PHILIPSBURG, Mont. — One day in July, Robert Littlejohn received a page from the county Sheriff’s Office about a disoriented senior citizen. A wildland firefighter for the U.S. Forest Service in Montana and an EMT with the Philipsburg volunteer fire department, Littlejohn waited for Granite County’s private ground ambulance company, Eagle Ambulance Service, to respond.
But Eagle had flown the coop.
Philipsburg is one of many rural areas struggling to sustain an ambulance service amid low call volume, increasing rural hospital closures and fallout from the pandemic.
At least 4.5 million people live more than 25 miles from an ambulance station, according to an analysis by the Maine Rural Health Research Center. Seventy-one communities have lost their ambulance service since January 2021, according to an industry media tracker.
Eagle had given the county notice that it would shut down in a week, citing an unsustainable financial model, but stopped responding to calls around 24 hours later. Littlejohn later saw one of their ambulances for sale on Facebook.
For the past year and a half, Littlejohn had served as a backup to Eagle if a call came while paramedics were responding to another emergency. With help from County Sheriff Scott Dunkerson — also an EMT — and his staff, Littlejohn spent the next few days answering emergency calls around Philipsburg in his truck, stabilizing patients until an officer or an air ambulance arrived.
“Most people are just shocked there’s not an ambulance when they need one,” he said.
Eagle could not be reached for comment.
A number of state and federal initiatives help support rural paramedics. But the hurdles are high, especially after the pandemic, and they don’t all necessarily address situations like Philipsburg.
“The whole payment structure needs to be revamped,” said Yvonne Jonk, deputy director of the Maine Rural Health Research Center. “But at the end of the day, we all need to decide, well, are we interested in subsidizing these low-volume services? And if not, then what else are we going to do?”
The concept of broadening paramedics’ role to include regular house calls has taken root in some areas. In 2019, the Health Resources and Services Administration funded rural “community paramedicine” programs in Ohio and South Carolina, finding they reduced costs, improved data and brought down ER visits.
The Biden administration also recently nixed a Medicare pilot that aimed to loosen requirements that ambulances take patients to an ER in order to be paid. The pilot launched in 2021, when health care workers were overrun with COVID-19 cases.
The pilot paid paramedics for treating people in their home or transporting them to other sites of care when appropriate. But since it required EMS agencies to have access to a non-ER location, like an urgent care clinic, it wasn’t workable in many rural areas like Philipsburg.
The Centers for Medicare and Medicaid Services decided in July to sunset the pilot two years early over low enrollment.
Matt Zavadsky, a director with the National Association of Emergency Medical Technicians, is now working with Congress to make the pilot law but lacks the necessary CMS data to get lawmakers on board. CMS said it plans to publish an evaluation in the future.
“We need a legislative change to make ambulance response — not ambulance transport — the covered benefit,” he said.
Relying on volunteers
Littlejohn now leads Philipsburg’s revived volunteer ambulance crew, which previously fizzled amid burnout from COVID-19 and the arrival of Eagle in June 2021. He relaunched the force by roping in friends and former volunteers and currently counts six paramedics and five drivers, along with one new ambulance and three in need of repairs.
Philipsburg receives only two or three ambulance calls per week. But in the frontier culture, where many prefer life off the grid, the calls are serious. Depending on where an emergency is located, it could take the ambulance 45 minutes or more to reach the patient.
And while most residents have coverage through Missoula-based air ambulance Life Flight, which costs just $75 annually for an entire household, the helicopters can’t fly in bad weather.
The crew’s limitations are evident. A window on the fire engine is shattered, and the water tank runs dry when the meter says it’s half full. The team often risks getting bodily fluids on their street clothes. There’s also a potential gas leak from a pipe in the ambulance bay.
In the immediate days after Eagle’s departure, Littlejohn and the Sheriff’s Office were missing around half of ambulance calls. But now it’s down around 10 percent, according to Dunkerson. He attributed the success to the tenacity of Littlejohn.
