The first responders’ biggest fear was realized one night in December when someone called 911 for help in rural Erie County and nobody came.

The first dispatch went to Union City Fire Co. When Union City couldn’t crew its ambulance, the call rolled over to neighboring Waterford Volunteer Fire Department.

Waterford couldn’t raise an ambulance crew either, so the call went to nearby Mill Village Volunteer Fire Department. Again, no answer.

Fifty-one minutes later, the county 911 center canceled the alarm, saying the caller was going to the hospital in a private vehicle.

“It’s here,” a somber Union City Fire Chief Isaiah Edwards told his firefighters a week later at a station meeting. “We’re dropping a ton of calls. It’s going to be a mess. I don’t have answers.”

See also: Low pay, high risk

Whether such dropped calls have resulted in a death in Erie County is unknown, but rescuers say it’s their biggest fear. And Union City isn’t alone.

Problems recruiting first responders, rising operating expenses and Medicare reimbursement that hasn’t kept pace with expenses are stressing emergency medical services throughout rural Pennsylvania.

The County Commissioners Association of Pennsylvania calls EMS problems a crisis and has made it a legislative priority. The Erie Area Council of Governments has been meeting with fire chiefs and EMS officials for the past year to better understand the scope of the problem in Erie and Warren counties — an area 44 times the size of the City of Pittsburgh.

Both agencies say solutions may be years away. Union City firefighters say they may have months.

“What if we can’t do this anymore?” Mr. Edwards, 31, a heavy equipment operator, asked the firefighters. No one answered.

A 50-year-old innovation

Horse-drawn wagons driven by police officers and volunteers once delivered the ill and injured to doctors’ offices for medical attention. Later, hospitals, fire companies and funeral homes operated the transport vehicles.

During the 1970s and ‘80s, emergency medicine rendered by trained personnel from rolling intensive care units became a standard of care in saving lives.

Seeds of the recent crisis were sown as insurers’ payments for emergency care began to lag behind the rising EMS operational expenses. “The financial situation of the state’s EMS agencies is a key reason for the ongoing declining number of agencies,” a 2018 state Senate report concluded.

Outside of bigger cities like Pittsburgh, emergency medical service is not supported by municipal tax money. That leaves the vast majority of nonprofit ambulance services reliant upon billing for care to keep their trucks on the road and staffed around the clock.

Medicare pays ambulances and other medical providers according to a set payment list, said Dom Pascucci, health insurance specialist at the Wexford offices of broker Emerson Reid.

“Most ambulance services don’t even negotiate with commercial carriers,” Mr. Pascucci said. “It’s take it or leave it. And if you accept Medicare, you can’t balance-bill” — turn to the patient to pay an amount not covered by Medicare.

To set its rates, Medicare surveys a number of ambulance services to determine average costs. Hospitals are required to file cost reports for providing various services. Medicare payments are typically based on a percentage of costs, with hospitals generally receiving 12%.

Because Medicare payments haven’t kept up for ambulances, some experts say tax support may be the only solution to guarantee first responders show up when someone dials 911.

“People need to treat EMS more like they do water, sewerage and garbage,” said Eric Henry, owner of Meadville Area Ambulance Service and newly elected Crawford County commissioner. “Nobody pays for EMS.”

‘No time to help out’

Last year, Union City couldn’t muster an ambulance crew for 200, or 28%, of the 710 total calls received. Even if the fire company answered every call, experts say the volume is barely enough to break even financially — a common story in small towns around the state.

As a Band-Aid, Union City hired two EMS responders a year ago, who double as firefighters. Union City Borough makes annual donations of $24,000 to the fire department, which is about one third of the $75,000 needed for the two paid employees.

Union City’s service is augmented by a private service, which charges between $150 and $200 per call, depending on the level of care provided.

The EMS math tightrope is similar across many such services in Western Pennsylvania.

Most of Union City’s ambulance patients have Medicaid or Medicare insurance coverage — not unusual for ambulance services — which pay $160 and about $400 per call respectively.

A new ambulance can cost between $150,000 and $200,000. And new power stretchers — which help load overweight patients while cutting worker’s compensation injury claims — cost between $60,000 and $70,000 each. The latest heart monitor costs about $90,000.

A tax hike?

Larry Obert is among the Union City EMS volunteers. He’s 79 and believes tax support is the best long-term solution.

“It’s a nightmare,” Mr. Obert said. “Somebody has to subsidize it.” 

At the January meeting of Union City firefighters, Mr. Obert made a motion authorizing the fire chief to ask borough and township officials to come up with the funds needed to hire an eight-person EMS crew for around-the-clock protection. Preliminary figures put the payroll costs at $326,000 a year.

If the municipalities balk, Union City would begin winding down its EMS service by June. A previous volunteer ambulance service shut its doors in 2015 and the fire department created a new service a year later.

