Vermont's Emergency Medical Services System Is Struggling to Survive. Can It Be Saved? 

Colleen Ballard knew her industry was in distress. The seasoned paramedic had been hearing doomsday predictions about the future of emergency medical services for years, and her colleagues at Essex Rescue were feeling the strain of rising call volumes, staffing shortages and underfunding.

But it was not until she took over as chief in early 2020 that she realized just how dire the situation had become.

Essex Rescue needs at least two ambulances and about 16 full-time EMTs and paramedics to cover the 30,000 residents it serves across Essex, Essex Junction, Underhill, Jericho and Westford. But a shortage of volunteers was leaving big gaps in the schedule, forcing the agency to bring on more paid workers — something it couldn't afford.

We're speeding toward a financial cliff, Ballard thought to herself, and it's going to be on my watch.

She raised the agency's rates, convinced the towns to pay more and started sending patients' unpaid bills to collection agencies, something Essex Rescue had never done in more than 50 years of service.

It wasn't enough; the agency ended last fiscal year $100,000 in the red, and the deficit was only projected to grow. Ballard saw only two options: raise the rates again, further burdening patients with no insurance, or ask the towns for more money.

In January, Ballard requested a total of $210,000 more from her five municipalities, bringing the combined ask to $543,000 — a 412 percent increase from the $106,000 the towns were collectively paying just two years ago, back when the agency's payroll was low enough to be mostly offset by insurance reimbursements. The request would have been far bigger had Ballard sought enough money to pay the two extra full-time employees she now desperately needs. Instead, she sought simply to close her budget gap, she said, viewing that as a compromise.

The selectboards did not share her thinking. They grilled Ballard at public meetings and four of them followed up in writing to demand a greater say in the agency's operations. And though they ultimately ponied up, Ballard is now worried about the towns' long-term commitment.

"If one of these communities opts out, we're going under," Ballard said. That would leave the county's 14 other ambulance services to cover the 3,000 emergency calls that Essex Rescue responded to last year.

EMS workers are the first responders of medical crises. They resuscitate the dying, bandage the wounded, pull people from car wrecks and help the elderly get back on their feet after falls at home. They are an extension of the health care system, bridging the gap between the hospital and your doorstep.

But the system they work in — a patchwork of mostly small-town rescue squads built on the backs of volunteers — was designed for a very different era. That system is now crumbling, and the people holding it together warn that it will collapse entirely if something doesn't change.

Vermont's aging population is fueling a dramatic rise in 911 calls, and understaffed ambulance agencies are struggling to keep pace. Some crews can no longer respond to all of their calls, forcing their neighbors to pick up the slack. The result: More ambulances are responding from farther distances, a frightening prospect in a field where every second can matter.

It's not just 911 response that's suffering. Fewer crews have the capacity to perform a secondary but equally vital role of EMS: moving patients between health care settings. Rural emergency departments say it has become harder to find ambulances that can take their sickest patients to the hospitals better equipped to save them. Some are dying while they wait.

The crisis was years in the making and, in many ways, inevitable. Ambulance crews have never made enough money to cover their costs, and the industry has been steadily losing its most vital subsidy: volunteers. To defray their growing payrolls, agencies are seeking more municipal support, frustrating local officials who have grown accustomed to cheap and reliable coverage. Many Vermont towns are just now learning the true cost of around-the-clock ambulance service.

The most promising idea for solving Vermont's predicament: regionalize the system.

By pooling resources, towns could spend the same amount — and, in some cases, much less — in exchange for a more reliable service, one capable of fulfilling both of the EMS system's responsibilities. These bigger, better-funded agencies could offer higher salaries and benefits, which might ease the workforce shortage.

The state already has some idea of what a regional system could look like. Vermont is organized into 13 EMS districts, each built around a hospital catchment area. The districts currently provide only limited oversight to the state's 79 ambulance agencies but could serve as a rough sketch of a new regional map.

Still, the road to regionalization is filled with potholes, and even some of the biggest supporters question whether it will ever happen. Vermont towns and cities greatly value their local control, and the drawn-out battles over school mergers have done little to ease the skepticism around forced consolidation.

Perhaps that's why state leaders have been so uninterested in taking a side in the debate. The Vermont Department of Health says it has no stance on the idea of regionalization, and lawmakers haven't had much to say on it over the years, either.

