A NorthStar EMS ambulance in Tuscaloosa. (Photo by Caleb Aguayo)
By Caleb Aguayo
Stretched thin.
TUSCALOOSA, Alabama. - Between decadent, ancient churches and mansions with paint peeling off the walls, right across the street from the county hospital in Eutaw, Alabama, sits a small grey house with a blood-red door. Inside, atop hardwood floors with sparse furniture, a team of 20 technicians provides ambulance service to the entire rural area of Greene County from just one station, according to county EMS director Chris Jones.
"It's like a big wad of Christmas lights," Jones said, adding, "Imagine having to undo that, but they’re covered in crap. That's what it feels like sometimes."
With four reliable ambulances, three crews of emergency medical technicians (EMTs), and a boat, the agency manages Greene County's emergency calls more effectively than ever, according to Jones and a third-year chairman of the county's emergency medical services (EMS) board, Joe Powell. He said response times and the service’s availability to handle multiple calls at one time have only increased in recent years under Jones’ management. However, both said that they are unable to keep up with costs for the service, which far outweigh any sort of profit.
"It's like a $20,000 per month shortfall," Jones said, though he said he was unable to provide a total budget for the service.
"We don't know how long we're going to be able to sustain the service," Powell said, noting that a lack of consistent funding for EMS services would eventually lead to a total loss of ambulance services for the county.
Downtown Eutaw, Alabama (left) and the Greene County EMS station (right). (Photos by Caleb Aguayo)
EMS services in West Alabama and nationwide are operating at a revenue deficit and have been for years, affecting rural counties the most. The journal EMS-1, using polls from the National Association of Emergency Medical Technicians, said this year that national average EMS costs due to EMT wages grew by about 11%, and equipment and supplies by about 12%, between 2019 and 2022. However, revenues per transport increased by only about 5% in the same time period.
And according to News 5 Cleveland in 2022, EMS chiefs in Ohio warned that the industry was on the verge of collapse at that time, citing issues in underfunding for basic services and increasing costs for maintenance, equipment, staff, and supplies. As early as 2019, NBC News noted the imminent collapse of some EMS services in rural North Dakota due to underfunding and staffing concerns.
In Alabama, according to a KFF Health News article, NorthStar’s EMS in Pickens County suffered substantial loss in funding since the closing of the county hospital. And Jones, who regularly works with Pickens County’s NorthStar EMS director, Vicky McCrory, said the agency there has struggled to keep its head above the water.
McCrory said, "We are funded by insurance, and that's it… Blue Cross, Medicare, Medicaid." With seven full-time employees and three working part-time, McCrory said the agency is unable to pay them competitive wages. A single call puts a crew out of service for up to three hours due to travel, but she said Pickens County EMTs are "just trying to hang in here and do the best we can with what we've got."
"We're losing about $250,000 a year," McCrory said. "We've always been able to maintain ourselves until the last couple of years." She added that the closure of Pickens County's hospital in 2020 directly contributed to funding shortfalls, as well as increased travel times, for the agency's transports. She said on a busy day, people can wait up to four hours for one of two ambulances to arrive.
And in Tuscaloosa, NorthStar EMS (NEMS) director Edgar Calloway said payroll costs between 2020 and 2023 have gone up by almost 40%, while reimbursement for basic services increased by only 10%. He emphasized that underfunding for basic transport amid mounting costs for the service is a national and statewide issue.
"It's not just a problem in the rural areas. It’s a problem nationwide, in urban and rural counties, with governmental agencies, quasi-governmental entities that run through the municipality, whatever. It is a problem everywhere," Calloway said.
Jones said, "The only rural service that I know of in Alabama that doesn’t have that problem is Choctaw EMS in Choctaw County, because they have a very large millage that they get from property taxes per year." He added that millage taxes, or taxes from county properties, were set by the county commissioners in the 1980s. Jones said they figure into only about $60,000 of annual revenue for Greene County EMS, noting that they sometimes spend more in one month's payroll.
