When health researcher Yvonne Jonk lived in North Dakota, she got a piece of information from the state’s emergency medical service director that shaped her work for years to come.
Then director Tom Nehring told her there were parts of the state where it was more dangerous to have an accident because there wasn’t an ambulance service nearby to respond quickly.
“He was talking about how those ambulance services are in crisis,” Jonk said in an interview with the Daily Yonder.
That remark led Jonk to study the geography of ambulance services in North Dakota. Subsequently, Jonk and others turned that project into a first-of-its-kind national study, which was released earlier this year by the Maine Rural Health Research Center. Jonk is deputy director of the center and an associate research professor at the University of Southern Maine.
The project was not as straightforward as it might seem.
“It took two years for us to try to obtain all the data from each of the states because we had to actually call each of the states’ offices and try to get this data,” Jonk said.
The study found a major disparity between rural and urban residents’ proximity to ambulance stations.
Jonk and her colleagues estimated that while less than 1% of urban residents live in an ambulance desert (defined as being more than 25 minutes’ drive from an ambulance station) about 5% of rural Americans live in one.
Nationally, about 4.5 million residents live more than 25 minutes from an ambulance station. About 2.3 million of those are rural; 2.2 million are urban.
Another way of understanding the rural disparity is that while about 14% of Americans live in a rural area, they make up more than half of the population that lives in an ambulance desert. Urban Americans constitute about 86% of the U.S. population but make up less than half of the population that lives in an ambulance desert.
Researchers found the highest number of people living in ambulance deserts in the southern Appalachian region, in Western states with mountainous terrain, and in the rural mountains of Maine, Vermont, Oregon, and Washington.
Eight states, all of them west of the Mississippi, had fewer than three ambulances covering every 1,000 square miles of land area. The states are Idaho, Montana, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming.
The study discovered that states in the South (Texas, North Carolina, Alabama, Kentucky, Arkansas, and Tennessee), the Midwest (Missouri), and the West (Montana) had the highest number of rural people living in ambulance deserts, while people in Rhode Island, Connecticut, Delaware, and Massachusetts had the fewest.
Part of the research effort was finding physical addresses for ambulance stations, rather than using post-office-box addresses.
“Some of the states could not give us (the physical location of the ambulances),” she said. “They don’t know where their ambulances are actually sitting. If they could not tell us the exact location, we couldn’t use their data.”
In nine states (Alaska, California, Colorado, Hawaii, Kansas, New Jersey, New Mexico, Pennsylvania, and West Virginia), information either wasn’t available or was so limited it wasn’t included in the report.
Once researchers had ambulances’ locations, they were able to compare that to population data from the U.S. Census Bureau and identify areas that were farther than 25 miles from an ambulance.
“It’s astounding to me the depth and breadth of this problem,” she said. “I knew it was a problem in North Dakota. I wasn’t sure how pervasive it was in the rest of the U.S. This just affirmed that we need to do something.”
The cause of ambulance deserts, she said, boils down to money. Medicare, Medicaid and commercial insurance reimburse ambulance service, but only if a patient is transported. The study found that reimbursement is often not sufficient to cover the operating costs of the service, particularly in rural areas where low call volume and longer drives combine to create higher fixed operating costs.
“Ambulance services are not a lucrative business,” she said. “The only time that ambulance service really makes any money is if they bring someone to the hospital… Hospitals and health care systems are not going after ambulance services because they are not a lucrative service line. And that’s a problem.”
That leaves most ambulance services being run by volunteers and funded through community goodwill. In many cases, operating costs are raised by scraping money together through levies or fish fries, she said.
For communities converting a health care facility into a rural emergency hospital, lacking a way to transport patients to the hospital or to other facilities could jeopardize their healthcare status, she said.
“The key component of the success of that rural emergency hospital model is ambulance services,” she said.
Because rural emergency hospitals cannot keep patients longer than 24 hours, the patients have to be transferred to another facility. Without ambulance services, that’s not possible. Of the five hospitals that have converted to emergency hospitals, two of them have ambulance services and the rest do not, she said.
Now that the scope of ambulance deserts has been identified, she said, the next steps will be to determine what kind of an impact ambulance deserts have on rural communities, how many of those ambulances have paramedics on them, and what can be done to fund ambulance services better.
“We need to figure out funding mechanisms for these ambulance services so that they continue to be a viable service within these rural communities,” she said. “Our next concern is what percentage of these ambulances actually have a paramedic on board because they should have a paramedic on board. I’m quite sure that when we open up that Pandora’s box, it’s not gonna be pretty.”