By David Rogers. October 9, 2020. BLOWING ROCK, NC – It is best not to confuse government goals and objectives with the private sector’s profit incentives when it comes to providing essential municipal services like public safety. And yet, that is exactly what the Watauga County Board of Commissioners unwittingly did years ago when it decided to outsource ambulance transport services.
Before we dig into this, here is a summary of what we are going to explore in this editorial:
- We question the wisdom of outsourcing primary governmental responsibilities to the private sector;
- We examine the response times for EMS services, especially vs. nationally recognized industry standards;
- We question the priorities with which the Watauga County Board of Commissioners allocates tax revenue collected from the constituents who elect them.
We acknowledge that the current board is at least paying lip service to catching up with Watauga County’s population growth when it comes to ambulance transport services. It has, in fact, modestly increased ambulance funding the last few years. At the recent Candidates Forum, incumbent Charlie Wallin even admitted that the County needs to do more when it comes to providing EMS services outside of the Boone town limits, including Blowing Rock.
That said, the Board simply isn’t doing enough — or fast enough – and when they raised property taxes last year largely to fund the construction of a $40 million community recreation center that will primarily benefit Boone, well…they have misplaced priorities however laudable the economic development potential that a recreation palace, they contend, offers. We are not saying that we don’t like the idea of a nice recreation center, but they should have addressed other, more important, and long neglected priorities first.
Whatever the jurisdiction – village, town, city, county – the folks paying taxes into the government budget expect pretty close to the same level of public safety services, whether living in the middle of a town or out on the fringes of a municipality. They are, after all, paying for those services, equally. In larger city and county jurisdictions, of whatever population or geographic size, the citizens paying taxes have the same expectations — and needs. That is why police departments in larger municipalities create neighborhood “precincts” and fire departments build additional “stations” to better protect what otherwise might be considered “fringe” populations.
When it comes to public safety, municipal preparedness has long been characterized as “overkill,” even if police or fire department personnel have a lot of idle time on their hands.
When it comes to law enforcement, of course, Watauga County is aided by the formation of police departments in incorporated communities: Boone, Blowing Rock, Beech Mountain and Seven Devils. The Watauga County Sheriff’s Department primarily serves the law enforcement needs of the unincorporated, rural areas, but is happy to help out with the various municipal jurisdictions, too.
Similarly, Watauga County provides a share of taxes collected to regional fire districts, such as the Blowing Rock district. That fire protection coverage includes not just the central Blowing Rock station on Valley Blvd., but two more stations, too, each of which are miles outside the Blowing Rock town limits. As it has evolved, the Blowing Rock Fire District includes a large swath of real estate to the east, north, and west of the actual Blowing Rock town limits, as well as the homes, businesses and properties inside the village.
While Boone is the largest population center, it is important to put Watauga County’s overall population into perspective.
Some of the Watauga County fire protection services are manned by volunteers, but Beech Mountain has a couple of fire stations, and there are other stations around the county in Beaverdam, Cove Creek, Zionville, Shawneehaw, Foscoe, Stewart Simmons, Deep Gap, Meat Camp, and of course two more manned stations in Boone. Look at a map of the county and you will see that these stations are pretty well spread out, geographically, to cover the whole county.
While there may be gaps here and there around Watauga County, for the most part law enforcement and fire protection services provide residents and business owners with very good “just in case” protection.
And yet, it is important to point out that those public safety services are NOT outsourced to a for-profit contractor. Sure, there are external funding contributions when you consider the work of volunteers helping out in more rural fire stations, but the County’s overriding priority is providing adequate coverage in the event of fire and it pretty much achieves that objective.
In the spirit of inter-agency cooperation, you might see Blowing Rock send personnel and equipment to Boone to help out if there is a big fire that taxes the resources there, and vice-versa, but it would be rare for the jurisdiction helping out to be left without coverage resources even during those times.
