• EMS agencies are considering solutions like consolidation to stay afloat, but the patchwork of funding makes financial sustainability challenging.

By Madelyn BeckWyoFile.com

Most businesses in Wyoming would go under if they were operating more than a million dollars in the red — but Star Valley EMS, which bore that deficit last year, is no ordinary business. It saves lives.

The agency also took on some unusual expenses the last few years as it merged with two struggling volunteer EMS outfits nearby, speeding up area response times.

“We saved Alpine and Thayne, and now we’re covering this whole valley,” said director Bud Clark.

Wyoming EMS agencies are increasingly consolidating as a way to try and stay financially viable in rural Wyoming. Sublette County, for example,  consolidated two EMS agencies into one. EMS crews in Campbell County, meanwhile, expanded to cover the towns of Sheridan and Newcastle in neighboring counties.

Gov. Mark Gordon’s office even recommended the Wyoming Legislature earmark $5 million this year for grants so that EMS agencies can hire someone to help them coordinate around the state — but the Joint Appropriations Committee shot that idea down.

“We’re disappointed in [the Legislature’s] lack of long-term planning and foresight and their lack of truly representing the residents of Wyoming,” said Luke Sypherd, president of the Wyoming EMS Association. “I am more than positive — especially after talking with many of them — that [EMS] is a priority for them and their future generations.”

In the second part of our three-part series, WyoFile looks deeper at funding hurdles, what those can mean for communities — delays, inadequate equipment, lost lives — and whether consolidation is a solution. What happens if these larger, consolidated EMS agencies can’t make it work financially?

“That’s exactly where I’m at now,” Star Valley’s Clark said. “How do I make what I’ve got sustainable? What happens if I fail?”

Mixed funding challenges

On average, about 45% of Star Valley’s 911 calls for EMS service aren’t reimbursed, Clark said. He’s increasingly concerned because more people are moving into the area to escape Jackson’s skyrocketing housing costs, but funding to support EMS is still scattered.

Some money comes from the hospital district — a special tax levy — while varying amounts come from six local governments the EMS agency covers.

“There are two of them that are paying actual money for services in their community,” he said. “There are another two that gave equipment, and we [contracted with] for five years. And then there are another two that give no money.”

That story echoes across the state: A combination of hospitals, counties, towns and patients pay for EMS with no uniformity or single point of responsibility.

That reality is further complicated by the diversity of EMS business models. Some EMS agencies are independent, private for-profit companies. Others are operated by non-profit or for-profit hospitals. Others still operate as local government programs, or are a mix of multiple models. There’s not even a federal agency tasked with overseeing EMS — coordination is scattered at that level, too.

For communities that rely on private companies, there is no guarantee they will stick around. American Medical Response, or AMR, is a major private EMS agency in the U.S., but it decided not to bid to stay in Fremont County in 2021 because it was losing too much money.

Even if AMR’s parent company Global Medical Response is profitable on the whole, each branch must be independently sustainable, said Kasandra Moloney, operations chief for AMR Cheyenne.

“[AMR Cheyenne has] our own budget, our own financial responsibilities, and we can’t be sustained off of other AMRs … you kind of have to be able to stand on your own,” she said.

Still, consolidation has helped provide services to areas that would be hard-pressed to fund EMS without them.

In 2009, knowing they didn’t have enough resources on their own, the small, southern Wyoming towns of Encampment, Riverside, Saratoga, Elk Mountain and Medicine Bow agreed to create South Central Wyoming EMS. Hanna joined a few years later.

“So all of eastern Carbon County is serviced by us,” director Stayton Mosbey told WyoFile last year. “We have over 4,500 square miles [where] we are the primary response for 911.”

So far, that source of funding — where each town pays based on its census population — has held, Mosbey said. The EMS service bills patients, but without city payments to supplement that income, the agency would be operating at a $160,000 loss per year, he said.

Mosbey also sees challenges down the road. Volunteerism has slumped in recent years, he said, creating a need for more full-time staff — the agency had 27 volunteers and five paid positions last November. 2022 was the first time in over a decade the agency had to ask the communities to fund the service at a higher level, increasing to $34 per resident.

It doesn’t help, he added, that state Medicaid reimbursements are low and slow.

“We should be paid what it costs to operate and serve that Medicaid patient, and it’s just not there,” he said. “If we got 50% of every bill that we sent out the door, I’d be ecstatic and our burden on the municipalities would be way less.”

As of last November, Mosbey estimates the agency was waiting on about $9,500 owed from Medicaid, alone.

And around that part of the state, EMS is critical, he said. Mosbey’s team revives people who’ve had cardiac events in Saratoga’s hot pools, he said, and responds to numerous crashes along the winding, sometimes treacherous roads. Time lost can be lives lost.

“Had a rollover last winter on [Wyoming Highway] 230 near the Colorado line,” he said. “A family of four had rolled. Dad was critically ill, mom succumbed to her injuries on scene, and two kids — a 9-month-old and a 4-year-old — we were able to get them to definitive care.”

