Camron and Shawna Ramsey, standing in front of Boone's newest ambulance. Photo by Quenton King

It’s hard to predict where a worker will end up during a 24-hour shift working at the Boone County Ambulance Authority. 

A car wreck in the middle of the night on the outskirts of the rural county. An unresponsive person experiencing an overdose who needs a dose of naloxone to recover. A baby sick in a crib. A trip as far away as Pennsylvania or Ohio to transport a patient because all of the hospitals in the surrounding area are full or not accepting patients. 

On a Friday in mid-October, it’s a COVID-19 positive nursing home resident with respiratory complications who takes Camron and Shawna Ramsey, out of the Danville station in Boone’s newest ambulance. The married couple returns two hours later, just after another crew comes back to the station after being out for the entire morning. 

Between bites at the station’s dining table, the four discuss working in Emergency Medical Services during the pandemic. They’re stretched thin, and feeling underappreciated compared to other health care employees. 

“The hospital [staff] has been viewed as frontline heroes, which is fine and understandable,” Camron Ramsey said. “But everybody forgets about EMS.”

In West Virginia, that even includes the governor.

In September, Gov. Jim Justice announced he would direct additional money to hospitals and nursing homes. The new initiative, dubbed Saving Our Care, would help pay for the extra expenses incurred during the Delta variant surge. Health leaders applauded the governor for the program.

But from Boone County EMS, the governor’s office received an email, asking “what about us?”

“So for 6 days I sat on my hands and kept quiet, but with each passing day, I’ve become more and more upset over Governor Jim Justice’s announcement about the ‘Saving Our Care’ plan,” begins the email from Boone County Ambulance Authority director of operations Joseph Smith, obtained via the Freedom of Information Act. He said while he understands the need to help hospitals and nursing homes, EMS departments are facing the same challenges.

“My heartburn lies squarely in the fact that not once was EMS mentioned. We all know and fully understand that EMS is and always will be the forgotten piece of the healthcare puzzle.”

His boss, Bryan Justice, says that being forgotten in this round of funding from the governor’s office reflects a longer trend, one that has relegated EMS departments and personnel to the back of the line when people talk about frontline workers. 

To Justice, the executive director of the Boone County Ambulance Authority, Saving Our Care would have been a short-term, but helpful, solution for his department. But he’s more concerned about what’s next.

“We have got to come up with a fix to fund EMS. If we don’t, in a few years there may not be EMS agencies in some counties,” he said. “If there is any essential service needed in our rural counties, it is EMS. We are the only health care that some of these people see.”

‘We are bleeding people in EMS’

Bryan Justice says a lot of people don’t fully understand the role that his staff plays.

“We are the ones doing the calls at 3 a.m going into houses,” he said. “We’re responding with two people. We don’t have a controlled environment. We essentially are operating an emergency room in a person’s living room.”

And that’s only gotten more challenging since the pandemic began in 2020, and more recently with the emergence of the Delta variant. That surge that crunched hospitals and nursing homes had a downstream effect on EMS departments in the state. With hospitals either at maximum capacity or unable to accept patients because of staff shortages, ambulances had to find other places to take patients.

In Boone County, that’s meant their ambulances have had to transport patients to hospitals in Charleston, Morgantown and Huntington, but even as far as Pennsylvania, Ohio and Virginia. This takes staff out of commission for hours at a time, sometimes leaving the 500-square-mile county with no  available ambulances. 

Boone County EMS headquarters in Racine. Photo by Quenton King

Emergency workers in Roane and Mercer counties say they’ve also had to transport people further with hospitals filled up this summer. And even when they get to a hospital, they still have to wait for staff there to accept the patient. Sean Cantrell of the Bluefield Rescue Squad says he’s waited for up to three hours with his patients on stretchers. 

And these challenges are magnified in an industry that has struggled to maintain a full workforce — even before the pandemic. 

“The biggest thing is the pay. That’s why we are bleeding people in EMS,” Bryan Justice said.

