When you call for help, you expect someone to come. That is about the most basic promise a community makes, and most of us count on it without ever thinking about it, whatever our politics. Out here, that promise is quietly coming apart, and not for the reasons we usually hear. It is not that we are too rural or too poor to keep an ambulance on the road. It is that we have built a system where the ambulance only survives if its calls turn a profit, and out here, they often don't.
Take the ambulance that covers Walker, Akeley, LaPorte, and Hackensack, right here in our own counties. It costs about $1,466 to answer a single call, and Medicare pays it back somewhere between $907 and $985. Most of the people it picks up are on Medicare or Medicaid, so even doing everything right, the service ended up about $251,000 in the hole in a single year. Walker couldn't cover that gap on its own, so last year Cass and Hubbard counties had to step in together and put it on the local property tax to keep that one ambulance running.
Walker isn't unusual. Across Minnesota, ambulance services billed insurers $1.2 billion in 2022 and were paid only about $450 million, and nearly three out of four of them lost money. The payment for a run doesn't cover what the run costs, and where one call can tie up your only crew for hours, there's no making it up in volume. When Greater Minnesota's cities asked the Legislature for about $420 million to steady these services, the state put up $24 million.
We pay the most, and get the least
It doesn't have to be this way, and it isn't an act of God. Care gets rationed by what's profitable because we let a handful of big insurance, hospital, and drug companies run the system, and they take their cut before the care ever reaches you. We spend about $14,775 a person on health care, roughly double the $7,860 people pay in other wealthy countries, and we still come out behind: a study of ten rich nations ranked us dead last, with the most preventable deaths and a shorter life span. A big share of that money isn't doctoring at all. It's paperwork: we spend about $2,500 a person just on billing and the fights over who pays, four times what Canada spends. That is money that never touches a patient.
And out here, we are already paying for most of it. In Cass County, more than half of us are on a public plan like Medicare or Medical Assistance; across our six counties it runs between forty-three and fifty-four percent, where statewide it is about a third. The public is already the one paying the bills out here, even more than in the state as a whole. We just do it the hard way, by waiting until someone lands in the emergency room or ends up with a bill they will spend years paying off. The question was never whether we should pay for everyone's care. We already do. The only question is whether we keep paying a company in the middle to decide what gets covered and what doesn't.
It's not just the ambulance
The same squeeze is hollowing out the rest of our care. In a rural county, the hospital is one of the biggest employers there is, Minnesota's hospitals and health systems support around 389,000 jobs and $31 billion in wages, and when one cuts a service, the care and the jobs leave together. We're watching it happen close to home: in 2024, Lakewood Health System closed the inpatient mental health unit at its hospital in Staples, and today it offers only outpatient behavioral health there. In Cass County, the number of nursing-home beds has fallen from 489 in 2005 to just 33 today, more than a ninety percent drop. Every service that disappears is one more decision, made somewhere else, that a place like ours wasn't worth keeping.
And all of it is one chain, with the ambulance at the front. Behind that ambulance is an emergency room. Behind that, a hospital bed, a surgeon, the clinic in town, a prescription you can actually afford, somewhere to turn for mental health or addiction, the nursing home down the road. An ambulance is only as good as the hospital it can reach and the care that comes after it. Save the ambulance and let the hospital close, and all you've done is buy a faster ride to a locked door. And plenty of those 911 calls happen in the first place because a link further up the chain already failed somebody, who couldn't get a regular doctor, or couldn't afford the medicine that keeps a manageable problem from turning into an emergency. You can't fix one link and let the rest rust out. The chain only works if all of it holds, for everybody, which is why we can't keep treating health care like a luxury that comes last. It's the chain a whole community hangs from.
The fix is proven
Here's the good news: we don't have to invent the answer, and we don't have to guess whether it works. The Walker ambulance is still running because two counties decided to share the cost instead of making one small town carry it alone. That is the whole idea, spreading the cost of the things everyone needs across everyone who benefits, and pieces of it are already working around the country.
Start with the ambulance itself. Only thirteen states and Washington, D.C. treat emergency medical service as an essential service the way every town treats the fire department, something local government is simply required to provide. Minnesota isn't one of them. The first step is to make it one: say plainly that an ambulance is essential, and pay for it like the fire truck parked next to it. And we can ask that ambulance to do more than wait for the worst day. Minnesota was the first state to let Medical Assistance pay for community paramedics, who check on people at home between emergencies, and in the programs that have been studied they cut repeat hospital stays and ER trips sharply. It is cheaper to catch a problem at the kitchen table than in the back of a rig.
Then the hospitals. They close because we pay them per procedure, so when a town gets smaller the money drains out from under a building whose costs don't. There is a proven alternative: pay rural hospitals a steady yearly budget so they can plan, instead of betting their survival on how many procedures they run. Pennsylvania tried it with eighteen rural hospitals, and through six years and a pandemic, not one of them closed. Maryland did it statewide and held costs down while saving Medicare about $975 million over five years. Compare that to the main thing Washington offers a struggling rural hospital today: a Medicare designation called the Rural Emergency Hospital, which pays a hospital more for its outpatient and emergency care, but only if it gives up its acute-care inpatient beds. One path keeps the hospital whole. The other pays it to give up the beds.
Underneath all of it is the simplest rule in insurance: the more people you put in one pool, the cheaper and steadier it is for everyone in it. That isn't ideology, it's how insurance has always worked. Minnesota proved it in miniature a few years back, when the state set up a pool to cover the most expensive claims and premiums on the individual market dropped about twenty percent. The hospital closures tell the same story from the other side: about two-thirds of the rural hospitals that closed over the last decade were in states that refused to widen their pool by expanding Medicaid. The broader we draw the circle, the fewer towns get left to fail on their own.