Fire and EMS

Just east of Mosbey’s territory, and across the Snowy Range, lies the community of Centennial where the local first responders —  the Centennial Valley Volunteer Fire Department — no longer transports patients, including those injured at the Snowy Range Ski Area.

“We had a year where we had no EMTs there, and so the state had to take away our ability to transport,” Fire Chief Sean Davis said last year.

While the agency was able to find more volunteers over last summer, it’s hard to find new people in an area that’s increasingly attracting older retirees, Davis said. EMTs there are often based in Laramie, 30 miles away.

The volunteer department already largely relied on Laramie Fire to deliver patients to advanced care after volunteers stabilized them. Davis’ department is also saving on ambulance upkeep costs.

Still, it’s one fewer resource during emergencies — and in other areas that are losing transports, there’s no nearby backup to pick up the slack.

“Across the state, it’s a lot bigger impact” when an agency loses its ability to transfer patients, said Laramie Fire’s EMS Division Chief Michael Hotchkiss, who’s also vice president of the state EMS association.

Paid and volunteer fire departments are increasingly focused on EMS duties because prevention and suppression techniques have reduced structure fire risks. In Laramie, Hotchkiss estimates that about 80-85% of the calls his fire department responds to are medical.

Laramie Fire has even partnered with Laramie’s Ivinson Memorial Hospital since 1979 to transport the hospital’s patients. However, Hotchkiss notes, when a large fire does occur, it requires a lot of resources. If non-fire EMS agencies shutter, that’ll leave fewer professionals to respond to medical emergencies.

“Even though it’s a small percentage [of calls], it’s high risk and manpower intensive to get that [firefighting] work done,” he said. “So indirectly, getting more EMS workforce has helped with the fire workload as well.”

A recently released third-party report examining the relationship between the Laramie hospital and city fire department also found that they’re facing serious challenges, including a need for better coordination, more staffing, increased funding and more planning in general.

“[Ivinson Memorial Hospital] depends entirely on the City to transport patients requiring tertiary care center services,” the report found. “This has resulted in a 10% annual increase in transport volume for the City EMS. This increase in volume has severely impacted the City’s ability to provide 911 emergency services to its residents.”

As several EMS agencies also noted in talking with WyoFile, there are more incentives to operate fire departments than EMS-only agencies, even if the two could work in tandem.

Home insurance prices go down if there’s a nearby fire department with certain capabilities, but similar health insurance incentives aren’t in place for nearby EMS.

Finding funds

A potentially significant, one-time influx of $10 million for EMS came via the American Rescue Plan Act, or ARPA. The Legislature had authorized it to be spent on “regionalization pilot projects.”

Those slated to receive some of that money included Campbell County Memorial Hospital, Castle Rock Health District, Powell Valley Health Care/North Big Horn Hospital, Cody Regional Health, Laramie Fire Department, Fremont County/Frontier Ambulance and Sublette County Health.

However, after sending out “award letters” to these departments letting them know they would get the funding pending a review, only one received its requested funds: Fremont County/Frontier Ambulance.

Gov. Gordon’s office had the final say in whether to grant those funds.

“After extensive review, these projects were denied funding because the Governor’s office determined that they were not eligible under ARPA,” Spokesperson Michael Pearlman said in an email.

In Cody, thinking the funding was on its way, the hospital budgeted to use the grant funds on new positions and ambulances, which have skyrocketed in price in recent years. Now, it’s having to reconfigure the budget and positions.

“What I can say is we’re incredibly disappointed with the Legislature and the state of Wyoming,” Sypherd said on behalf of the Wyoming EMS Association, noting that lawmakers could have ensured some money could make its way to them if ARPA dollars didn’t. Legislators put $1.4 billion aside in savings in 2023, and another $700 million this year, he noted.

Other EMS agencies had similar plans for ambulances and facilities, and also felt let down by the state, giving them hope for this limited funding and letting it fall through the cracks.

In Fremont County, plans for the ARPA money included buying and staffing an ambulance to use exclusively for interfacility transfers to help alleviate the need for as many pricey air ambulance rides. Waiting on the funding, county commissioners had already bought the vehicle because it was needed so badly, gambling that they’d get some ARPA money to recoup costs and staff the rig. It’s a gamble they won.

“We were awarded $1 million to put together a pilot program that would allow us to send non-emergent transports by ground, which would primarily be to Casper,” said Fremont County Commissioner Mike Jones.

Fremont County has struggled for years to keep EMS available in its Vermont-sized region. In 2016, facing ever increasing cost of providing the service itself, the county privatized EMS. It contracted with Guardian — later taken over by AMR — which left in 2021 after losing $1 million the year before.

Now, Frontier Ambulance is serving the area with county-owned equipment, but in 2022, the county was set to subsidize the agency with $1.45 million. More recently, that’s increased to around $1.8 million, Jones said.

“That’s a big hit that’s all on the general fund,” he said, adding that while state revenues from fossil fuels are up for now, busts will happen again.

