These are the first four links that appear on a Google search for news articles related to “EMS Crisis.” Nearly every day, somewhere in America there is another article or report on emergency medical services facing financial, personnel and staffing or decreasing volunteerism. Legislators, community organizations and EMS agencies across the country are identifying that EMS is struggling and that there is a perceived EMS crisis, a crisis that may come to impact anyone who needs medical care, is involved in an accident or otherwise has need for an ambulance.

Modern EMS developed about 50 years ago with the publication of the National Academies of Science report “Accidental Death and Disability: The Neglected Disease of Modern Society” in 1966. This report looked primarily at the number of injuries and deaths that were occurring on the nation’s roadways from vehicle crashes and prompted the development of emergency care from the funeral home provided ambulance services that offered little more than a quick ride to the hospital. The 1970s television show “Emergency” introduced America to the capabilities of paramedics and was a social driver of EMS system development. As EMS has developed over the years, it has become a system that offers advanced level skills, equipment and procedures that otherwise might only be found in emergency departments or intensive care units.

However, as EMS passes it’s 50th birthday, the EMS system is under pressure from a variety of sources and faces significant change in the coming years. EMS agencies face financial pressure from increasing costs coupled with flat or decreasing reimbursement; difficulties in recruiting and retaining personnel to staff their ambulances; and decreasing volunteerism in rural areas, all coupled with an aging population and increasing numbers of calls.

For the first few decades, EMS agencies were able to be profitable and support their operations primarily on their receipts from billings. As insurance reimbursement has failed to keep pace with inflation and costs, especially for Medicare and Medicaid, which for many agencies represents 70% or greater of their patient’s insurance coverage, and increasing personal deductibles for private insurance, agencies are also being squeezed by increased costs for personnel, equipment and vehicles. EMS agencies may have a cost of $650 per call yet are forced to accept payment from government-based insurers at pennies on the dollar, sometimes as little as $150-200. With no ability to bill the patient for the outstanding balance, they lose money on most of their responses. If they are a 911 response agency, they have no choice but to respond and provide care regardless of the patient’s ability to pay. Continuing financial losses can only be sustained for so long before something has to give.

As the care available to EMS patients has dramatically increased, so have the costs for equipment and vehicles. Ambulances can cost about $250,000, excluding the heart monitor, stretcher, medications and other equipment that easily adds another $100,000 or greater to the cost of providing care. In order to meet those costs, EMS more frequently turns to municipalities for help in meeting its costs. Municipalities may be able to provide support or assistance indirectly by providing fuel, repairs, workers compensation insurance or by providing tax funds to support and maintain their emergency response capabilities, although many are reticent to raise taxes, even to maintain an essential service.

EMS, like other public safety entities, also faces difficulties in recruiting and retaining staff. The providers that started in the early days are starting to age out of the field or leave due to injuries or mental health issues. Younger providers only remain in EMS for relatively short periods of time before they leave the field to pursue other public safety or health care positions.

In the EMS1.com and Fitch & Associates’ 2019 EMS trends report, when a provider was asked whether they would recommend a career in EMS to their children, they replied, “Working in a 911 system will change you as a person. Once you do this job, it’s hard to imagine doing anything else. The highs are incredible and rare. But the lows are tough. There are so many jobs in the world that pay better, provide the same satisfaction, and don’t affect your personal life like this job.”

EMS workers face low pay, long hours and frequent exposure to critical events that negatively impact their family lives and mental health. A recent study from Washington University found that EMTs and paramedics are seven times more likely to have thought about suicide than the general public. Projects are underway to address the mental health impacts.

Many providers work at least two if not three or four EMS jobs to make ends meet. For the cost and time commitment of a paramedic training program, a provider can continue for a few months longer to receive a registered nurse or other health care provider license that pays better and has fewer hours, less risk and better working conditions.

In rural areas, where reliance on volunteer EMS agencies is high, the impact is becoming more pronounced. Rural areas are becoming older while younger people are moving to more suburban or urban areas for jobs and are not as apt to volunteer for their local community ambulance service or fire company. It is not unusual at a small rural agency to have a core of three to five people, many in their 60s or 70s, that comprise the active membership of the organization.

Volunteerism in all social areas is also decreasing due to multi-income families, family responsibilities and the decrease of shift work. When factories were operational and people worked shifts, there was always someone around to take a call. Now that most people in rural areas drive to work and are away during the day, agencies struggle to find responders for daylight emergencies. A recent incident near Erie, Pa., resulted in the dispatch of multiple agencies, none of which were available to respond before the patient was transported by private vehicle 50 minutes later.

The cost of training, continuing education and the time commitment to both maintain certification and provide care are also barriers to rural EMS. In Pennsylvania, courses that used to cost $75 are now $750 to $1,000 for EMTs due to changes in the funding models for community colleges. It requires a person with true dedication and resolve to overcome those barriers and agree to become a member of their local ambulance service.

We have hit a middle-aged slump and are struggling to find the combination of funding, training, recruitment and retention to allow EMS to continue in the coming decades. However, the EMS model needs to change to address the pressures the system faces. In five to 10 years, EMS will not look the same as it does today. It remains to be seen what the future holds. Agencies are already looking to become providers of community-based and preventive care medicine, that will provide additional career ladders, funding sources and opportunities to develop in areas that as of yet remain untouched. EMS is a great career where you can immediately see the impact that you have on a person’s life. It can be extremely rewarding. I have been there for the first breath of life and, unfortunately, also the last. It is truly the passion and dedication of those EMS providers who are out in the field every day that keeps the heartbeat of EMS going. They are the ones who will adapt and overcome, as EMS always does to move us forward into the future.