County Commissioner Rick Bailey knows immediately when one of his Johnson County constituents has suffered a health scare. That’s typically when the calls and texts roll in from residents wanting to know more about ambulance service for those living outside the city limits of Cleburne or Burleson.

“I do get complaints if there has 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 midst of an unprecedented boom. More Dallas and Fort Worth retirees are either cashing in on their homes and relocating, or younger, working adults, unfazed by a longer commute, are opting for a more affordable lifestyle, choosing among 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 a little larger than the size of Houston, has 17 proposed municipal utility districts, the first signal from developers that they want to raise funds to pay for new infrastructure for new housing construction.

Factor in highway expansions and roads at capacity, counties like Johnson will see a rise in traffic accidents that will need a more immediate medical response than smaller towns, with their combined fire and EMS services, can offer.

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In 2023, more than 152,000 crashes happened in rural areas across the state.

“We’ve exploded with growth, and with so many vehicles on the road, the roads were not designed for this much traffic or this much delay,” Bailey said. “It’s only going to increase.”

Adding to the need for more ambulances, Johnson County has a shortage 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 he hospital also shut down its maternity department, because of a decrease in the number of deliveries there. Now, residents here can expect that when a medical emergency happens, they will 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 those situations, county officials know they must have multiple ambulances at their disposal in case one is in use transporting a patient miles away.

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

To help shore up the ambulance service outside Johnson County’s largest cities’ fire departments, commissioners this year approved a $1.5 million contract with Grand Prairie-based CareFlite, which adds five full-time ambulances and another one part-time to cover unincorporated areas. To save money, the county paid the contract in full, up front. 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 cap on property tax hikes. Cities and counties cannot raise property taxes beyond that 3.5% cap without taking the issue to local voters. Bailey said the need for better EMS service, something counties are not required to provide, is making working within that cap tougher, especially as rural hospitals close or reduce beds because of rampant health care workforce shortages.

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

The pressing EMS need statewide

The complaints from counties about how to pay for emergency medical services are not new, says Rick Thompson, program director for the County Judges and Commissioners Association of Texas. As the demand for EMS service grows, the old volunteer fire department model for smaller towns concentrated in one or two areas of a sprawling county is forcing counties to explore hiring paid county staff members and buying ambulances or contracting with private ambulance companies.

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

But it’s become a more pressing one as the rise in housing prices has pushed more people into metro-adjacent counties where homes are more affordable and as the number of older residents who have more medical needs and emergencies grow. The coronavirus pandemic also made workers more mobile and less location dependent, able to work anywhere there’s 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% reported having open EMS positions and about half indicated they had zero volunteer staff, Thompson said. Also, about 55% reported EMS round trip times of an hour, 38% reported round trips of two hours and 26% reported three-hour round trips. The nearest trauma center for counties ranged from less than 5 miles to 200 miles away.

And even though counties are not required to provide ambulance services, they do it to keep from dying out completely and becoming ghost regions.

Last month, Grayson County’s district attorney put the question squarely before the state attorney general’s office after EMS contractors notified the county 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 service to residents living in unincorporated areas?

“There is a problem on the horizon wherein Grayson County residents living in higher density subdivisions will not have emergency services,” the Grayson County request to the attorney general stated.

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

About 40 minutes northwest of Lubbock, Lamb County Judge James “Mike” DeLoach can recall how rural ambulance service was a “load and go” type of operation, where residents were placed in the beds of pickup trucks and driven dozens of 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 that has reached a critical juncture. While his county is not seeing the growth spurt Johnson County is experiencing, Lubbock’s growth has translated to more health care personnel working there, where salaries are higher. And the need is growing for emergency medical transport as his residents get older.

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

Texas is aging at a rapid clip. According to Texas Health and Human Services, the state has the third largest population of people 50 years of age and older. That population is expected to grow 82% to 16.4 million by 2050 and a lot of the over 50 demographic choose to live where it’s more affordable: in rural and metro-adjacent counties.

Among those aging are the volunteers who now staff EMS positions at small town fire departments. Current volunteers are retiring and finding their replacements is getting tougher as rises in the cost of living deter 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 tough to recruit EMTs and paramedics to his county when they can work in Lubbock and make $57,000.

Then there’s 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 their ER. That means taking patients to more specialized care elsewhere.

The cost is rising because of both the specialized training and equipment needed on board.

“It’s going up because in theory there are more requirements. They have to have all sorts 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 be asking lawmakers for a better, dedicated way to fund emergency medical care that would help counties from raising property taxes.

They have their eyes on a successful remedy secured by rural law enforcement agencies. A year ago, a new $330 million grant program was approved for rural policing 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 foundational funding to support rural EMS,” said Thompson, of the county judge and commissioners association. “Nobody wants to be that person on the side of the road and nobody’s coming.”

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

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

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