Financial concerns in areas like Fremont County prompted hard-fought changes at the Legislature in 2023. Sen. Cale Case (R-Lander) sponsored legislation to allow communities to increase property taxes beyond the 12-levy state limit to fund EMS districts.

While there was already a way for residents to create a special district to fund EMS, it required 60% of landowners holding at least 60% of the area’s property value to petition county commissioners. Locals should have the final say, but the process should be streamlined, Case said at the time.

“If the voters want more services, they’d be able to vote for more services,” he told WyoFile.

There were concerns about this type of property-based taxation, though. Rep. Tomi Strock (R-Douglas) said in February 2023 that rural landowners already pay the brunt of such taxes and often have the least access to EMS.

“My dad had got[ten] mauled by a bull and had 11 broken ribs and a punctured lung and pretty beat up, but we took off an end gate, put him in the back of a vehicle and made our way to town,” she told lawmakers on the House floor. “We’re self-sufficient and we take care of ourselves and we’re the ones that get taxed the most, and we don’t even have the use of these, of the ambulances really. By the time they make it, we better have got our loved ones to town.”

Jones shares at least some of Strock’s concerns over fairness. He estimated last year that about a quarter of 911 calls go to the Wind River Indian Reservation, where residents don’t pay property taxes.

Wyoming Department of Health listening sessions in 2022 reflected the same concern.

“It was reported during this listening session that EMS services for the Wind River Indian Reservation are significantly underfunded by the [Indian Health Service],” the department’s report states. “Stakeholders also reported that IHS only funds the two tribes on the Wind River Indian Reservation at 40% of the actual need.”

In a January AARP webinar, Fremont County Commissioner Larry Allen said the county had recently talked with the Eastern Shoshone and Northern Arapaho tribes about EMS funding.

“I just had a meeting last week with the tribes, and they understand the need,” he said at the time. “They’re trying to figure out what they can do to contribute to us. And with that being said, that’ll be a big help.”

There was even a short film called “Winding Path” shown at the Sundance Film Festival that demonstrates the deadly consequences of not having timely EMS around the reservation.

Sales taxes in stores outside the reservation could also establish a way for more people to help fund EMS, Jones said, but finding a way to make funding equitable is difficult.

In towns along major roadways, there are also concerns about asking landowners to pay for EMS when so many calls are for drivers passing through. Visitors contributed about $247 million in tax revenue last year and spent around $4.5 billion on goods and services here, according to the governor’s office.

“I-80 comes through our county,” Eric Quinney of Uinta County Fire and Ambulance said during a committee hearing. “I can have my crews be on the interstate all day long going from wreck to wreck to wreck checking on patients and never have a transport all day long because there’s minor injuries.”

No transfers means they won’t be making money on those calls, passing the expenses along to others.

Other states — like Idaho and Colorado — pull extra funds for EMS from driving-based sources like license plate sales and registration fees. Bob Foster is part of an effort in Idaho to address EMS struggles on that side of the border.

While some have suggested using gas taxes to support EMS in Wyoming, Foster cautioned that it may not be the best way to fund the service into the future.

“[I]n the last task force meeting, there was a discussion about this because, with the onset of electric vehicles, and of course the price of gasoline, the Idaho Transportation Department is struggling with gas tax income,” he said.

Much of the rural West is in an EMS crisis, Foster added, but in some ways, agencies have almost been too good at making things work with fewer and fewer resources.

“We oftentimes hear this, that EMS has shot itself in the foot because historically, our rural units — all of our units— have figured out a way to operate no matter what,” he said. “And our elected officials, both at the local, regional and state level are used to that. So [they’ll say] ‘You’ve always figured it out some way, what’s the problem now?’”

Essential

Kathy Wise has lived in Worland for more than 40 years. Around fifteen years ago, when she was the school district’s technology director, Wise was driving with a colleague to Pine Bluffs. It was around 8:45 a.m. when they were turning by Kirby, she said.

“There was a vehicle full of guys who had come off the oil rig outside of Riverton, and they’d been drinking all the way home,” she said. “They missed their turn … and then they just pulled right out and hit me in the side of my car.”

The passenger door crumpled in, but her Audi A3 didn’t roll, only spun, avoiding what could have been a deadly wreck. The car stopped short of the barrow ditch. Multiple people checked on them, but there wasn’t cell service, so they had to wait until someone with OnStar came over to call for help.

Wise’s colleague suffered multiple broken ribs and spent a few nights in the hospital, she said. Wise had whiplash that destabilized previous neck issues, and she said she had to undergo surgery about 18 months later.

Even with the delays and challenges from that day, Wise said the crash solidified her belief that EMS is essential.

“I think it should be considered an essential service in Wyoming,” she said. “I don’t know why it is not. We have such great distances, and we can’t get rid of any more [services] than what we have.”

Wise knows that many are unhappy with their property taxes in Wyoming and that fossil fuel revenues are declining, but she said residents still need to consider how they’ll pay for these emergency services.

“I believe it’s important enough, I would be willing to pay additional taxes for it,” she said. “I’m not sure how many other people would.”