That's slowly starting to change, however, as legislators awaken to the crisis engulfing their hometown ambulance services. Nearly three dozen lawmakers recently signed on to a bill seeking to stabilize EMS and plan for its future. The measure would inject up to $20 million into the system annually over the next four years and create a study committee to explore regionalization. It's not expected to move forward this session, though.

Until it does, ambulance crews have no choice but to hope that towns agree to pick up the increasingly expensive tabs.

"And pray that no one closes their doors," said John Keating, chief of Saint Michael's Fire and Rescue.

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Disappearing act

When Mike O'Keefe first joined Essex Rescue, he wore a white jumpsuit and responded to calls in converted vans. It was 1982, and he was one of more than 40 people who kept what was then a fully volunteer agency running. Many of his colleagues were either housewives or workers from IBM, which encouraged community service, even on company time. Volunteer interest was so high that the agency kept a waiting list.

Forty years later, O'Keefe is one of just 20 active volunteers left and among only a handful experienced enough to be the crew chief on an ambulance. The 65-year-old hopes to stick it out a bit longer, but he's not sure if his health will cooperate. "I don't want to be the kind of person who sticks around longer than I should," he said.

Volunteers such as O'Keefe are aging out of the EMS workforce faster than they can be replaced, putting enormous pressure on ambulance crews. The shortage has created a vicious cycle in which unpaid providers are asked to do more and more until they eventually decide that there are less stressful ways to spend their free time. The trend is likely irreversible and has driven up costs in an industry where the average volunteer can save agencies tens of thousands of dollars per year.

The nationwide loss of EMS volunteers has been especially disruptive in Vermont because of just how instrumental unpaid labor has been.

When regulations and rising costs pushed funeral homes out of the ambulance business in the middle of the 20th century, groups of service-oriented residents stepped up to fill the void, launching dozens of volunteer squads across the state.

Many years later, the EMS system still bears the handprints of those grassroots efforts. Services are still provided exclusively at the local level: Municipalities either offer it themselves — often through fire departments — or contract it out to private nonprofits. The workforce is also still primarily volunteer, though increasingly less so.

The disappearance of that free labor has been felt most acutely in rural Vermont, where the pool of potential applicants is shallowest. Chittenden County has colleges and a major academic medical center to draw from; towns farther out mostly rely on people living and working in the community.

"We used to have a contingent of folks that worked in or around town who could jump on an ambulance for an hour or two," said Peter Brescia, chief of the Alburgh Rescue crew. "Those days are gone." Retirees now help cover most of the daytime shifts, but gaps remain: The agency dropped a few dozen calls last year because it had no one to staff its ambulance, forcing other agencies to respond from farther away.

Even in more populous areas, the busiest agencies are finding that their workloads are often too much for volunteers. The number of EMS calls in Vermont has risen from 99,000 in 2020 to 118,000 last year, and Chittenden County made up a third of the increase. Essex Rescue alone went out 700 more times last year than in 2019.

"The model is just not sustainable when you're asking volunteers who have full-time jobs to run eight calls in a 12-hour shift or come give us a night a week where you don't sleep," said Leslie Lindquist, chair of Vermont EMS District 3, which covers Chittenden County.

Scott Willits can attest to that. He decided to volunteer with Essex Rescue last June after moving to the area for a job at Beta Technologies.

The agency was asking volunteers to work one 12-hour shift a week, plus one weekend shift every month. It was a demanding schedule, but one that Willits, a U.S. Air Force veteran, thought he could handle.

He was wrong. Willits would come to the station directly from his day job and spend the next 12 hours averaging about six calls — enough to keep him awake all night. He'd usually manage only a quick nap before returning to his paying job.

This year, Essex Rescue eased its requirement to provide more flexibility. Volunteers now can sign up for six-hour shifts, as long as they hit a total of at least 36 hours each month. Willits appreciated the gesture but said even that was untenable, leaving him only a handful of free weeknights per month once he factored in his work schedule and shifts as a ski patroller. Reluctantly, he resigned last month.

"Giving myself seven nights a month of free time to do laundry and hang out with my wife? It was too much," he said.

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Where's the Money?

Because the pool of free labor is evaporating, almost every crew in Vermont now pays at least some staff, either full time or by the shift. Another may soon start doing so: Voters in Alburgh will weigh in on a town budget next week that includes funds to pay their volunteers.

Such a change may create more problems.

Agencies that begin paying some but not all of their workers may find that the inequity rubs their volunteers the wrong way. Some end up leaving to go work at another agency where they can get paid for their efforts.