Build the best
Follow every one of those fixes to its end and they point the same way: stop carving people and places out of the system, and put everyone in. So I am not interested in a watered-down version. We should build the best health care in the world, right here, where everyone is covered, nobody goes bankrupt because they got sick, and nobody waits months for the care they need. We already spend more on health care than any nation on earth. We have the money and the know-how. What we have been missing is the will to stop letting a few companies skim it.
It pays for itself
Can we afford it? We are already paying for it. The only question is what we get back, and the money lost in the middle is money that could buy care. Spend it on prevention and it returns about fourteen dollars on the dollar, because a clinic visit is cheaper than an ambulance ride. Cover people and our hospitals stop eating the cost of the uninsured, which is why uncompensated care fell by a third where coverage expanded. Every dollar the state puts into Medicaid draws down federal dollars, as much as nine to one, that land in local clinics and paychecks instead of leaving the state. And a workforce that can see a doctor is a workforce that shows up: untreated illness already costs American employers about $530 billion a year.
And think about who that covers. People who can't afford care now don't get healthier on their own; they get sicker until it's an emergency, and they go without the addiction or depression treatment that keeps a life from coming apart. When Medicaid expanded, that showed up in the numbers: counties that expanded it saw sharply fewer arrests, especially drug arrests, than the counties that didn't, because people could finally get treatment instead of getting hauled to jail. That's the part a budget sheet misses. A neighbor whose diabetes is under control keeps showing up to work. The kid whose asthma gets handled isn't a 2 a.m. call for the crew. And when somebody finally gets help with addiction or depression, a whole crisis just never happens, for them and for everyone around them. Covering people isn't only the decent thing to do. It makes for a healthier and steadier place to live, and a safer one too.
Health is infrastructure
You don't ask whether you can afford the fire department before the house is burning, or price out the road by the trip. Some things you pay for once, together, because everyone needs them and no one knows whose turn is next. Health is one of those things. The danger in the way we do it now is simple: when one company's spreadsheet, or one rule written in an office far from here, decides whether care reaches you at all, you've built a single weak point into every life out here. Bring it close to home, share it the way we share the fire truck and the road, and no faraway decision can take it away.
We pay for the care. We should get to keep it.
Sources
- Walker ambulance district costs, payer mix, shortfall, and the joint county taxing district — KAXE, Jan. 23, 2025. link
- Minnesota ambulance services billed $1.2B, collected ~$450M, ~72% lost money (Exec. Dir., MN EMS Regulatory Board) — MPR News, Jan. 9, 2024. link
- Greater Minnesota cities' $420M rural-EMS funding request — Detroit Lakes Tribune, Sept. 16, 2024. link
- 2024 Minnesota law: $24M in EMS aid — Minnesota House of Representatives. link
- U.S. health spending per person and as a share of GDP vs. peer countries — Peterson-KFF Health System Tracker. link
- U.S. ranks last overall and on health outcomes among ten wealthy nations — Commonwealth Fund, Mirror, Mirror 2024. link
- U.S. administrative health costs (~$2,497/person) vs. Canada (~$551) — Annals of Internal Medicine, 2020. link
- Public health-coverage rates by county, ACS 2024 5-year, Table S2704 (variable S2704_C03_001E): Cass 53.7%, Wadena 51.2%, Hubbard 49.7%, Becker 46.1%, Todd 44.4%, Morrison 43.1%; Minnesota 34.7% — U.S. Census Bureau. link (swap the geography code for each county)
- Minnesota hospitals/health systems support ~389,000 jobs and ~$31B in wages — Univ. of Minnesota Duluth / Minnesota Hospital Association. link
- Lakewood Health System closed its 10-bed inpatient psychiatric unit in Staples in 2024 and now provides only outpatient behavioral health there — MPR News, May 14, 2024 (link); Lakewood Health System behavioral health services, accessed 2026 (link).
- Cass County nursing-facility beds fell from 489 (2005) to 33 (2024), −93% — Center for Rural Policy & Development, Nov. 2024. link
- Only 13 states and D.C. designate EMS an essential service — EMS1, citing NCSL, Sept. 2023. link
- Minnesota was the first state to reimburse community paramedicine through Medicaid — Center for Health Care Strategies. link
- Community-paramedic home visits cut readmissions ~43.6% vs 75.6% and ER visits ~40.7% — Western Journal of Emergency Medicine, 2023. link
- Pennsylvania Rural Health Model: 18 rural hospitals on global budgets, none closed through six years and the pandemic — Rural Health Redesign Center. link
- Maryland all-payer model saved Medicare ~$975M (2014–2019) — Milbank Memorial Fund. link
- Rural Emergency Hospital (REH): enhanced Medicare outpatient payments plus a monthly facility payment in exchange for giving up acute-care inpatient beds (a distinct-part skilled nursing unit is allowed) — Rural Health Information Hub. link
- Minnesota reinsurance cut individual-market premiums ~20% — Minnesota Dept. of Commerce. link
- ~69% of rural hospital closures (2014–2024) were in non-Medicaid-expansion states — KFF. link
- Public-health interventions return a median ~$14 per $1 — Masters et al., Journal of Epidemiology & Community Health, 2017. link
- Uncompensated care fell from $62.8B to $42.4B/yr after coverage expansion — KFF. link
- Federal government pays 90% of costs for the Medicaid expansion population — KFF. link
- Poor health costs U.S. employers ~$530B/year in lost productivity — Integrated Benefits Institute, 2018. link
- Medicaid expansion associated with lower arrest rates, driven by access to treatment — PLOS One, 2021. link
Prepared and paid for by Skylar Fynboh for Senate District 5, PO Box 6, Akeley, MN 56433