With the Greene County EMS receiving just under 200 calls per month, Jones said its EMS agency handles "just a drop in the bucket" compared to more populated areas like Tuscaloosa's 80 calls a day. For rural areas like Greene County, he said this means less business and a greater risk of losing the EMS agency.
The Greene County EMS fleet: four ambulances and a boat. (Photos by Caleb Aguayo)
A national and local dilemma.
In the United States, the median national income is almost $75,000, according to the U.S. Census Bureau in 2022. However, the U.S. Bureau of Labor Statistics reported in the same year that EMTs, on a national average, only make about $40,000 per year. Even with an EMT salary below the median income, EMS agencies are becoming increasingly unable to pay them.
The National Rural Health Association (NRHA) noted in a 2018 briefing that an EMS agency's maintenance leads to "sunk costs," or investments that cannot be recovered, but fewer phone calls to agencies in rural counties gives them an inconsistent stream of revenue. Because of these lower volumes of calls and large upkeep costs, rural EMS agencies pay more per transport than their urban counterparts.
In addition, because of longer distances between scattered residents in a rural county, the Rural Health Information Hub (RHIhub) said that rural agencies have a higher cost per trip. Because of the costs associated with operating an EMS agency, the RHIhub noted that an increasing number of rural agencies are beginning partnerships with other organizations, in addition to traditional funding sources, to assist with upkeep and payroll costs.
The NRHA report said that around 83% of the rural EMS agencies in the study reported multiple funding sources, such as fundraising events or partnerships between private companies and municipal leaders. Among the total of the rural agencies polled, the study said that around 75% of them are funded by counties or local municipalities. Around 60% of the rural agencies reported hosting community fundraising events to pay for their operations. In addition, the majority of the rural agencies within the study said they were unsure about the financial possibility of operating in the future.
Greene County is a completely rural county, according to the U.S. Census Bureau in 2010. The bureau’s 2021 data said the county's median household income is well below average, at around $29,000, compared to Alabama’s median income of almost $60,000. Additionally, the bureau reported that around 35% of the county population is currently employed, compared to the state’s employment rate of 56%.
The U.S. Census Bureau also reported, in the same data, that around 40% of the county population is considered impoverished. With Alabama’s poverty rate of just over 16% and the U.S.’s rate of almost 12%, a large portion of Greene County’s residents are unable to pay for health insurance.
The bureau reported that just over 8% of the U.S. population is not covered by health insurance, and Alabama sits at around 9%, but nearly one in five Greene County residents does not have any coverage. And according to Jones, when patients do not have health insurance, the EMS agency goes un paid for taking them to a hospital.
With high operating costs and little comparative pay, as well as the risk of not being paid at all, Greene County EMTs service nearly 8,000 residents across 640 square miles, or over half of the area of Rhode Island, according to the Ocean State's historical webpage.
Staying afloat
In Greene County, the EMS agency's founder retired in 2019. And after several interim directors came and left again, the problems culminated in May 2022 with the resignation of the last interim EMS director, Zac Bolding.
In a letter to Alabama State EMS director Jamie Gray, published by the Greene County Independent on Facebook, Bolding scheduled a suspension of county EMS services amid his departure due to a lack of funding.
"The impact of having no dedicated EMS response agency for such a large area will have a definite impact on patients experiencing even some of the least complex of medical emergencies," Bolding wrote in his resignation letter suspending the services. And according to AL.com, false claims then began circulating that Greene County was losing its EMS agency.
But Jones, who was an EMT under Bolding at the time of his departure, said he was asked by the EMS Board in Greene County to keep the services functioning.
"That started the uphill battle of turning this place around," Jones said. "When I took over, following [Bolding's] exit, a lot of our employees left. So, I had maybe six employees, including myself, to cover ambulance shifts."
Part of that uphill battle, Jones said, was the logistics. Until he could hire more people, he said he covered 80- to 90-hour shifts. He added that the agency originally had one "good" ambulance, a 1995 model "well in its age," and one that was "broken down more than it was on the road."