Raising the municipal donation is out of the question without a tax hike in a part of rural Pennsylvania that’s already stressed, borough council president Dan Brumagin said before the firefighters met.

Union City, located 22 miles southeast of Erie, is a manufacturing town of about 3,200 people that lost its 35-bed hospital and newspaper years ago.

Mr. Brumagin said the borough is among the poorest communities in the county. The poverty rate is 17.7%, above the Erie County rate of 16.8% and the national rate of 13.1%.

“If we have those kinds of services, it would definitely mean a rate increase,” he said. “We’re not Philadelphia; we’re not Harrisburg. It’s a huge, huge problem.”

Membership drives

Questions about the future of Union City’s ambulance arose as the fire department made plans for its annual membership drive, which launches in April for the year starting in July. Selling memberships is a way EMS agencies raise money for uniforms, stretchers and ambulance repairs.

Union City’s annual subscription costs $40, but this year’s signups were trailing last year’s count, said Shirley Lafferty, fire company treasurer.

An ambulance subscription keeps patients from having to pay the full balance of the bill remaining after payment by the health insurer. Many households pay for a subscription that is never used.

At the firefighters’ meeting, Mr. Edwards floated a compromise — seek municipal contributions totaling $75,000 to allow for another paid first responder to ease the staffing shortage.

Treasurer Ms. Lafferty worried about being able to attract job applicants to a small town and selling a service that may not be reliable, even with the extra help.

“We can do it the way we are now, but are we serving the community?” Ms. Lafferty, 80, said outside the firefighters’ meeting. “We can’t continue like that. It’s not fair to the public.”

The idea of adding a paid employee was eventually dropped in favor of expanding to a round-the-clock service. Mr. Edwards, a third-generation volunteer firefighter, was not hopeful: upgrading the EMS service would mean a big increase in municipal contributions.

Union City wouldn’t be alone if it were to fold: ambulance services in Allegheny, Blair and Erie counties have closed in recent years. Between 2012 and 2018, the number of EMS agencies statewide fell 22% to 1,278, according to the state Senate report.

People and money problems shuttered Blair County ambulance service in December, which was operated by the Williamsburg Area Volunteer Fire Department, said chief Ted Hyle, 63, a volunteer firefighter for 45 years.

“We just wanted to break even,” said Mr. Hyle. “We weren’t getting reimbursed as much as what it cost us.”

‘We can no longer subsidize this’

When small EMS agencies like Union City can no longer answer calls, bigger, private services with all-paid crews have been quick to step in. Consolidation can mean improved medical care and operational efficiencies.

But experts say big ambulance services aren’t immune to the forces threatening emergency services. Pittsburgh EMS, for example, answers some 64,600 calls a year, yet is expected to run an $11.4 million operational deficit in 2020. Tax money will make up the shortfall.

Among other big guys treading water is Citizens’ Ambulance Service, located in Indiana County. It answers about 8,300 calls a year.

Citizens, a nonprofit entity started in 1964, began running an operational deficit in 2013. Annual municipal donations of $5,500 haven’t been able to close the gap.

Citizens’ deficit reached $750,000 because the EMS math quit working, said B.J. Pino, 67, chief operating officer: the average ambulance trip costs Citizens $883 and the Medicare payment is $379 — less than half the cost.

“Can we sustain?” asked Mr. Pino, a 40-year EMS veteran. “The answer is no.”

To retire its deficit, Citizens has begun an ambitious membership drive. In 2019, it sold 6,300 memberships; this year’s goal is double that to generate $860,000.

By late January, Citizens had reached 5,800, including 375 new members. Individual memberships cost $75, seniors pay $65.

Citizens has seven stations to minimize response time. If the membership drive falls short — and depending on the size of the shortfall — Citizens will consider cutting staffing hours, Mr. Pino said.

“We’ll have to find another way to do business.”

Between 2011 and 2019, the payment from popular Medicare managed care plans rose 8% to $425, during a period when McCandless spent $1.6 million for new ambulances and other equipment, said Steve McKinniss, administrator.

The expenditures didn’t include $700,000 in capital improvements needed through 2025.

McCandless-Franklin Park has been dipping into savings to plug budget holes, but that can’t continue.

“At some point, we are going to have to say, ‘The bank is empty,’” Mr. McKinniss said. 

EMTs chase higher wages

Fayette EMS, a nonprofit service that answers about 24,000 calls annually from a rural, 798-square-mile service area, has managed to avoid operating deficits, but only with municipal support.

About 100 calls a month are needed for a station to break even; the Farmington station had between 50 and 60 calls, said Fayette EMS Chief of Operations Rick Adobato.

The community balked at the planned closure.

The result was $125,000 in municipal and other donations to keep the station open for another year. Mr. Adobato is banking on county funding in future years to keep the station viable.

“We’re going through hell right now,” Mr. Adobato, 65, said. “We’re just trying to hold it all together.”