Emergency alert: States confront EMS shortages

A bipartisan group of Minnesota legislators declared an “EMS emergency” in late February and asked for an infusion of $120 million simply “to buy some time and address short-term funding challenges,” in the words of Dylan Ferguson, executive director of the Minnesota Emergency Medical Services Regulatory Board.

In a supplemental budget released last month, however, the governor proposed closer to $16 million. “With $3.5 billion left on the bottom line, I’m stunned to learn the governor wants to pinch pennies before funding emergency medical services for greater Minnesota," state Sen. Andrew Land was reported as saying at the time. “This is a laughable amount, and no one should be proud of this proposal."

The EMS emergency in Minnesota has been building for some time. Response times for ambulances are getting longer. The worker shortage for EMS has become debilitating. And the funds to provide ambulance care are getting tighter and tighter. But these difficulties weren’t a front-burner issue in that state until relatively recently. As they’ve grown more severe, they’ve turned into front-page news. “There is more attention paid by state and local elected officials now to EMS in Minnesota than at any time in the state’s history,” says Ferguson.

“In some communities, the situation is becoming dire enough that not only are the ambulances not sufficient, but there’s not even someone to answer the phone when 911 calls the ambulance company,” says David Kirchner, evaluation coordinator for the Minnesota Office of the Legislative Auditor.

Minnesota isn’t alone in confronting significant problems with its EMS services. It’s a national problem, says Dia Gainor, executive director of the National Association of State EMS Officials. This is largely due, she argues, to the fact that many EMS systems—including those in Minnesota—are based on an approach established half a century ago that is no longer effective.

“In the 1970s through 1981,” she says, “a significant amount of federal funding flowed to areas in all states to purchase ambulances and to get training where it did not exist. They were then able to get a real ambulance instead of relying on the funeral home or the back of a paddy wagon to get people in distress to the hospital. Now, 50 years later, it’s not rational for communities to rely on 50-year-old paradigms of emergency medical provision.”

One of the biggest issues Minnesota and other states confront has to do with a combination of demographic changes and the way emergency services are reimbursed. In prior decades, ambulance services were often paid for out of individuals’ insurance. But as the population has aged, most reimbursements are coming from Medicare. And that presents a huge problem. As Gainor explains, EMS is “considered transportation by Medicare. So, if the ambulance arrives at someone’s home, and EMS workers are able to take care of an individual on-site, then there’s no federal reimbursement.”

As a result, EMS providers in Minnesota are not able to bill insurance in 28% of the instances when an ambulance is dispatched to the scene of an emergency because the patient isn't transported to a medical facility, according to the Minnesota Emergency Services Regulatory Board.

At the same time as the system of reimbursement is grows increasingly outdated, costs have been going up. For example, the price to buy an ambulance is up 50% from pre-pandemic to now and inflation has caused the cost of medical supplies to rise dramatically as well.

What’s more, a lack of qualified workers, including paramedics, ambulance drivers and emergency medical technicians, is putting pressure on officials to improve pay and benefits. “More people are leaving the EMS system every year than are entering it,” says Michael Juntunen, coordinator for Community Paramedicine at the Mayo Clinic and president of the Minnesota Ambulance Association. In 2022, which was the most recent year for which the state had data, 3,000 more people left the field than came into it.

Currently, many EMTs are paid about the same as people who work in gas stations or fast-food restaurants. What’s more, EMT jobs are extremely stressful.

“It's hard to say you should come and help somebody who could be torn apart on the interstate versus, you know, stocking shelves for the same pay,” says Juntunen “The stress level is just not the same. It’s hard to compete.”  

These kinds of jobs can easily lead to burnout, “and that’s a significant challenge,” says Ferguson. “I would say that burnout and mental health issues were influential factors that drive people to leave the field.”

The strains on EMS systems are particularly difficult in rural areas where many of the EMT jobs have long been performed by volunteers. “There’s been a dwindling number of volunteers who are going to get up from their dinner table to go through whatever the weather is and quickly arrive at an emergency,” says Gainor. The volunteer gap reached such a difficult point in Tennessee that (though its motto is the “volunteer state,”) it is no longer relying on volunteers altogether. But in Minnesota, a large percentage of the square milage of the state is still covered by volunteers.

Despite these challenges, an ambulance continues to arrive at the scene of an emergency, but it might have to come from a neighboring community. “This happens all the time,” says Kirchner. “An ambulance service that has only one ambulance may have it in use right now and so the call goes to another service. And that service only has so much capacity.”

One obstacle in Minnesota and elsewhere to resolving EMS problems is that the systems for measuring its success are feeble at best. Response times, for example, are generally based on the time between an EMS vehicle setting out on the road and arriving at its destination. But for people calling for help, they really care about how long it takes after they make the call for the ambulance to appear.

In addition, when a call comes in to 911 for an ambulance and none are available, “that’s not being measured, because no one measures nonresponse,” says Kirchner.

There are other serious shortcomings in the lack of data. “Pretty much all our standards for ambulance services are based on capacity. For example, do you have a functioning ambulance?” says Kirchner. “They’re all about what you can do, not about what you do. Just as important are questions like, ‘Of all the time that you went on a call, did you follow the stroke protocol?’ Other states have standards like that. This is something that hasn’t been done in Minnesota. The District of Columbia has a protocol like that.”

Dealing with the EMS crisis in Minnesota and elsewhere is made particularly complicated by the variety of ways in which the service is offered. “EMS is neither fish nor fowl,” says Kirchner. “It is a public service that people expect to have like the police department or the fire department, and yet it’s never been paid for the same way as police or fire.”

There’s been a movement recently in several states to declare EMS an “essential service.” By doing so, a state would be required to provide or fund the service. To date, more than a dozen states have passed laws designating or allowing local governments to deem EMS as an essential service. Minnesota is not one of them.

“We have both some profit and many nonprofit services in Minnesota, some of which are run by a large health care system,” Kirchner says. “Others are run by cities. Of these, some are managed by their fire departments. This variety of approaches has made it challenging to find solutions.”