When it comes to public safety, municipal preparedness for emergencies has long been characterized as “overkill”, even if it means police and fire personnel have a lot of idle time on their hands. When you need them, you need them NOW — and whether that idle time is spent napping, playing cards, polishing fire trucks, or eating doughnuts at a local coffee shop, those front line professionals are lightning quick to respond to an emergency call.
Any county board of commissioners that does not adequately serve the public safety needs and concerns of almost half their jurisdiction’s population is failing in its mission.
That is not necessarily the case with ambulance transport services in Watauga County. The Watauga Medics professionals may be trying, but the deck is stacked against them. In short, they are not receiving sufficient funding from the County to achieve what should be the Board of Commissioners’ mission. Right now, that mission may be implied or even parroted, but it is not embraced.
While we are not aware of any regulatory standard for how fast an ambulance arrives at the scene of a 9-1-1 call, there is a well-publicized “guideline” that 90% of a jurisdiction’s population be reached in nine minutes or less. However, EMS World, an industry trade association, reports that the National Fire Protection Association (NFPA)’s “NFPA 1710” establishes a standard for emergency medical operations. That standard suggests a “turnout” time to be one minute (or less) and four minutes or less for the arrival of a unit with first responders or higher level capability at an emergency medical incident. “This objective should be met 90% of the time,” EMS World reports.
Watauga County’s Board of Commissioners apparently uses a different standard than what the industry guidelines deem acceptable.
To get anywhere close to that five-minute industry standard established by the NFPA, there has to be a 24/7/365 ambulance based in Blowing Rock.
On its website, the County’s private contractor, Watauga Medics, proudly reports that it responded to 6,142 calls in 2019 and the “average” response time was 8 minutes and 46 seconds.
On the surface, at least, having an average response time of 8:46 would appear to be pretty good. Look closer, though, and you find that it fails, miserably, because the 8:46 average is greatly distorted by the large number of responses within the town limits of Boone, served by two 24/7 ambulance bases. With that much “firepower” targeting Boone, those in-town calls may often be responded to within two to five minutes. In much of the rest of Watauga County, the response times are far beyond the industry standard. As you get away from Boone they are all too often 2x, 3x and even much longer than the five-minute standard deemed acceptable by NFPA 1710.
The published data we have seen for ambulance response times to locations within the Town of Blowing Rock – the second largest population center in the County – when an ambulance has to respond from Boone is 12-19 minutes. And for local residents who frequently make the 10-15 minute commute to and from Boone for work or shopping, that is about what you would expect. Even with sirens blaring, lights flashing, and drivers ahead pulling over to the right to let an emergency vehicle by, it is pretty hard for an ambulance to overcome the spatial challenges of distance vs. time traveled. To get anywhere close to that five-minute industry standard established by the NFPA, there has to be a 24/7/365 ambulance based in Blowing Rock.
In these pandemic times, ambulance responses have often been much longer, even as much as 45 minutes to Blowing Rock, but that is as much because of “special” coding assigned by County dispatchers receiving 9-1-1 calls making judgments about whether or not the emergency medical event is “life-threatening.” That will be the subject of another editorial and only tangentially relevant here.
And that out-of-Boone number doesn’t even count the population explosion that occurs in resort towns like Blowing Rock, Beech Mountain and Seven Devils when the seasonal residents and vacationers arrive for five to six months of the year.
Understanding Your Constituency
While Boone is the largest population center, it is important to put Watauga County’s overall population into perspective. Of the 56,177 people living in Watauga County (the latest estimates are for 2018), only 19,562 reportedly live within the Boone town limits. Even if you add in 20,000 Appalachian State students for nine months of the year (which would swell the estimated Boone population to 39,562), the estimated 36,615 residents of Watauga County who DON’T live in Boone is just short of identical to those living in town. And when you don’t add the students, the number living outside of the Boone town limits dwarfs the number living in town. Any county board of commissioners that does not adequately serve the public safety needs and concerns of more than half their jurisdiction’s population is failing in its mission.