Jones said that local organizations like the Sheriff's Office, private donors, and towns in the county came to help, donating the money for new ambulances, an all-terrain mini-truck, and a boat for river rescue. To keep up with payroll and maintenance costs, he said he has started scheduling transports within nearby counties to make additional cash.
"Some people might give donations," Powell said, adding that Jones has arranged paid partnerships with local schools and colleges for providing standby EMS at sports games and rodeos.
Jones said, "We don't make money off 911 calls, as sad as it is. The reality is that 911 calls are a necessary evil. They're not what makes money, but it's what you’ve got to do, also, in order to function in some places. But dialysis, doctor's appointments, inter-facility transports, those are how ambulance services make their money." But according to Powell, all those side jobs are still not enough to offset costs.
Powell said, "We are hanging on with the stuff we've got, but we have bills to pay like insurance and workman's comp. And it's a hit because we don't get that much from transporting."
According to Jones, most insurance companies cover only about 30% to 40% of the cost it takes to transport a patient to a healthcare facility, but he added that most patients they transport do not have any insurance. He said payroll, gasoline, and vehicle maintenance also figure into growing costs for the Greene County service.
Eutaw mayor Latasha Johnson, another EMS Board member, said, "We have been having a little problem with financial difficulties, but we are trying to work out a plan to keep it flowing steady."
Jones said, "If we can get a monthly subsidy, it would be a game changer for this service. My dream is to get this service to where we're self-sufficient and don't have to rely on funds from anywhere else." And Powell agreed with Jones on the need for subsidy funding, but he also stressed the need for a cut of the funds from local gaming.
According to ABC 33/40, local charity bingo propped up Greene County’s economy in recent years. The former GreeneTrack bingo hall was the largest employer in the county until its closure amid a pending gambling lawsuit, according to the Greene County Democrat. ABC 33/40 also noted the subsequent opening of Greene County Entertainment, a location for racetrack betting.
Jones and Powell said that Greene County Sheriff Jonathan "Joe" Benison collects revenue from the charity gaming halls. And though they said he regularly disperses the funds and subsidizes different organizations like the Greene County Health Systems and the fire department, Benison only occasionally gives donations to the EMS without providing consistent funding. Both Jones and Powell said they have wanted the sheriff to let the EMS in on the money for some time.
And, although none of them say they know why, Jones, Powell, and Johnson said no one in the county has received bingo funds for months.
Benison, the sheriff, did not respond to repeated requests for comment.
A donation from the Sheriff's Office (left) and signs supporting local charity bingo in front of the county jail (right). (Photos by Caleb Aguayo)
"We can’t point fingers," Johnson said, "because we don’t have a set of bylaws for who’s responsible for it. But we do know that it belongs to Greene County as a whole. As a mayor, I feel like we’re all responsible for the EMS."
NEMS director Edgar Calloway said, "Adversity makes you better at what you do. As you make a situation difficult, you begin to learn new things in efficiency. Better ways to staff, better ways to deploy." His EMS agency in urban Tuscaloosa has begun to find alternative funding opportunities.
"You find a better way to build the mousetrap, which is kind of where we are now," Calloway said.
Neighboring perspectives
According to Dr. Marcia Pugh, the CEO for Greene County Health Systems (GCHS), the Greene County Hospital (GCH) in Eutaw is struggling to keep up with costs, as well. Although she said the county health system and the EMS work as a team to provide emergency medical response, the lack of funding creates obstacles for providing service.
"GCH, like other Alabama hospitals, has its financial woes," she said. She added that the health system, which includes the hospital, a nursing home, and a clinic, employs around 140 people in total. But like Jones, who noted that insurance companies pay only a portion of the bill, Pugh said the gap between various costs and reimbursement also affects the hospital's bottom line.
"The shortfalls not paid by Medicare, Medicaid and insurance carriers make it difficult to operate," she said. Pugh did not disclose statistics about the hospital’s current funding, but she did speak about issues in Greene County’s EMS.
