For years, a single family, the Morgans, ran the volunteer ambulance service in La Barge, Wyoming. A town of some five hundred people, La Barge is nestled in a barren, beautiful corner of the state between the Green River and the base of the Wyoming Range. Lyle and Tammy Morgan, who were in their forties, would alternate shifts with Ginnie, their daughter, and Joey, who was then Ginnie’s husband. The phone would ring, and either the older couple or the younger couple would drive to the ambulance station—if they weren’t already there—climb into the ambulance, and drive past miles of sagebrush and rock formations to the home of a sheepish oil-field worker whose wife made him call, or that of a begowned old matriarch whose chest hurt. Then they’d take the patient’s vitals, load him or her onto a stretcher, and drive to the nearest hospital, South Lincoln Medical Center, in Kemmerer, which is fifty miles from La Barge.

One evening in October of 2008, Ginnie got a call. Her father had collapsed at home. When she and Joey arrived with the ambulance, Lyle was in cardiac arrest. By the time they got him to Kemmerer, he was dead. After that, Ginnie managed to keep La Barge’s ambulance service going for a few years, but, eventually, she moved, and it shut down.

Andy Gienapp heard this story soon after he became Wyoming’s director of emergency medical services, in 2010. It’s his job to make sure that ambulances get the ill and the injured to the hospital as swiftly as possible in a state with a lot of land and not a lot of hospitals. Gienapp is lean and has a big forehead. He spends his free time hunting elk and grew up in small towns in Iowa and Maryland. “I thought I knew rural,” he said. “But then I moved out here, and holy shit.”

Forty-six million people live in America’s rural counties, and, for decades, they have relied on volunteer ambulance services to respond to their medical emergencies. Today, that system faces collapse. As these communities become grayer and less populated, there are fewer people left to drive ambulances, and fewer people left to pay the taxes that keep the ambulances in service. “Nobody’s put the resources and manpower together to figure out how many rural ambulance services are facing closure,” Gienapp told me. When a town’s ambulance service closes, E.M.T.s and medics in neighboring communities are often called on to cover more ground, which means longer ride times, and, as E.M.T.s say, time is tissue. “We’re facing a crisis in rural America,” Gienapp said. “Someone needs to do some planning or one day we’re going to call 9-1-1 and nobody’s going to come.”

Emergency medicine as we know it now was first developed fifty years ago, as a response to the car crashes of America’s new highway system. Driving fatalities increased forty per cent in the fifteen years after President Eisenhower’s authorization of the Interstate Highway System, in 1956. Thousands of seat-beltless Americans were catapulting themselves through their windshields miles from the nearest hospital. To address this, Congress passed the E.M.S. Systems Act, in 1973, which gave states more than a hundred and fifty million dollars to experiment with their ambulance services. Towns across the country started programs. Regulations and funding models varied from county to county and state to state. “If you’ve seen one E.M.S. system, you’ve seen exactly one E.M.S. system,” Art Hsieh, an E.M.S. instructor and rural medic in Santa Rosa, California, told me.

In 1981, President Reagan stripped money for E.M.S. from the federal budget. In cities and suburbs, tax bases were big enough to keep full-time public ambulance services going, and there were enough customers around for private companies to fill in any gaps. But in rural America countless services could survive only by relying on volunteers, and many didn’t survive. In big cities, if someone calls 9-1-1, an ambulance can be there in minutes, and at the hospital in minutes more. In La Barge, if someone gets in a car crash, she could call 9-1-1 and wait for E.M.T.s from Kemmerer, but she’ll usually get to the hospital faster if a friend takes her. At South Lincoln Medical Center, clinicians can treat minor injuries, but if there’s significant enough trauma they’ll put the patient on a helicopter and fly her to Utah for more comprehensive care.

Dia Gainor, the executive director of the National Association of State E.M.S. Officials, wishes lawmakers and rural community members would regard E.M.S. as an essential public service, like fire departments and law enforcement. Though rural fire departments also struggle to recruit volunteers, financial incentives and federal grants help them stay afloat. “Fire departments get the love because of community insurance ratings,” Gainor said. If rural towns don’t have fire stations, it’s more expensive for people to insure their houses. Many rural E.M.S. programs rely on resources shared by town fire departments. In La Barge, for example, the firefighters and E.M.T.s used the same station. But this dependence frustrates rural E.M.S. advocates. For every person who calls for help putting out a fire, ten call for help with a medical emergency. Gainor believes that if E.M.S. received the same support that law enforcement receives—federal grants, advocacy by a federal agency, national research foundations—rural ambulance programs wouldn’t struggle as much as they do. “I live in Idaho, so I’d never call for government intervention to the extent of control,” Gainor said. “But a greater degree of federal involvement would help state and local governments do their jobs.” Gienapp agreed. “It’s going to be expensive, but there have to be limits,” he said. “Do we have a right to an ambulance within five minutes of our home? Within forty minutes? The answer isn’t going to make everybody happy. Cities are going to have to help write the checks, and they can’t just say, ‘Tough nuts, hillbillies.’ ”

States and local communities have tried different ways to replace the labor that rural E.M.S. programs have lost. The state of Oregon offers a two-hundred-and-fifty-dollar tax credit to rural E.M.S. volunteers. Grand County, Utah—the home of Arches National Park—levied a small tax in 2016 to pay for its E.M.S. system. Some small-town businesses offer their employees paid time off for shifts on the local ambulance. But these are small measures, limited in scope.

Substantial structural changes will require more state and federal money. Congress could let rural ambulances make more money by billing for the care they provide. It could legislate higher reimbursement rates for Medicaid and Medicare, the way it did with the Critical Access Hospital program, which has helped rural hospitals increase their revenue. Federal lawmakers could also establish grants to help fund E.M.S. volunteers and full-time medics, and commission national-scale research on E.M.S. In states that have not expanded Medicaid under the Affordable Care Act, lawmakers could vote to do so. “Large parts of rural America are uninsured, which sucks for ambulance companies because they may not get their care reimbursed and lose tons of money,” Hsieh said. In 2018, activists in Nebraska, Idaho, and Utah collected hundreds of thousands of signatures to put Medicaid expansion up for referendum, over the protests of their state legislators. In November, all three states voted in favor—a development many E.M.S. advocates welcomed.

Gienapp wants local lawmakers to do some budgetary soul-searching, too. “Is an ambulance more important than, say, someone plowing your road when it snows? More important than a new school?” he said. “For many towns, it might not be.” But, in other cases, an ambulance service could be a priority. Guy Dansie, Utah’s E.M.S. director, told me that part of Grand County’s rationale for funding its E.M.S. program was to accommodate the tourists on whom the local economy depends, and who likely come from places where they expect an ambulance to be available if they need it. He thinks it was crucial that the county imposed its local tax for its ambulance service through referendum and not legislation, the same way his state expanded Medicaid. That way, as he said, “It doesn’t feel like a tax.”