And that out-of-Boone number doesn’t even count the population explosion that occurs in resort towns like Blowing Rock, Beech Mountain and Seven Devils when the seasonal residents and vacationers arrive for five to six months of the year. What’s more, a lot of those arriving for “the season” are part of an older demographic that more frequently is at risk for needing emergency medical attention and transport to a hospital, be it heart attacks, injuries from falls, or life simply happening.
Over the last 40 years, Watauga County has seen population growth of approximately 77%, most of it outside the town limits of Boone. While the county seat saw its population swell roughly 92% from 1980 to 2019, largely due to the growth of Appalachian State, the 9,000+ growth in population is dwarfed by the roughly 25,000 person growth in the rest of Watauga County. When you look at ambulance response times of 12- to 45-minutes outside of Boone, you have to ask: has the Watauga County Board of Commissioners kept up in adequately providing emergency services to the constituents who elect them to look after their interests?
…has the Watauga County Board of Commissioners kept up in adequately providing emergency services to the constituents who elect them to look after their interests?
How Do We Compare?
Let’s look at the numbers another way, all gleaned from publicly available sources on various surrounding counties’ respective websites.
Common sense suggests that (other than available funding) there are two primary variables when it comes to providing adequate ambulance transport services:  How large is the population? And  what is the geographic size of the region requiring coverage? You might also add any terrain challenges, but Watauga and most of its surrounding mountain counties share more terrain similarities than not.
Given those variables, we were curious to know how Watauga County’s investment in ambulance services compares to surrounding counties. Admittedly, in some cases it is almost like comparing apples with oranges because many, if not most jurisdictions don’t outsource ambulance services. Those counties presumably own, operate, and staff their transport vehicles and also have some administrative overhead budgeted. In those cases, they are not mixing the responsibilities of government with private sector profit incentives. It is also important to point out that when the patients transported are billed for ambulance service, the dollars collected represent revenue captured by the county, not by an outsourced private contractor.
They may not be perfect comparisons, but what we were looking for are three numbers:
- What is a county’s expense per capita?
- What is the county’s EMS investment per square mile of its jurisdiction?
- What are the surrounding counties’ ambulance or EMS annual investment as a percentage of its overall, general fund budget.
Just to understand how challenging it might be for a governmental body to “keep up” with its funding of ambulance transport services, we also calculated each county’s estimated 40-year growth in population.
% OF GENERAL FUND BUDGET
INVESTMENT PER CAPITA
INVESTMENT PER SQUARE MILE
40-YEAR POPULATION GROWTH
By the way, if we had included the App State student population or the seasonal resort populations into the Watauga calculation, the investment per capita would be much, much less.
Admittedly, this may be a small sample size and counties like Allegheny, Avery, Yancey, Burke, and Caldwell, where the EMS services appear to be county-owned and operated, include some administrative overhead (not just outsourced ambulance transport services). But whether looking at the percentage of General Fund budget, investment per square mile, and in particular investment per capita, Watauga County may well be viewed as under-funding its investment in EMS and ambulance transport services, at least relative to its regional peers.
The consequences and ramifications of population growth has caught this Board of Commissioners and its predecessors by surprise.
Of course, when you look at Watauga’s population growth of 77% over 40 years, which in most cases is three to four times the growth rates of the surrounding counties, it is a little easier to understand how the demand for those essential public safety services might sneak up on a governmental decision-making board. The consequences and ramifications of population growth has caught this Board of Commissioners and its predecessors by surprise.
What happens when the service is underfunded and outsourced to a private contractor? In an effort to provide good service to as many people as possible, the contracted ambulance service shifts its crews around with an emphasis on service to the largest population center, in this case Boone. Even though there is supposed to be now a 9-hour shift, five days a week based in Blowing Rock, all too frequently that crew appears to be moved to Boone when one of those regularly scheduled crews responds to a call. Essentially, that leaves Blowing Rock uncovered and subject to those much longer response times.