Nor is it easy to recruit paid workers. To find them, agencies have had to raise wages, which still aren't very high.

AmCare, a fully paid service in Franklin County, has increased its pay 35 percent over the past two years in an effort to retain the people it already has. Even then, a starting EMT makes just $16 an hour. "That's less than what you'll make at McDonald's starting out," said Clement Roger, the agency's chief. "And, let's face it, we work out in the cold, the rain, the snow, cow manure."

The upward pressure on wages has benefited people looking to make a career out of EMS. Until now, many of them have needed to work well over 40 hours to make a livable wage. But the trend has put rescue chiefs in a tough spot.

Indeed, the ballooning payrolls have raised existential questions for smaller crews, who already weren't bringing in enough revenue to sustain themselves.

"It's a scary future," said Maggie Burke, executive director of Waterbury Ambulance Service, which expects to end the fiscal year $100,000 in the red.

The problem is that rural ambulance crews cannot possibly break even, given the way their services are paid for.

While all EMS squads rely on towns for a portion of their budgets, the bulk of their revenue comes from reimbursement by insurers — most often, Medicaid and Medicare, which cover more than two-thirds of medical calls in some Vermont communities. But the cost of running a 24-7 ambulance service has always exceeded what insurers are willing to pay.

Last year, the maximum Medicare reimbursement for an ambulance trip was $500. Medicaid, whose rates are set by the state, was even lower, at $390. Most ambulance crews say they need to make far more per trip to cover their costs.

The deficit compounds quickly. Essex Rescue billed insurance companies $1.8 million last fiscal year, but only $1.1 million of that total was eligible for reimbursement based on its contracts with insurance companies. Another chunk of the bill went unpaid when patients didn't make their co-pays. In the end, Essex Rescue recovered only $880,000, less than half of what it initially billed.

Another injustice of the funding model: Ambulances are usually paid only when they transport someone to the hospital. But more and more calls don't end up at the emergency room.

Medical advancements have made it easier for EMTs and paramedics to treat people in place, without going to the emergency room. And EMS agencies are often plugging gaps in the rest of the health care system. Responders routinely hear stories from patients about how their conditions worsened as they waited to get in to see primary care doctors or specialists at hospitals.

Art Groux, the recently retired chief of the Bennington Rescue Squad, offered another common scenario: Your home health provider calls in sick, and their understaffed agency doesn't have anyone to fill the shift.

"You need help getting from the toilet back to bed. What do you do? You call 911. We come out; we pick you up. We will help you," Groux said. "But we don't get paid for that."

All this means that while ambulance crews are busier than ever, they aren't necessarily making more money. Groux's former squad took in an average of $325 per call in 2018. That figure dropped to $275 by last fall. The cost of each response, meanwhile, was around $435. Put another way: The agency lost, on average, $160 per call.

Rescue chiefs don't expect this will change anytime soon. Medicare, which has acknowledged that it underfunds EMS, is currently conducting a study that industry leaders hope will lead to significant pay hikes. Any changes are probably years out, though. Until then, money-losing ambulance squads are turning to the only place they can to raise revenues — towns — leading to some friction.

In Bennington, selectboard members bemoaned their local squad's request for $20,000 more this year and expressed frustration that they only hear from the organization during budget season.

Ludlow Ambulance Service has added three full-time staff since 2014 and recently implemented a seasonal pay scale that bumps its workers' salaries during the winter to compete with the nearby Okemo ski area. To cover the costs, the agency asked the Town of Ludlow for more money: from $60,000 a few years ago to $310,000 now.

Stephanie Grover, the agency's chief, said frustrated community members don't understand why they're being asked to pay for a service that, until now, has been almost free.

"They want you to be there when they need you, but they don't want to foot the bill," she said.

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To the Rescue

In Brattleboro one recent day, a loudspeaker crackled to life: male, late seventies, complaining of chest pain and dizziness. Recent history of heart attack.

It was the third time in less than eight minutes that someone in the Brattleboro area needed emergency medical assistance. Rescue Inc. had responded to the first two calls immediately, despite the fact that the nonprofit rescue squad already had a few ambulances out helping a neighboring Vermont agency.

This time was no different. Less than a minute after the latest alert, an ambulance at the agency's West Townshend station radioed back: call acknowledged, en route.