“You just couldn’t make him go away,” he said.
The sheriff’s office triggers a townwide siren in the event of an emergency, which sends the crew scrambling for their phones and cars. The team was in perfect position several years ago to respond to an explosion up the street when, according to locals, a resident’s attempt to convert food waste into biofuel went awry during the annual “elk feed” barbecue fundraiser.
But the downside of relying on volunteers is that they’re not always available. Wildland firefighters are often unreachable during fire season, and ranchers have their hands full during calving season. Others aren’t interested in volunteering or eventually burn out.
Granite County Medical Center CEO Brian Huso has been searching for a way to launch an ambulance service to partner with the volunteer crew. A 40-year veteran of hospital administration, he took over in June after federal regulators ousted previous management over abuse in the long-term care facility.
But the medical center is 29 miles away from the hospital in neighboring Anaconda — just 6 miles under the 35-mile threshold needed to qualify for a 1 percent bonus on ambulance payments through Medicare’s Critical Access Hospital designation.
Without critical access status, Huso estimated, an ambulance service could cost around $150,000 annually. The hospital is already $600,000 in the red.
“It’s going to take some kind of change on the federal level,” he said.
The hospital itself qualifies as critical access under the 15-mile threshold for mountainous roads, but that lower limit doesn’t apply to ambulances.
Montana Sen. Jon Tester, a Democrat facing a tough reelection fight next year, intends to introduce legislation around the 15-mile threshold and other rural hospital issues, but a spokesperson did not offer details. Tester’s staff has also been working to connect the county with resources and grants through the Department of Agriculture, the Substance Abuse and Mental Health Services Administration and the National Association of Emergency Medical Technicians.
“Montana is a big state, and access to rural hospitals can be the difference between life and death — which is why it’s critical that our health care systems are fully staffed in every corner of the state,” he said in a statement.
Between two worlds
Once a 19th-century mining town, Philipsburg is now a ranching community with burgeoning appeal to both tourists and vacation-home seekers, along with patrons of an all-inclusive luxury dude ranch.
Philipsburg claimed just 841 residents in the 2020 census. The town’s old-timey feel is one reason that investment banker Jim Manley bought the luxury ranch in 2007, and it now serves as a wedding venue for the likes of Kate Bosworth and Scarlett Johansson.
But the town is now caught between two worlds. Granite County property values increased by 67 percent from 2022 to 2023 — the highest in the state.
“If we weren’t already here, there’s no way we could be here now,” said Matt Smith, a volunteer ambulance driver and owner of a motorcycle restoration business.
The lack of affordable housing also undercuts the hospital’s financial viability. Huso said 60 percent of the hospital’s nurses and 58 percent of certified nursing assistants are temps from staffing agencies, which can cost twice as much as regular employees.
Littlejohn is still renting after moving from upstate New York in 2020, and he regularly sees the travel nurses cycle through his street.
The hospital, like many in towns around America, is one of the largest employers and a critical anchor for the community. Losing the emergency room could mean a longer commute for the ambulance team when someone’s life is on the line.
“The truth is I would have a hard time living here without a hospital,” said shop owner Shannon Drage. “I have young children.”
But community support has waned over the years amid repeat tax assessments to keep the facility running. Residents of neighboring Drummond often head straight to the larger hospital in Missoula, where Granite County Medical Center sends patients in need of intensive care.
The last assessment passed by only 51 votes.
“Every time there is a vote in the county to maintain the hospital, it passes,” said Town Council President Scott Lyons, a hotel manager. “But it’s passing by slimmer and slimmer margins.”
The community has to weigh trade-offs for its rural, remote lifestyle, Sheriff Dunkerson said, but ambulance and hospital care should not be one of them.
He fears the cycle will continue unless the county comes up with a new plan.
“We’re going to have the same discussion in a year or two if we do the same thing,” he said.
This reporting is supported by a fellowship through the Association of Health Care Journalists and funding by the Commonwealth Fund.