JOHN YANG: When people call 911, they expect an ambulance to respond quickly and deliver medical care.

But nearly four and a half million Americans live in what's known as ambulance deserts in a medical crisis, they have to wait as long as 25 minutes or even longer for an emergency medical crew to arrive.

Ali Rogin tells us what's causing these shortages and what's at stake for people who live in these ambulance deserts.

ALI ROGIN: In medical emergencies, getting swift transportation to a hospital can mean the difference between life and death.

But with a limited number of ambulances to dispatch some states are struggling to meet that need.

Nick Nudell is the president of The American Paramedic Association and spent almost 20 years as a paramedic in Montana and California.

Nick, thank you so much for joining us.

Can you first just describe to us what the emergency medical services industry in this country looks like?

NICK NUDELL, President, American Paramedic Association: The EMS industry is comprised of a number of different elements, and can be provided by government agencies or private companies, and in some cases is also provided by hospitals that operate an ambulance service.

In many rural areas of this country the ambulance service is provided by unpaid volunteers from the community.

So it's really depending on the availability of community members to provide that voluntary service.

And so, if you're in an even more rural or more remote area, you may have to wait quite a while for an ambulance to be able to get to an emergency, if you have one.

ALI ROGIN: Has the situation always been this bad in terms of the lack of volunteers, and the difficulty that people have accessing these emergency ambulance services when they need them?

NICK NUDELL: No, I don't think it always has been as bad as it is today.

Over the past couple of decades, there has been a strong decline in the number of people available to be providing voluntary services in rural communities.

So because of that there are fewer and fewer people who are available to replace the older volunteers who in many cases are now approaching their 60s or 70s and still volunteering.

But we know that that can't last for very much longer.

ALI ROGIN: Nick, you yourself worked as a paramedic for over 20 years, can you describe the human toll put upon these workers when they're having to meet this overwhelming need?

NICK NUDELL: Yeah, the rural EMTs and paramedics that especially those that volunteer giving up their time, their family time, they have many missed birthdays, and celebrations and just really have to dedicate a lot of their own personal time in order to provide the service on top of all of their other responsibilities.

And that has a great toll on them personally, and that's why so many of them continued to do it for decades, because it's difficult to find somebody to replace them.

ALI ROGIN: There are only a few states that designate EMS services as an essential service.

And it seems like that is coupled with low salary rates for a lot of these jobs.

What other factors are involved in there simply not being enough people to do these jobs.

NICK NUDELL: With elected officials really just kind of kicking the can down the road and not owning the problem of funding.

That leaves the service provision to the volunteers and other community members who often have bake sales or spaghetti sales or other kinds of local fundraising efforts to pay for the fuel or to buy ambulances if EMS was declared as an essential service.

And then real effort was put into finding funding mechanisms that would be sustainable for providing the service that would go a long ways towards being able to support the rural ambulance services especially and could address the ambulance desert issue.

ALI ROGIN: And what is the federal government doing to address this issue?

Are they doing anything?

And what do you think they should be doing?

NICK NUDELL: The federal government recently did declared EMS as an essential service along with all of the grocery store workers and truck drivers and many other essential occupations during the COVID pandemic, that declaration really kind of faded with the ending of the pandemic.

ALI ROGIN: Tell us about how the way that the United States does Emergency Medical Services differs from other countries?

NICK NUDELL: Well, in the United States, because it's not an essential service being provided by the government, like it is in other countries, we have somewhere on the order of 22,000 Ambulance Services, you could contrast that with Australia, with 10 states, they have 10 Ambulance Services.

And so it's much easier for the government to provide that level of service when there's fewer organizations and people involved.

And so it's a much more efficient system.

And they're able to provide better care for their entire country, where here we have so many services that it's difficult to provide that same level of service across our country.

ALI ROGIN: And in fact, you found places where there's a great concentration of ambulances, in fact, even more than are necessary for the population that surrounds them.

NICK NUDELL: Yeah, that's right.

We did look at one state, the state of North Dakota, and we were able to determine that they had more than enough ambulance services to provide for the entire state to have no ambulance deserts, but it would require moving where those ambulances are to help provide better coverage.

So, I assumed that that's going to be the case in other locations to where really if you were able to take that systematized approach, instead of having a patchwork approach, you can provide all the services needed so it doesn't necessarily mean it's going to be more expensive.

ALI ROGIN: Nick Nudell, the president of the American Paramedic Association.

Thank you so much for joining us on this important issue.

NICK NUDELL: Well, thank you very much.