Under Emergency Services Director Kent Graham, Blowing Rock Fire Department has developed an exceptional, well-trained team of first responders to help stabilize a patient until a Watauga Medics ambulance arrives. And yet, even though they have an ambulance serving Caldwell County, Blowing Rock Fire cannot use that or any other ambulance to transport patients within Watauga County — because of the County’s contract with Watauga Medics.
…but the population growth in Blowing Rock and its surrounding areas deserved one more than decade ago!
Why is this issue taking center stage now? Well, the Watauga County Board of Commissioners is once again aiming to increase EMS funding, but by all reports are aiming to put a new ambulance base on the east side of Boone, in Deep Gap.
We get it that the population growth occurring east of Boone along the U.S 421 corridor is creating new demands for EMS services in that area of Watauga County. The widening of the highway several years ago as well as the recent and planned extension of water and sewer along that corridor will bring that result.
But the population growth that the east side of Boone is now seeing occurred long ago in other parts of the county and especially in Blowing Rock. The east side of Boone merits a new 24/7 ambulance base — but the population growth in Blowing Rock and its surrounding areas deserved one more than decade ago!
And what frustrates any knowledgeable Blowing Rock resident or business owner even more is that the County doesn’t need to build a base in Blowing Rock. An ambulance bay and essential living quarters while a crew is on standby already exist in Blowing Rock Fire Station One, at no cost to the county!
We have spoken to individual members of the Watauga County Board of Commissioners about this issue previously. What we have been told is that because Blowing Rock is on the southern edge of Watauga County, then it would be inefficient, geographically, to put a 24/7 ambulance base in Blowing Rock because the coverage would be relatively limited.
And yet, the height of hypocrisy is obvious when the commissioners now favor, we understand, placement of a new ambulance base in Deep Gap, which is just a stone’s throw from the extreme eastern boundary Watauga County shares with Wilkes County.
What’s more, much of their rationale for a Deep Gap facility is based on a 2017 study which, in our opinion, is one of the shoddiest, most unprofessional pieces of academic work we have seen in more than 50 working years. It is obvious that someone “commissioned” that study to justify a base in Deep Gap over any other considerations. Each member of the Watauga County Board of Commissioners embracing that study as valid should be embarrassed by their intellectual naivete.
When we have asked Board members about why the county decided to outsource ambulance transport services to a private contractor, we were told that outsourcing transfers any future legal liability to the private contractor. Well, that may sound good, theoretically. However, anybody who knows anything about litigation knows that if someone is going to sue for negligence or malpractice, they are probably going to name not just the private contractor, but also whoever hired the contractor — the entity(s) with the deepest pockets from which to recover financial damages.
This is how we see it: if the Watauga County Board of Commissioners raises taxes to fund a $40 million recreation complex that will primarily benefit Boone, then it should place equal or even greater priority in providing essential public safety services to ALL taxpayers in the county, including ambulance transport services.
Here are the options, as we see them:
- If staying with the outsourcing model, then the County needs to at least DOUBLE the amount paid to Watauga Medics so that 24/7/365 transport services can be based in Deep Gap as well as Blowing Rock, with additional consideration given to a base in Meat Camp, Todd or Zionville in the north and Beech Mountain or Valle Crucis in the southwest
- Move away from the outsourcing model and form a Watauga County EMS department charged with fully covering the county and getting as close to the NFPA 5-minute standard as possible
- Allow the Town of Blowing Rock and any other municipality outside of the Boone town limits, at their option, to own, operate, and st ff their own ambulance transport service. This would most likely result in a reduction of the County’s financial obligations to Watauga Medics, but better serve the citizens of Blowing Rock and its surrounding areas.
Whatever choice is made, it needs to be made sooner than later. Maintaining the status quo is intolerable and we can only hope that whomever is elected to the Watauga County Board of Commissioners next month, as well as those remaining, will fully embrace the rest of their public safety mission.