reducing the average call response time to 9.1 minutes. Though the overall effect was an increase in response time for rural areas county wide, going from 11.2 minutes to 12.1 minutes on average.

“I think that this is a uniquely difficult issue in that the crisis is unfolding in slow motion,” Carver said. “You can see a one-minute increase in response times across the county and it feels like ‘Okay, so what?’ But the reality is that if you extrapolate over decades, that’s meaningful.”

Credit: (Carver, McDonald, Song, Wange, Wu, 2022)

Overall, the recommendations made in the CIPA report Carver co-authored advocate for pressure to be lifted off of municipalities and communities attempting to fight the tide of issues their EMS operations are facing.

“The unfortunate reality is that [EMS] shouldn’t be but is a municipal issue,” said Carver.

State funding would be the “the primary factor, I think that would help to maintain a resilient EMS network” in rural areas, Carver said.

As for projects at reach for Tompkins County, the report Carver worked on concluded that a training pipeline would benefit all the various EMS agencies, which need to coordinate those efforts on their own.

Carver said that the conclusions shared from the report he worked on “aren’t particularly shocking or surprising. Certainly anyone who’s read any of these historic reports wouldn’t wouldn’t be surprised.”

A bill was passed through the state legislature and signed by Gov. Kathy Hochul in January establishing a task force to study challenges faced by rural ambulance companies. The 12-member task force will deliver recommendations to the state legislature on how to better the state’s EMS network for rural communities. 

Jimmy Jordan

Jimmy Jordan is a general assignment reporter for the Ithaca Voice. Questions? Story tips? Contact him at Connect with him on Twitter @jmmy_jrdn