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Raising money is always an issue among the 200-some emergency medical service providers who are members of the Central Minnesota EMS Region, said Marion Larson, the coordinator of the region centered on St. Cloud and spreading across 11 counties.

"There's always a pancake benefit breakfast or a pork chop dinner that's in the works," Larson said. "They rely on those to make sure they can meet the needs of their community."

This year, the Legislature approved $24 million to try to fill the persistent budget shortfalls for ambulance and emergency medical services in rural Minnesota, along with $6 million for a paramedic pilot program in Otter Tail and St. Louis counties to try to cut down delivery times and gather data on how best to serve the areas.

Advocates say while the one-time funding is appreciated, it will not go far toward solving the problems that are making emergency medical services unsustainable. The additional $24 million could give services some "temporary breathing room," Larson said, "but I think we need to find a permanent solution to our overall funding issue."

Larson and Kelly Asche of the Center for Rural Policy and Development said some of the structural problems include care that no one pays for, too few medics, growing travel time and distance and a rising number of calls for help.

Ambulance services are often not reimbursed for the full cost of the care they provide, especially for patients who have insurance through Medicare and Medicaid, which Larson estimated cover between 80% and 85% of rural Minnesotans. And if someone is treated without being taken to a hospital, there's no reimbursement at all.

Asche said rural areas do not have the same economies of scale as urban areas, adding to the problem of too-low reimbursement.

"They [providers] have to have all the overhead to be ready, but they don't have the call volume to pay for those things," Asche said.

The problems are compounded by long distances rural ambulances must travel — which are getting longer as hospitals in smaller cities close and consolidate. Asche said some ambulances in southwestern Minnesota have to spend three to four hours making round trips to the nearest trauma center in Sioux Falls.

And transporting a patient with emergency mental health needs might mean a six- to eight-hour round trip to one of a handful of facilities capable of treating them.

Long drives make it harder to recruit volunteers, the backbone of rural EMS services that are unable to pay staff. Recruitment has been growing harder as fewer people work where they live, Asche said, and the prospect of having to take off four hours or more of work to respond to an emergency makes it harder to volunteer.

And as Minnesota's population ages, there are more and more calls.

Asche contrasted the reimbursement system that funds ambulance services to the way police and fire departments are funded by property taxes, though all three are meant to be ready around the clock to respond to emergencies.

One-time money could help EMS services buy or repair equipment, or pay for training, Asche said. "That's all good and dandy, but it's not the structural fix."

Some of Larson's central Minnesota agencies said even a $120 million one-time aid package — as some lawmakers called for — would not have made much of a dent.

Raising Medicare reimbursement rates can only happen through federal legislation, though the state could act to raise Medicaid rates. Asche said he also wonders if there should be some kind of statewide support for emergency medical services.

Cities and counties could ask property taxpayers to contribute to EMS agencies, he said, but Asche said he hoped to see an ongoing stream of statewide funding, similar to the way Minnesota provides aid to school districts.

Beyond funding, Asche said he wanted to see more collaboration between agencies, such as sharing equipment. And he hoped more agencies could find a way to hire professional managers to recruit volunteers, set up training, write grants and do other administrative tasks, rather than relying on volunteer leaders.

However it might happen, Larson said she wants agencies to be able to focus on providing care.

"I would want to be in a world where the EMS agencies don't have to worry about how their budget is going to cover equipment, staff and training," she said.