"Presently, there is no county or city funding, with few municipalities providing funding assistance," Pugh said of the EMS agency. A member of the Greene County EMS Board, she said she regularly works with Jones to come up with solutions to their organizations' funding concerns.
Because of the hospital's funding concerns and inability to transport its own patients, she said losing the county EMS would be "devastating" to its residents. Pugh added that the nearest EMS agency is a 30-minute drive away from Eutaw, and other areas of Greene County are even further.
"Patients arriving in privately-owned vehicles and other ambulance services would be in more distress and require the staff and physicians to treat a much sicker patient," she said.
According to Pugh, the Greene County EMS is the only ambulance agency which services the hospital over the ground, though she said the hospital also contracts a helicopter ambulance service.
The Greene County Health Systems (left) and its helipad for air transports (right). (Photos by Caleb Aguayo)
In March of 2020, funding shortfalls led to the closure of the Pickens County Medical Center. And according to McCrory, a local doctor, and former workers for the hospital, the change affected daily life. The Pickens County EMS agency now also relies on helicopter transports, when available.
McCrory said, "Depending on where you are in Pickens County, you could be anywhere from 32 to 50 miles from a hospital." The nearest hospitals to Pickens County are Druid City Hospital (DCH) in Tuscaloosa, Alabama, and Baptist Memorial Hospital (BMH) in Columbus, Mississippi. She also noted the lack of a county hospital’s impact on its residents.
"They've been dying without the hospital," McCrory said. She added, "It's like we're stuck out here on an island, and nobody cares. People are suffering and dying every day, and it doesn't much matter how you beg or plead. We're still where we were a year ago when we started asking for help."
Dr. Julia Boothe, a local family practice doctor working at a private clinic called Pickens County Primary Care, said people call or come in "all the time" for spontaneous healthcare visits requiring a hospital.
In late November, Boothe said a patient came into the clinic who had a cardiac change in the hours prior to the visit. When Boothe called the ground EMS and the helicopter transport lines, everyone was busy and unable to respond to a call for several hours. She decided to drive the patient to the hospital in her personal car, calling the cardiologist there and relaying the information on the way. But Boothe said when EMS is available, the clinic does its best to stabilize patients until an ambulance arrives.
She added, "Some days it's an urgent care. Some days it’s a zoo." Boothe said over the years, her practice has added new techniques and equipment to provide for local patients, like laceration repairs, treating bone fractures, and short-term intravenous (IV) fluids.
"It probably makes no sense to my bottom line," Boothe said. She added, "But you're going to take care of the patients that are in front of you."
Boothe also referred to healthcare professionals who stay in rural counties to work. She said, "These are the patients that they grew up with. These are their family members." She mentioned that others stay because of a special calling they feel to help. But, according to her and former hospital workers in Pickens County, staying behind was difficult.
According to Cecelia Miller, a businesswoman in Carrollton, Alabama, and former outpatient clerk for the Pickens County Medical Center (PCMC), the Tuscaloosa News alerted the hospital staff of its closure just five days beforehand. Having worked there for 23 years, Miller said the hospital's loss was "like somebody died." She added, "I miss it dearly. We are in need of it because there's nowhere in Pickens County to go."
Miller said between 250 and 270 were laid off when the hospital closed, losing any compensation for saved-up sick days or vacation days. And according to Miller, many of those who were laid off were older, unable to find employment after the closure. "I am a healthcare worker. I enjoy working with elderly, sick people. So passionate. But what do you do?"
"We are in need of an emergency room," Miller said. She mentioned that the most critical need is a place to stabilize patients before they can make it to a hospital for full treatment.
Miller said, "I think that the commissioners, the governor, everybody needs to do their part, look into it, and make sure it happens. It could be some of their relatives that need that attention."
Kristen Sanders, a former secretary for PCMC's medical-surgical unit, needed an ambulance on 8 November. Sanders' family found her unconscious, and her son performed CPR on her. The family waited for 45 minutes until an ambulance could arrive. The drive to Baptist Memorial Hospital in Columbus, Mississippi, was another 45 minutes. While the ambulance's EMTs stabilized her on the way, she found out the cause of the event was two blood clots in her lung.
