County Commissioner Rick Bailey is acutely aware when a resident from Johnson County faces a medical emergency, particularly when it comes to the ambulance services for those living outside of Cleburne or Burleson. Complaints typically flood in after someone experiences a critical event, such as an accident or a heart attack, and residents inquire about response times. “I frequently receive messages asking why the ambulance took so long,” Bailey stated.
Situated around 15 miles south of Fort Worth, Johnson County is witnessing extraordinary growth. Many retirees from Dallas and Fort Worth are downsizing and relocating, while younger professionals are choosing to live in the area for its affordability, despite longer commutes. Over the past three years, the county’s population has increased by 25,000, with another 60,000 projected to move there by 2030. Currently encompassing 734 square miles—slightly more expansive than Houston—the county has earmarked 17 proposed municipal utility districts. This indicates a clear intent from developers to gather funds for infrastructure necessary for the new housing developments underway.
As highway expansions take place and roads reach maximum capacity, Johnson County is likely to witness an increase in traffic accidents. These incidents will require swift medical assistance, a challenge that smaller towns, which typically utilize combined fire and emergency medical services, are often unable to meet. Preliminary data indicates that over 152,000 accidents occurred in rural regions of Texas in 2023. “Our rapid growth has led to a surge in the number of vehicles. The existing roads were not designed for this level of traffic and corresponding delays,” Bailey noted. “The situation is only set to escalate.”
Further complicating matters is Johnson County’s scarcity of health care facilities. The only hospital within the county, Texas Health Harris Methodist Hospital Cleburne, can only accommodate overnight patients and recently closed its maternity unit due to a decline in deliveries. Thus, residents facing medical emergencies will likely need to be transported to hospitals located in neighboring Tarrant and Dallas counties, causing delays ranging from 40 minutes to an hour, depending on the care required. Officials recognize the necessity of having multiple ambulances available, especially when one is occupied transporting a patient over a great distance.
Bailey recalled a specific incident concerning a woman in her second trimester who was anxious about the lack of local maternity care, saying, “What are we going to do? I was depending on the hospital out here.”
In a move to bolster ambulance services in unincorporated areas, the county commissioners recently sanctioned a $1.5 million contract with CareFlite, a Grand Prairie-based emergency medical service. This agreement will deploy five full-time ambulances alongside one part-time unit. To cut costs, the county opted to pay for the contract upfront. This expenditure represents a significant portion of Johnson County’s total general fund budget, estimated to be around $102 million.
In a context where the state implements strict regulations on property tax increases—capped at 3.5% without local voter approval—Bailey noted that meeting the demand for emergency medical services has become increasingly challenging, particularly as rural hospitals close or downsize due to workforce shortages in healthcare.
Across Texas, counties share similar issues, and Rick Thompson, program director for the County Judges and Commissioners Association of Texas, highlighted the increasing strain on emergency medical services. The traditional model of volunteer fire departments is dwindling as many counties are now exploring the hiring of paid staff and acquiring ambulances, or entering contracts with private companies. “This is a significant concern,” Thompson remarked. “Having collaborated with counties for 25 years, I can confirm that this challenge is persistent.”
The necessity for improved services is becoming even more urgent as housing costs rise, pushing more individuals into suburban counties where homes remain affordable, and the aging population requiring medical attention expands. The pandemic has also facilitated greater worker mobility, making telecommuting a norm for many, allowing them to live anywhere with reliable internet.
A survey recently conducted across 236 of the state’s 254 counties highlighted troubling statistics: 48% of counties surveyed reported vacant EMS positions, and almost half lacked volunteer staffing altogether. Moreover, 55% of the counties experienced round trip times for emergency services exceeding an hour, while 38% indicated an average round trip of two hours, and 26% reported trip times of three hours. Locations of trauma centers varied dramatically, ranging from under five miles to upwards of 200 miles.
Despite the absence of a mandated requirement for counties to supply ambulance services, many are compelled to do so to ensure their communities do not fall into disarray. A recent inquiry from Grayson County’s district attorney to the state attorney general asked whether counties have a legal obligation to provide emergency services in unincorporated regions, particularly as some EMS contractors withdrew their service from planned developments.
In Lamb County, north of Lubbock, Judge James “Mike” DeLoach notes a change in how rural ambulance services have evolved over the years. Previously, emergencies relied on a “load and go” approach, transporting patients in pickup trucks across vast distances. Now, DeLoach, who has been a paramedic for 38 years, notices a shift towards more organized services, yet encounters a significant challenge in staffing due to higher salaries luring personnel to Lubbock. “While our county isn’t seeing the rapid growth that Johnson County is, we face an aging population increasingly in need of EMS,” he shared.
With Texas’s population of individuals over 50 expected to surge by 82% to reach 16.4 million by 2050, many in this demographic seek residence in more affordable rural counties. Compounding the issue, the volunteers traditionally staffing these EMS positions are aging out, and attracting new volunteers is increasingly difficult due to rising living costs. Counties that offer better compensation often experience employee turnover as personnel migrate to larger counties offering better salaries.
Judge DeLoach expressed the frustration of trying to recruit emergency personnel to his area when lucrative positions in Lubbock are plentiful, offering starting salaries of $57,000. The operational costs for private ambulance services also continue to climb as long-distance transports to specialized care facilities become more necessary, alongside the financial burden of acquiring necessary training and equipment.
As lawmakers prepare to convene in January, county officials like Bailey and DeLoach will advocate for more reliable, dedicated funding sources for emergency medical care, aiming to alleviate the fiscal pressure on local property taxes. They look to draw inspiration from a recent $330 million grant program designed to bolster rural law enforcement, hoping for similar support to fund rural ambulance services.
“Counties are joining forces with the state to seek foundational funding dedicated to EMS,” Thompson explained. “No one wants to experience the fear of waiting for help while stranded on the roadside.” He emphasized that traditional fundraising efforts, like pancake breakfasts, are no longer a feasible solution for covering the costs of modern emergency medical services, underscoring that “you simply cannot organize enough bake sales to fund a $400,000 ambulance, let alone equip and staff it.”