Sitting in a training room back at the Brattleboro headquarters, Drew Hazelton, the agency's chief of operations, went quiet. A few seconds later, the sound of a garage door could be heard.

"There it is," a grinning Hazelton said. Two of his administrators were moving an ambulance to have it ready for service at the now empty West Townshend station.

Hazelton often gets asked how Rescue Inc. has managed to go seven years without needing to rely on another agency to answer one of its 911 calls. "That's how," he said.

The 57-year-old nonprofit provides regional coverage for a dozen towns in Windham County and two in New Hampshire; it's been one of Vermont's most stable ambulance agencies in recent years. Its annual budget increases have held steady at around 1 percent for the past decade. It's fully staffed and has continued to provide reliable transport services between state hospitals. And using money made during its wide-ranging COVID-19 response, the agency recently launched a new EMS training academy. More than 250 people have taken classes at the academy since it opened in October, including some who have gone on to become certified critical care paramedics and EMTs.

The regional model on display at Rescue Inc. could be Vermont's best chance at ensuring there's always an ambulance around when you need one. The idea seems to be catching on even in the profession itself: The EMS Advisory Committee, which includes industry representatives from across Vermont, recently recommended that the state provide incentives to towns to develop regional partnerships.

"In many areas of the state EMS services are struggling to meet even the most basic needs of the community," the report says. Despite efforts to stabilize the system in recent years, it is now "failing."

A major source of the problem, according to the commission, is that Vermont simply has too many small ambulance agencies — one for every 8,000 people — which has contributed to growing costs and widespread inefficiencies.

Consider, for instance, an oft-overlooked but vitally important piece of EMS: moving patients between health care facilities. Small crews often can't take hospital transfers because it removes a rescue vehicle from the 911 system. That makes it harder for hospitals to find rides for their patients.

They might have to wait a few extra hours for a ride back to the nursing home. Or, more seriously, for a potentially life-saving treatment.

Say you end up at Northeastern Vermont Regional Hospital in St. Johnsbury suffering from chest pain, and it's decided you need a cardiac catheter procedure. Northeastern, like most small hospitals, doesn't have the technology to do that, so it would seek to transfer you to a bigger facility that does.

You can't just drive yourself — you're having a heart attack — so the ER docs at Northeastern call around for an ambulance to take you. They can't get just any ambulance, though: They need one with a critical care paramedic on board in case you take a nosedive during the trip. But the area around Northeastern is served primarily by small ambulance crews that can't pay enough to recruit critical care paramedics, the most highly trained EMS professionals. So you wait — in some cases, for 12 hours or more.

Similar scenarios are playing out at rural hospitals across the state, according to ER chiefs. Faced with the prospect of waiting for a ride that may come too late, some patients have left ERs against medical advice so that their family can drive them to a bigger hospital. Others have stayed — and died.

And though it's impossible to know whether they could have been saved, "there are definitely situations where things did not go the way they're supposed to go," said Dr. Josh White, chief medical officer at Gifford Hospital in Randolph.

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Making 'Regional' Work

Back in Brattleboro, Rescue Inc. not only provides regular critical care transports but is also branching out into new territory: The agency has partnered with the Brattleboro Retreat on a new project in response to Vermont's mental health crisis. Every weekday from noon to 8 p.m., Rescue Inc. has an ambulance whose sole task is to transport psychiatric patients down to the Retreat. It's staffed by crews trained in responding to mental health crises and will pick patients up at any Vermont hospital.

The ability to do all this and still manage the busy 911 system is a direct result of Rescue Inc.'s regional model, said Hazelton, the agency's chief. With 11 total ambulances, a staff of more than 90 and a budget of around $4.5 million, Rescue Inc. is big enough to be nimble — a luxury in a chaotic field.

Driving through his 500-square-mile territory last week, Hazelton described a typical day.

Each shift begins with at least four staffed ambulances: three in Brattleboro and one at the West Townshend station. These are all merely starting points, though, because the fleet is in flux throughout the day, constantly shifting to meet the agency's needs.

The stations are located strategically so that no part of the territory is farther than 18 miles away, a relatively short distance in the world of rural EMS. Still, for some calls, every second counts, which is why Rescue Inc. has worked closely with its member towns to create "first-response agencies."

These agencies have volunteers trained in the most basic life-saving supports, such as CPR and rescue breathing. Most are based at fire departments and can respond to 911 calls in their personal vehicles — ahead of ambulances — to start treatment.

