An ambulance of the Central Aroostook Ambulance Service. Credit: Courtesy of the Central Aroostook Ambulance Service

MADAWASKA, Maine — Aroostook County has an ambulance problem. Costs for equipment and training are higher than ever, insurance reimbursement rates are lower than they were in the 1990s and nobody can fully staff their roster of paramedics.

The state’s authority on emergency medical services, Maine EMS Board, is convening a working group this fall to discuss the future of ambulance services. Meanwhile, in The County, a few departments have taken matters into their own hands in a move that some officials say is untenable given the financial crisis the industry is experiencing.

In the mire of the rural ambulance economy — high costs, diffuse population, low staffing and inconsistent reimbursements — three new ambulance departments have sprouted in Aroostook County in the past year. Two are now fully functional: Fort Fairfield Fire-Rescue ambulance service and Central Aroostook Ambulance Service, based in Blaine. The third, Southern Aroostook Ambulance Service, awaits legislative approval.

The trend comes amid a wave of closures of ambulance departments across the rural U.S., where many struggle to maintain access to essential emergency medical care.

The new services aim to fill gaps in coverage and combat rising fees from larger departments. Established services raising rates and smaller towns forming their own departments are two of the areas the EMS Board hopes to tackle in its fall meetings — two wholly different approaches to the same crisis.

The first two of Aroostook’s new ambulance services sprung up in 2020 in the fallout of Northern Light Medical Transport (formerly Crown Ambulance) canceling 911 services the year prior. Lee Farley, manager of the Central Aroostook Ambulance Service and one of its two full-time paramedics, said that having worked for Crown for several years, he knew going into his new role that running an ambulance service is no money-making business.

“It’s a big gamble,” Farley said. “If you don’t have the call volume there to offset your operational costs, you have to rely on the taxpayers.”

But the alternative is to rely on other departments, which in rural, diffusely populated places like Aroostook County can mean long wait times and unreliable coverage from towns 30 or more miles away. In the end, it wasn’t a choice.

Facing an impending gap in care, Blaine, Mars Hill and Bridgewater voted to form Central Aroostook Ambulance Service. Farley said that so far, the department has done okay, moving from just about 15 calls a month at the beginning to closer to one call a day. But it will be years before it can afford to add more full-time staff or a new ambulance.

Ambulances from Houlton, Presque Isle and Crown Ambulance respond to a crash on U.S. Route 1 in Bridgewater in 2019. Credit: Courtesy of Maine State Police

Aroostook’s newest potential department, Southern Aroostook Ambulance Service, is forming around a collective of about a dozen towns outraged at an unexpected 400 percent fee hike from Houlton Ambulance Department, which has been covering the towns — in some cases for decades. All but two of the towns have committed to the consortium, and the organizers await a vote of approval from the Legislature.

Hodgdon town manager Jim Griffin maintains that based on advice he has received from industry veterans, the new Southern Aroostook department will become a moneymaker for participating towns in time. He said he is well aware of the risks and the high costs of starting a new department — buying ambulances and hiring paramedics, for example — but said it was worth it if it meant the taxpayers would have some control over the ambulance costs in a few years.

Maine EMS director Sam Hurley said that he can’t imagine an ambulance service of that size turning a profit in rural Maine.

“Our concern is nationally the estimates are that it takes about 1,500 to 1,800 calls annually to support a single full-time staffed ambulance,” he said. “[If towns have less than that], that presents a large gap that needs to be covered somehow — needs to be paid for somehow.”

Houlton ambulance and fire chief Milton Cone said that of his department’s almost 2,000 calls annually, roughly 30 percent came from outside Houlton and Houlton Regional Hospital in each of the past three years — from the potential Southern Aroostook Ambulance Service towns. That’s about 600 calls.

Caribou’s fire and ambulance chief Scott Susi leads one of the larger departments in The County, but he said no matter how many calls his ambulances respond to annually, it is nearly impossible to profit due to low insurance reimbursements. The rates haven’t kept up with the rising medical and equipment expenses, he said.

“I’m worried that you have all these companies starting up — and kudos to the town they’re trying to solve a problem — but realistically somebody has to pay for the services,” Susi said. “It’s not going to be done through reimbursements so it’s going to have to be paid through the taxpayers. That’s the cold hard truth.”

So far in The County, taxpayers have largely been discontent with the rising costs of keeping an ambulance. Houlton wasn’t the only town to raise its rates. In 2020, Caribou faced similar backlash when it raised its ambulance fees.

One option the state might consider is regionalized, county-wide services, Hurley said. In his native North Carolina, some ambulance departments in rural areas operate at this level, and Hurley said the system helps relieve the burden on taxpayers.

In Aroostook, murmurs of a regional solution are spreading among some town managers and ambulance department heads too. Both Farley and Griffin back the idea.

Susi said that he believes the only real solution is for insurance providers to pay up and for the state to agree to spend more on ambulances in general.

“It’s hard for me to talk about money because my heart believes we’re providing a service for the community, that’s our function,” Susi said. “On the other side of it, the business side of it, we have to make it sustainable so we can continue to do this for our community and surrounding communities.”

Hannah Catlin

Hannah Catlin is a reporter at the St. John Valley Times/Fiddlehead Focus in Madawaska, Maine.