He was able to give his employees raises over the last year. But even so, Boone County’s EMS workers start out making between $12 to $15 an hour. And this means he’s competing for workers, both in the county to places like Walmart and Wendy’s, and out of state to other EMS agencies. He says he has lost two staff members to temporary EMS jobs in Texas that pay $70 an hour.

EMS administrators say their agencies need more support from the state and federal governments.

“The federal government is doing a great job as far as trying to get money out to everyone who needs it — except EMS,” said Jody Ratliff, director of Roane County Emergency Squad. “Last year when everything was so bad, we were able to tap into the CARES Act. That helped tremendously. Well, that stopped and now we’re not able to tap into that.”

Other states have given “hero pay” to frontline workers during the pandemic. An attempt by Gov. Justice to do the same last year in West Virginia using CARES Act funds led to confusion for local governments: counties each got $100,000, but the governor gave little guidance on how it could be used. 

Some counties, like Roane, did use those funds to give EMS staff hero pay. Boone County commissioners gave bonuses to some frontline personnel, including the 911 call center and the fire department. Bryan Justice says that Boone EMS was left out of that.

The governor’s office did not respond to a request for comment for this story.

 ‘All we want is to be included in the discussion’  

In addition to staff shortages and low pay, hospitals and EMS share another challenge in West Virginia: insurance reimbursements. West Virginia has one of the highest shares of residents on Medicaid and Medicare in the country. According to Bryan Justice and Ratliff, the majority of patients that their EMS departments treat are on one of those insurance plans.

Justice says that the Medicaid and Medicare will typically pay only about 30% of a patient’s bill. 

“Sometimes that doesn’t cover the cost of fuel. Especially now with the fuel prices being above $3 a gallon. You take a patient as far a distance as we’re taking them now and we bill Medicare [or] Medicaid. It’s really not doing very good on our reimbursements.We’re probably losing money by the time you paid maintenance, fuel costs, [and] crews,” Justice said. 

Bryan Justice is the director of Boone County EMS. Photo by Quenton King

Insurance reimbursements aren’t the only way that counties like Boone fund their EMS agencies. Justice says a significant portion of Boone County Ambulance Authority’s budget comes from the county’s EMS levy. And in that county, faced with declining population and revenue, a levy that brought the department $1.8 million a decade ago may not even bring in $800,000 this year.

In Roane County, residents voted to continue their EMS levy last year. Ratliff appreciates the local support, but says more help from the state is needed. 

“The citizens of Roane County really stepped up to help out,” he said. “And now we’re at the state level. The state has to step in and help out the EMS in the state. If they don’t, it’s gonna be a disastrous issue for the state’s EMS.”

Chris Hall, executive director of the West Virginia EMS Coalition, agrees with Ratliff that the state needs to create a long-term funding structure for EMS agencies. In an email, he said that county support varies across the state. And while neighboring state governments provide assistance to their EMS through tickets, fees or block grants, West Virginia has done the opposite. 

“In fact due to repeated budget cuts, the Office of EMS within DHHR has increasingly relied on fees assessed to EMS agencies, paramedics and EMTs to support its regulatory functions,” Hall said.

He also says in 2018 the legislature passed a bill to create a fund for equipment and training for EMS within the West Virginia Office of Emergency Medical Services, but they’ve yet to allocate any funds.

Back in Boone County, Bryan Justice stresses that he’s not bitter that hospitals and nursing homes are getting additional help under Justice’s Saving Our Care program. He says he knows those employees are under pressure, too. 

“All we want is to be included in the discussion,” he said. 

In the meantime, he’s happy about recently getting a new ambulance with the help of a federal grant. Now the county has five in rotation, though a couple have more than 400,000 miles on them.

“Excited as I am about a $250,000 truck, now I gotta get back to work and figure out how I’m going to buy the next one,” Justice said.

Quenton King is a native West Virginian, born and raised in Charles Town in the Eastern Panhandle. He previously worked as a policy analyst for the West Virginia Center on Budget and Policy and the National...