"We're not just an ambulance service," Hazelton said. "We are the center of an EMS system."

Perhaps the most instructive lessons from the Rescue Inc. regional model are the way it's funded and governed — and how both have changed over time.

The agency subsisted almost entirely on donations during its first 15 years in business. Transported patients were never charged, and towns only occasionally kicked in support, usually to help fund the purchase of a new ambulance.

But as community donations fell and payroll grew, the agency had to start seeking support from its member towns. Just like other agencies are experiencing now, local officials called for greater scrutiny of the agency's budget and demanded a bigger say in its operations.

In response, Rescue Inc. gave each town a voting spot on its board of directors — a governance model that continues today. The board meets regularly, reviews policies and approves Hazelton's annual budget. Every three years, it adopts a new assessment for member towns.

It's by no means the cheapest service around: Towns pay between $26 and $30 per person, about average for the state. (Essex Rescue, by comparison, is now seeking an $18 per capita rate from its towns.)

But for just $56,000 a year, less than the cost of a full-time EMS position with benefits, Newfane's 1,600 residents receive around-the-clock service capable of sending multiple units into town.

The agency is stable despite losing Brattleboro, the largest community in its service area, last year. In April, the burg decided to cut ties with Rescue Inc. so that it could launch its own EMS service within its fire department.

Officials initially suggested the takeover would save them money. But to spend less than the $285,000 they paid Rescue Inc., they'd need to cut the service. The officials later said they wanted more local control.

It's been a rough transition: The fire department has experienced a high level of turnover since taking on EMS.

Rescue Inc., meanwhile, has not laid off anyone, even though it is responding to about half the number of calls. In fact, it's looking to add more staff.

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Survival of the Fittest

On a frigid evening in late January, members of the Missisquoi Valley Ambulance Service gathered in a cramped, gasoline-scented ambulance bay to try to save their squad.

They needed to convince the four Northeast Kingdom town representatives before them that their small service was worth the rising costs. Rumors were swirling that the towns wanted to ditch the agency for the regional Newport Ambulance Service, a move that could force Missisquoi to close.

Bill Mapes, chief of the Morristown EMS Department and one of Missiquoi's few remaining volunteers, spent the better part of an hour describing how small, rural agencies get shafted in the nation's antiquated funding system.

To drive home his point, Mapes plopped a cardiac monitor onto a folding table. The machines have a recommended life cycle of just seven years, he said: "The two that we've had here? One was built in 2004, and one was built in 2009."

At his full-time job in Morristown, he continued, ambulances get replaced every five years. "This," he said, pointing to an ambulance behind the seated officials, "is a 2013 truck with 120,000 miles on it. The truck on the other side is a 2009 with 140,000 miles on it."

"This squad isn't looking to purchase a new vehicle," Mapes said, pausing for effect. "It's not about extravagance, my friends."

If the presentation was meant to change the local officials' minds, it had the opposite effect. Newport — a better staffed, more financially stable regional agency — planned to charge the same amount as Missisquoi, "and we're not talking about trying to replace monitors that are 17 years beyond their life," said Dave Sanders, chair of the Jay Selectboard. "We're not talking about trying to replace trucks that are beyond their life.

"We're talking about a system that is up-to-date, up to speed and properly staffed," he said.

A week later, the four towns voted to end their contract with Missisquoi. Barring a last-minute Town Meeting Day reversal, Missisquoi's final day serving the towns will be later this month.

As lawmakers, EMS leaders and local officials prepare for what could easily become a drawn-out debate over regionalization, Missisquoi's fate is a reminder that it's already happening.

After the meeting, Danielle Lemieux walked out of the station, lit a cigarette and started to cry. A few of her colleagues joined her in the cold darkness, trying to make sense of the news.

Lemieux, 30, joined Missisquoi Valley Ambulance in late 2021 and became EMT certified shortly after. Since then, she'd worked a shocking amount of overtime, spending 80 hours on-call some weeks. She personally didn't mind; a lot of that time was spent at home — the station isn't up to code to allow overnight stays — and the extra hours made up for her $15-an-hour salary.

But now, even that had just evaporated before her eyes.

"These people here are my family. We see the worst of the worst, and we try our best to sustain life and get you to somewhere where a long-term option is possible and—" she said, her voice trailing off.

Choking back tears, she finished the sentence: "It will just never be the same."

Clarification, March 2, 2023: This story was updated to reflect how many selectboards wrote to Essex Rescue about accountability.