The push to make Emergency Medical Services 'essential' in Idaho, and why it matters
Last month on the second floor statehouse rotunda, about two dozen uniformed EMS personnel and leadership gathered among displays, handouts and $45 thousand dollar stretchers, all meant to grab the attention of lawmakers. Ada County’s Chief Paramedic, Shawn Rayne, was there.
“Issues from funding to recruitment and retention of personnel, education requirements. Volunteerism is down; [We have] a lot of different issues,” he explained.
Many attendees at this ‘EMS Day’ are also members of a task force formed in the wake of a 2021 report from the state Office of Performance Evaluation, which cited the issues Rayne mentioned.
A big one: EMS is not considered an ‘essential’ service in Idaho, which means the 44 entities - one in each county - don’t receive state funding. They also aren’t required to respond to every call for help.
In the state’s most populous county, EMS last year responded to more than 36,000 calls, about a 14% increase from 2020.
Rayne said the Treasure Valley’s growth - new homes and businesses where miles of farmland existed before - has created a conundrum.
“The way that we're funded is I can either pay people more or I can add more resources, but I can't do both at the same time,” he said. This conundrum can stretch response times, which Rayne said are still on target in most areas: under 8:59, 90% of the time. In some areas of the county, response times are under nine minutes only 80% of the time.
Hiring enough staff was already an issue; the stress of the pandemic caused many to leave their paramedic careers. Other staff leave because local fire departments or services like LifeFlight can pay considerably more. Paramedic Dawn Rae has been with Ada County for nearly two decades, lately enduring more overtime demands and schedule changes.
“Technically, I worked Friday, Sunday and then had Monday through Thursday off,” she explained. “But more often than not, I was coming in and working another 24-hour shift or even more than one 24-hour shift during my days off.”
Adding to the staffing challenges are on-the-job injuries and illness, which Rayne said have been on the rise. That includes mental health, which is often affected by the situations paramedics encounter in the field.
To balance out the scheduling, Rayne shifted demands to add a third 24-hour shift in five days before getting four straight days off. Periods of mandatory overtime are also used to fill out staffing.
That’s a hard fit for people with families, Rae said, noting the change forced some of her colleagues to leave or consider leaving the department.
“It's the addition of that third day that, you know, it's a strain on people,” Rayne said, some frustration evident in his voice. “After a pandemic where we've asked these folks to work harder than they've ever had to work in their career and then to come back to them and say, you know, this is the solution?”
It’s a stop-gap solution, he said. Hiring has gone well, with 17 recent or current vacancies likely to all be filled - though some paramedic positions will be staffed by emergency medical technicians. Rayne noted those EMTs are likely to continue their education and become paramedics down the road.
In rural areas, the problems are similar - funding, staffing, scheduling - but different because the majority of rural emergency responders are volunteers.
“We cover more than 1,700 square miles,” explained Clark County EMS Director Jill Egan.
If you’ve driven up Interstate 15 over Monida Pass or camped in that area, you’re in her territory. Many of the calls for help come from non-residents and can require hours-long drives.
“We were 47 or 48 calls in 2017. And this last year we're double about what we were over the last five years,” she said.
Recently, Clark County added a second ambulance, but the volunteer staff of about two dozen reliable responders has shrunk by about half to 14.
“A lot of volunteers are, you know, 70 as an average age of volunteers. So there's just not a lot of people raising their hand to fill those spots,” Egan said.
The 2021 OPE report identified seven out of every ten EMS responders in rural Idaho are volunteers. Statewide, the ratio is four out of ten.
“If someone has a heart attack in the middle of the woods, EMS is not required to go,” explained Senate Majority Caucus Chair Mark Harris (R-Soda Springs).
“If it's out of the range of the EMS personnel, they're not required to go and assist.”
“But they do?” I asked the senator.
“But they do,” he replied. “And that's the beauty of the system that we have.”
But in many rural places, the system is in danger of breaking down. Harris this week introduced a concurrent resolution to declare EMS as essential in Idaho, and direct a task force of EMS leadership to come up with legislative solutions to some of the problems the service is facing.
“It's very hard to pay for a $200,000-$250,000 ambulance with bake sale funds,” he said. “So that's what we're trying to do is figure out a way to declare it or get it declared - the EMS service - an essential service. Therefore, the state can come in and supplement.
But it’s a purposefully slow process. State Health and Welfare EMS director Wayne Denny said they don’t want to spook lawmakers by asking for too much too fast, or deliver proposals lacking polish.
Harris says respecting the commitment of rural EMS volunteers who might balk at more oversight or paid responsibilities is also important because a change resulting in staff walking away wouldn’t help the problem.
Clark County’s Egan echoed those concerns, but also says she’s near a tipping point.
“I have EMRs who are a year into it and saying they're tired because they have run so much. I really don't know what the answer is, and that's really why we are here with the task force,” she said.
Back in Ada County, Chief Paramedic Shawn Rayne pointed out tax revenue is only 28% of the Ada County Paramedics budget, and fees charged for service calls have to cover the rest.
The OPE report showed each response in the county for a Medicare or Medicaid patient incurred a more than $500 loss. Many patients can’t afford the service fees EMS bills out after a call, and reimbursement rates often don’t cover the full cost of response. More than a quarter of EMS directors in the state reported in 2020 their budgets were insufficient to cover costs.
Property tax levies are a common way to fund county EMS programs. In Ada County, lawmakers capped the amount EMS can increase its budget in the mid-1990s, limiting the agency to a maximum of three percent growth annually. The levy amount changes each year as home values and the county EMS budget changes, but those increases haven't been able to keep up with the area's population growth.
“The true cost of EMS is not for that response when they come to your house,“ Rayne said. “It's the fact that the ambulance that came there has been on duty 24-7, 365 for the last, you know, ten years.”
The Senate Health and Welfare committee voted to print the resolution and Harris expects it should receive a hearing next week. House Majority Caucus Chair Megan Blanksma (R-Hammett) is expected to sponsor the version in that legislative body.
If the resolution passes, legislation to support local EMS operations wouldn’t likely be presented until next year.