"[The hospital is] needed… not just with elderly people, but with sick people. And my own experience speaks for itself… Even if it was one of my kids or my friends, it's just scary to not have a hospital close," Sanders said. She added, "I’m just thankful that I had help. We need to get a petition going around or something."
In the same room, Miller said, "We did it before, remember?"
Sanders responded, "Yeah, we did! But they just shut that down," referring to the Pickens County commissioners. Both said citizens have made several attempts to get the hospital back in recent years.
Dr. Boothe said the healthcare situation in Pickens County, which she described as "like a third-world country," resulted from a combination of factors. In addition to the local EMS agency's lack of funding and manpower, long travel distances within the county cause higher response times. Furthermore, the closure of the hospital meant that patients must be transported out of the county for any medical care, which Boothe said doubled response times from before its closure.
She added that the problems are not unique to Pickens County, affecting all the counties around Greene and Pickens, as well. Boothe said funding and staffing shortfalls impact the entirety of West Alabama's healthcare systems.
"We've got to have some directional help, nationally and statewide," Boothe said. "We can't keep saying that this is okay. There's a quality and a level of care that everybody should have access to, and that's what's getting lost in this."
The hospital sits vacant, with the lights still on and the furniture decaying. (Photos by Caleb Aguayo)
Getting off life support
In 2022, as part of a study, the Journal of Emergency Medical Services outlined points which could potentially help EMS agencies amid a funding shortfall. One of those included that counties could combine EMS services into a more serviceable geographic area.
Jones said Greene County's EMS has recently begun to work with other bordering counties that need help, like Pickens, Marengo, and Sumter counties. He said he has been speaking with the local towns, the sheriff, and the Greene County commissioners to get a larger budget, though he did not disclose the total amount needed.
"Two of the towns have been paying into us. But it equals up to about $3,000 a month, which is great. I'm very thankful for that. But compared to what we actually need, it's a very small portion of that whole picture," Jones said.
Garria Spencer, a Greene County commissioner for District 1, said the county commission paid for a new ambulance and EMS funding for three months, which amounted to $18,000. Spencer said after the EMS received the ambulance and funding, Jones asked for an ad valorem tax, or a county tax meant specifically for the ambulance service.
"If they want a tax, then they have to do the legwork," Spencer said. He added that the EMS agency should make the community more aware of funding issues before it asks people to pay more taxes. He said, "I just think it's incumbent upon them to present a plan and show these folks what they're going to do with the money." Spencer mentioned that securing an ad valorem tax for the agency would require unanimous approval from the county's five district commissioners and a passed bill in the Alabama state legislature.
"I think it has to exist, but at a smaller scale than what it's operating at now," Spencer said of the EMS agency. He added that he thinks it is "top heavy," with too many employees for its scarce funding.
Powell said, "[Jones is] out there working, daily, trying to secure funding. I have to give him that: he’s a very dedicated worker."
Johnson said, "We're all still in discussions because we need our EMS. We know it's a great need, so we are communicating more about ways that we can keep it open."
For NorthStar EMS in Pickens County, McCrory said, "We just don’t have the staff. We don't have the call volume to support [ourselves]… and it all comes down to funding." She said the Tuscaloosa-based company paid for the agency's second ambulance, but the staff and funding shortages mean that it operates only five days per week.
McCrory added that the theoretical re-opening of a hospital in Pickens County would solve the EMS agency's funding and staffing concerns. Until then, she said, those that keep working there do so out of "dedication to the community."
In Greene County, Jones said he hopes for future talks with the county commissioners and Benison, the sheriff.
Jones said, "I think they [the Sheriff's Office] are fixing to restart their [bingo charity] fund distribution. And they asked for some financial reports that I've given them. So, I'm hopeful that this is going to finally turn out to be a fruitful endeavor so we can start getting that kind of revenue."
"But we need something that’s long lasting, something that’s permanent."
(Photo by Caleb Aguayo) The Greene County EMS.
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