RENEE MONTAGNE, HOST:
An ambulance is usually just a phone call away. But in states that are largely rural, there's a delicate financial balancing act that has to be made before a paramedic can get behind the wheel. As Grace Hood of member station KUNC reports from Colorado, several counties are struggling to keep emergency medical services on the road.
GRACE HOOD, BYLINE: The scene is an accident on the edge of Fort Morgan. Medic Joe King stands near a stretcher on the side of a road. He's talking to a woman in her 20s who was in a fender bender.
JOE KING: And all of this is just so we don't accidentally twist your spine while we're taking you to the hospital.
HOOD: The vital signs for Morgan County Ambulance aren't good. The operation covers 36 square miles and only averages six calls a day. Reimbursements from Medicare, Medicaid and private insurance don't cover its $1 million annual budget. Since the county is unable to pitch in, King is left with difficult choices. He's both the director of the Morgan County Ambulance and the secretary because he couldn't fill that position last year.
KING: Sometimes it can be overwhelming. But the way it is where we get no subsidies and we're relying only on user fees, we had to do that.
HOOD: In rural America, low call volume, fixed overhead costs, and vast geography typically translate into red ink for ambulance providers. Even in places like Utah and Colorado, where state grants help, times are tough. One hour to the east of Morgan, a private ambulance service in Logan County went bankrupt. An hour to the west, Weld County transferred its service to a local medical center after writing off $4 million in uncollectable bills last year.
SEAN CONWAY: It was like a big bucket of cold water being thrown in our face.
HOOD: Weld County Commissioner Sean Conway says factors in the decision included a rise in uninsured patients. And even though Weld County is profiting from an oil and gas boom, it wanted out of the ambulance business.
CONWAY: There are things that a hospital can do that we could not do as a county government. County government is not structured to provide health care.
RANDY KUYKENDALL: Our local governments are faced every day with very, very difficult choices.
HOOD: Randy Kuykendall is with the National Association of State EMS Officials. He explains that America has a patchwork of ambulance models run by private companies, hospitals and governments. Because it doesn't pay to be in the rural business, the task is often left to cities and counties, which don't have a lot of money.
KUYKENDALL: So it's that ongoing battle of how much public support is necessary to keep that EMS system, and ultimately that health care system in place.
HOOD: Other challenges include recruiting and training volunteers. Ambulance services in states like Wyoming are almost completely volunteer-run. But Kuykendall says the median age of EMS providers is going up, not down.
KUYKENDALL: At what point do we no longer find ourselves in a position where maybe folks are willing to volunteer? And then local government is faced with, you know, how do they convert that potentially into some form of a paid system.
UNIDENTIFIED WOMAN: (Unintelligible) twenty-two...
UNIDENTIFIED MAN: (Unintelligible)
HOOD: At Morgan County Ambulance, which switched from volunteer to paid service six years ago, Joe King is living out those challenges every day. He points to a modified 2009 SUV.
KING: So here's one of them here.
HOOD: The county started using it to transport patients between hospitals.
KING: The big savings is with the fuel and the maintenance of the vehicles. Last year we figured we saved $36,000 by using these for inter-facility transports.
HOOD: But he says changes like these only help the service break even, not invest in the future. With population declining in many rural areas, and median age on the rise, King says both residents and elected officials need to start talking about what kind of ambulance service they want and, more importantly, how they'll pay for it.
For NPR news, I'm Grace Hood in Fort Collins, Colorado. Transcript provided by NPR, Copyright NPR.