Stefan Hofer's ambulance company, West Traill EMS, in Mayville, North Dakota, has received only one or two calls that weren’t related to Covid-19 over the past two months. But he said the case count has ballooned by 20 to 30 percent because of the pandemic. At the same time, the company's expenses have mounted, its revenue has cratered and its workforce is being decimated by the virus.
The company — which is private and supported by volunteers, a few employees and four trucks — covers more than 1,500 miles of North Dakota prairie and serves about 10,000 people on the far east side of the state.
Private EMS services, both in urban and rural centers across the country, collectively received $350 million in Covid-19 relief funds in April, but those companies said that money ran out within weeks. Months later, the need remains great as they face another coronavirus surge.
Hofer said he doesn’t know how long his company can keep up its current pace — much less how it will manage the increase in cases they expect from the Thanksgiving holiday — if ambulance services like his don’t receive additional federal aid. He said he may lose employees soon. That could mean answering fewer calls, too.
“This isn’t going to be over tomorrow, and that’s the big thing,” he said. “We got to make sure that we can still take care of people six months from now, and that’s what’s gotten really hard to figure out.”
In a letter sent to the Department of Health and Human Services and exclusively obtained by NBC News, the American Ambulance Association said “the 911 emergency medical system throughout the United States is at a breaking point. Without additional relief, it seems likely to break, even as we enter the third surge of the virus in the Mid-West and the West.”
An HHS spokesperson said the agency has delivered nearly $107 billion to more than 550,000 providers across the country and opened a third round of funding of $20 billion last month, which they said is available to ambulance services.
That third phase of funding, however, comes with a limit. It’s available to every health care provider and supplier up to 2 percent of their 2019 revenue. EMS services said they’re thankful for the money, but it won’t keep them from potentially going under.
All the funding that the federal government gave us, whether it was PPP funding or money from HHS, all of that is long gone.
The issue for private ambulance companies like Hofer’s is that they no longer get the valuable 911 or hospital transfer calls they once received, as hospitals, nursing homes and people put off surgeries and other medical procedures because of the pandemic. Meanwhile, ambulance services have been forced to buy more personal protective equipment, which has gotten 20 to 25 percent costlier in recent months, to stay safe.
But revenue has collapsed even further because ambulance services are also now expected to treat people in place at the scene of an emergency. It’s the new standard of care during the pandemic, but the Centers for Medicare and Medicaid Services refuses to reimburse companies for this method of treatment if the patient isn’t technically transported.
That’s a huge financial hit to ambulance companies that answer 911 calls across the country, especially because if Medicare doesn’t cover it, most insurance companies won’t either.
“All the funding that the federal government gave us, whether it was PPP [Paycheck Protection Program] funding or money from HHS, all of that is long gone,” said Jim Finger, the chief administrative officer of the Regional Ambulance Service in Vermont who chairs the American Ambulance Association rural provider task force. “But we still have all these issues, and we’re trying to find ways to financially survive and continue to do our jobs.”
‘The reality doesn’t look good’
Private ambulance services look after about a third of the communities in the U.S., often in rural areas, but they have only received that $350 million in relief from the federal government — about the same amount as dentists.
Hospitals and nursing homes, meanwhile, have in total received more than $30 billion.
“America’s ambulance services provide skilled, on-demand health care round-the-clock to every family in our nation, despite soaring costs and decreased revenue driven by the Covid-19 pandemic,” Aarron Reinert, president of the American Ambulance Association, said in a statement. “These financial challenges are exacerbated by staffing shortages as EMTs and paramedics quarantine after exposure to or infection by coronavirus.”
The association said in its letter to the Department of Health and Human Services that the paramedics and emergency medical techs who make up ambulance services across the country need $2.62 billion — about $43,500 for each of the approximately 60,000 ambulances that answer 911 calls. They suggested that the funds be pulled from the Provider Relief Fund, a $175 billion pot created by the Coronavirus Aid, Relief, and Economic Security (CARES) Act to support health care workers and distributed by HHS.
Despite the ambulance association’s ongoing request for support, they haven’t received anything beyond the $350 million they received in April.
“Compared to what others that we know in the health care industry have received, it's a fraction, and it’s a fraction of the losses that we've incurred,” said Hanan Cohen, a paramedic and director of corporate development at Empress EMS, which operates in the Bronx and Yonkers in New York. “We’re hoping for more, but the reality doesn’t look good for aid. We’re also looking for structural changes in how EMS and ambulance services are reimbursed in the United States. It’s been an issue for 20 years.”
While the fact that ambulance services are increasingly cash-strapped in the United States is not a new problem, the issue is growing increasingly dire during the pandemic.
The rising case count nationwide is also getting worse than most imagined. Many ambulance companies said that the current wave appears to them to be as bad in their communities as what New York EMS services experienced in March and April.
“We had no idea when we saw all the spikes that happened in New York that we would be one of those places where the spikes have just been incredible and intense,” said Rachel Harracksingh, the president of Life Ambulance Service in El Paso, Texas. “I’d love to give hazard pay because of conditions that we’re having to go into and what we have to see every day. It’s nonstop.”
No aid in sight
President Donald Trump was asked about the financial challenges faced by ambulance services at a news conference in early August. The American Ambulance Association, he was told, was worried that EMS companies nationwide had not received the aid they needed.
Trump said it was the first he had heard of it.
After praising “the ambulance people” as well as health care workers, members of law enforcement, the military and the Federal Emergency Management Agency, he said: “I will certainly look into it. I mean, you’re telling me something for the first time. Nobody is complaining about not getting paid too much, but we’ll take a look at the ambulance drivers.”
Four months later, the White House declined to comment. Meanwhile, ambulance companies — especially smaller ones serving rural areas — said they are seeing their staff's nerves fray amid the unrelenting nature of the pandemic and little promise of relief.
“I can tell you that the mental stress is about 10 times what it normally would be for us health care workers,” said Ronald Nichols, the emergency services director at Chambers County EMS, which serves a large rural county 50 miles east of Houston.
Still, more support is unlikely to appear from the current pot of money or even in a new aid package.
All of our guys are on the front lines doing the same things as those doctors and nurses. We just have less access to funding than they do.
A Republican staffer on Capitol Hill who is familiar with the current pandemic relief fund negotiations said it is doubtful that the ambulance companies will get the help they’ve requested in the aid package now being negotiated, though additional funding of $50 billion to $100 billion to health care providers is currently being considered as part of that bill.
That money won’t specifically go to groups like ambulance companies, however.
“If we start making designations, then all of a sudden we’re asking to be lobbied nonstop about how the pot is divided,” the staffer said, noting tentatively that negotiations appeared recently to be on the right track. “I just don’t think Congress is itching to put in any kind of language that would carve out anything specific to industries.”
They’d prefer to use the same language they used in the CARES Act, which delegated much of that decision making to HHS.
But the department is also using similar reasoning, fearing that if it acquiesces to the ambulance companies’ demands, they will be pressured by a growing number of people in the health care industry.
Ambulance companies across the country, however, insist that something must be done. They are the first ones to respond to the needs of Americans suffering from the greatest medical emergency in modern history, and they say they are the closest to breaking.
The situation, many said, is increasingly demoralizing and emotionally taxing.
“We have stressful lives to begin with, but we chose to serve our communities, serve the public,” Nichols said. “We’ve always done it without recognition — and we got much more now with Covid-19 than we ever have — but the state legislators and Congress need to realize that all of our guys are on the front lines doing the same things as those doctors and nurses. We just have less access to funding than they do.”