County Commissioner Rick Bailey knows right away when one of his Johnson County constituents has suffered a health problem. That’s usually when the calls and texts come in from residents wanting to know more about ambulance service for those who live outside the Cleburne or Burleson city limits.

“I get complaints if there’s been an accident or a heart attack, saying, ‘Hey, why did it take so long?'” Bailey said.

His county, about 15 miles south of Fort Worth, is in the in the midst of an unprecedented boom. More retirees in Dallas and Fort Worth are either cashing in on their homes and moving out, or younger, working adults, unbothered by a longer commute, are opting for a more affordable lifestyle, choosing from the hundreds of new homes being built there.

In the past three years, Johnson County has added 25,000 more people, and by 2030, another 60,000 are expected to relocate here, Bailey said. Right now, the county, which at 734 square miles is slightly larger than the size of Houston, has proposed 17 municipal utility districtsthe first signal from developers that they want to raise funds to pay for new infrastructure to build new homes.

With freeway expansions and roads at capacity, counties like Johnson will see an increase in traffic accidents that will require a more immediate medical response than smaller cities with their combined fire and EMS services can provide.

In 2023, more than 152,000 accidents it happened in the rural areas of the state.

“We’ve exploded with growth and with so many vehicles on the road, the roads weren’t designed for that much traffic or that much delay,” Bailey said. “It’s only going to grow.”

Adding to the need for more ambulances, Johnson County has a lack of health care options. The county has only one hospital — Texas Health Harris Methodist Hospital Cleburne — within its boundaries that can admit patients overnight, Bailey said. This summer, t The hospital also closed its maternity warddue to the drop in deliveries there. Now, residents here can expect, when a medical emergency happens, to be transported to hospitals in neighboring Tarrant and Dallas counties, which can take anywhere from 40 minutes to an hour, depending on the type of care needed . In these situations, county officials know they must have multiple ambulances available in case one is in use transporting a patient miles away.

“We got a call for a woman who was in her second trimester,” Bailey recalled. “She said, ‘What are we going to do? I depended on the hospital here.”

To help bolster ambulance service outside the fire departments of Johnson County’s largest cities, commissioners this year approved a $1.5 million contract with Grand Prairie-based CareFlite that adds five ambulances with full-time and one more part-time to cover unincorporated areas. To save money, the county paid the contract in full, in advance. That’s a lot for a county that has a total general fund budget of about $102 million, Bailey said.

In 2019, Gov. Greg Abbott signed into law a measure that puts a ceiling for property tax increases. Cities and counties cannot raise property taxes beyond the 3.5 percent cap without bringing the issue to local voters. Bailey said the need for better EMS service, something counties are not required to provide, makes working under that cap difficult, especially as rural hospitals close or reduce beds due to health care workforce shortages.

“As the population grows, so will the need for more ambulances,” he said.

EMS is urgently needed at the state level

County complaints about how to pay for emergency medical services are not new, says Rick Thompson, program director for the Texas Association of Judges and Commissioners. As demand for EMS service increases, the old model of volunteer firefighters for smaller towns concentrated in one or two areas of an expanded county forces counties to explore hiring paid county personnel and purchasing ambulances or contracting with private ambulance companies.

“It’s a huge problem,” Thompson said. “I’ve been working with counties for 25 years, and as I’ve traveled the state, it’s always been a problem.”

But it has become a more pressing one as rising home prices have pushed more people into metro-adjacent counties, where homes are more affordable, and as the number of older residents with more medical and emergency needs grows. The coronavirus pandemic has made workers more mobile and less location dependent, able to work anywhere there is internet access.

This summer, a survey was sent to 236 of the state’s 254 counties about their EMS services. Of the 81 counties that completed the survey, about 48 percent reported having open EMS positions, and about half indicated they had no volunteer staff, Thompson said. Also, approximately 55% reported EMS round-trip times of one hour, 38% reported two-hour round trips, and 26% reported three-hour round trips. The nearest trauma center for the counties ranged from less than 5 miles to 200 miles away.

And even if the counties are not required to provide ambulance services, they do so in order not to die completely and become ghost counties.

Last month, Grayson County District Attorney ask the question right before the state attorney general’s office after EMS contractors notified the county that they would not provide ambulance service to planned housing developments being built in unincorporated areas.

Does the county have a legal obligation to provide fire and ambulance services to residents who live in unincorporated areas?

“There is a problem on the horizon where Grayson County residents living in higher density subdivisions will not have emergency services,” the attorney general said in Grayson County’s application.

Calls for comment from Grayson County officials were not immediately returned.

About 40 minutes northwest of Lubbock, Lamb County Judge James “Mike” DeLoach can remember how rural ambulance service was a “load-and-go” type of operation, where residents sat in the beds of pickup trucks and drove dozens miles to the nearest. hospital.

Today, DeLoach, a paramedic for the past 38 years, says the job is more sophisticated, with competition for trained emergency personnel reaching a critical juncture. While his county is not experiencing the growth that Johnson County is experiencing, Lubbock’s growth has resulted in more medical personnel working there, where wages are higher. And the need for emergency medical transport increases as its residents age.

“We don’t necessarily see the influx of people,” DeLoach said. “But we’re seeing an aging population that needs EMS more.”

Texas is getting old fast. According to Texas Health and Human Services, the state has the third largest population of people aged 50 and over. That population is expected to grow 82 percent to 16.4 million by 2050, and many of the 50-plus demographic are choosing to live where it’s more affordable: in rural and metro-adjacent counties.

Among the seniors are the volunteers who now fill EMS positions at small-town fire departments. Current volunteers are retiring and finding replacements it gets tougher and tougher as the rising cost of living discourages people from working for free. Counties that pay EMTs or paramedics often lose them after a few years to larger counties that can pay them more.

DeLoach said it’s hard to recruit EMTs and paramedics in his county when they can work in Lubbock and make $57,000.

Then there is the overall operational cost associated with a private ambulance service forced to travel long distances to hospitals. Even when there is a local hospital, not every hospital in a rural county can treat every injury or illness in the emergency room. That means patients will receive more specialized care elsewhere.

The cost is increasing because of both the specialized training and equipment required on board.

“It’s increasing because in theory there are more demands. They must have all kinds of equipment. It’s very expensive,” said Fannin County Judge Newt Cunningham.

More dedicated state funding

When the Texas Legislature convenes in January, county leaders like Bailey and DeLoach will ask lawmakers for a better, dedicated way to fund emergency health care that would help counties raise property taxes.

They have their eyes on a successful remedy provided by rural law enforcement agencies. A year ago, a new 330 million dollars grant program was approved for rural police needs. Counties would like to see such a grant program to help counties pay for rural ambulance services.

“Counties are working with the state to find core funding to support rural EMS,” said Thompson, of the county judges and commissioners association. “No one wants to be that person on the side of the road and no one is coming.”

And, as Thompson notes, the days of pancake breakfasts and other fundraisers to help pay for volunteer ambulance services are over.

“You can’t have enough bake sales to afford a $400,000 ambulance and then equip it and staff it,” Thompson said. “It’s not realistic.”

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This story was originally published by Texas Tribune and distributed through a partnership with The Associated Press.