Maine knew for years its ambulance system was collapsing. Then a woman died.

Michael Hunter was panicking.

When his wife, Rachel Worster Hunter, woke up the morning of Jan. 8, 2025, the 54-year-old couldn’t speak clearly or focus her eyes. Michael recognized that she was suffering from low potassium, something she had long grappled with. This time, it was worse than ever.

He called 911 at 9:21 a.m. and assumed an ambulance would soon arrive at their home in Macwahoc Plantation, located in the southern tip of Aroostook County, as it had a year ago when he last called for help. Rachel only needed IV fluids.

Minutes ticked by. The 911 dispatcher called departments spanning Aroostook and Penobscot counties, eventually putting out a call to “any agency” that could get there.

“Alright, Michael, I’m gonna have to be honest with you here for a moment,” the dispatcher told Hunter at 9:51 a.m., according to a transcript of the call provided by Rachel’s family. “I have toned every ambulance between Houlton and Old Town and I cannot find anyone.”

Ten departments refused to save Rachel’s life that day. Hunter wept as Rachel’s breathing slowed. She died shortly after 10 a.m.  

When you call 911, you expect help will arrive. Most Mainers consider it an essential service that’s guaranteed when we live and pay taxes in a community.

But Maine does not require towns to provide ambulance service to residents. After decades of emergency services shrinking or shuttering completely across the state, they are now “at the edge of a cliff,” a committee convened to study the issue told the Legislature two years before Rachel’s death. The same panel echoed those concerns in a 2024 report.

Despite years of dire warnings, the state has failed to meaningfully address the lack of ambulances in Maine’s most rural communities, according to more than two dozen people the Bangor Daily News interviewed for this story, including first responders, town officials and state legislators. Little has changed since Rachel’s death, leaving more Mainers vulnerable to growing wait times for help to arrive — if it comes at all.

“It gives me sleepless nights,” Wil O’Neal, director of Maine EMS, said of the lack of urgency to address the factors that led to Rachel’s death.

“The terrible event where someone lives in an area that they don’t know does not have emergency coverage, and they call for help and no one comes and they die — that has already happened. I’m worried that could happen again tonight because we have not been able to take more aggressive, meaningful steps towards a remedy.”

A tangled network

Maine’s largest cities and towns often have their own ambulance services, which run through their respective fire departments. In Bangor, ambulances come from one of the city’s three stations.

But small communities typically rely on others to send help, either with publicly owned ambulances staffed by nearby fire departments or through private services, such as those run by a hospital or local company.

The result is a tangled network of arrangements in rural Maine, where one town may respond to a fire while a different service provides an ambulance. Yet another may answer the call if the primary agency is unavailable. Mainers rarely know the details of such arrangements.

Depending on the area, an ambulance may not be required to show up at all. State law deems the service “essential” but does not mandate coverage, as it does for law enforcement. Whether they know it or not, about 14% of Mainers live in areas with no ambulance coverage, O’Neal estimates. Such a distance is typically referred to as an “ambulance desert.”

“Most residents in those areas that don’t have service now, I don’t think they are aware that they’re in a situation where we cannot require someone to come to their aid,” said O’Neal, who oversees the regulatory body responsible for licensing workers and agencies and investigating complaints, but that does not set policy.

The BDN called every fire department and ambulance provider in Penobscot County to create a first-of-its-kind database of who responds to which towns in an emergency. About two-thirds responded. It found that these agreements range from formal contracts between communities to decades-old handshake deals with little enforcement.

Towns without their own fire departments now tend to have contracts with fixed costs in place. For example, the Lincoln Fire Department has a contract to provide EMS and fire services to Winn, a town of about 300 people, for about $115,000 a year.

Macwahoc Plantation had long relied on neighboring departments to help in emergencies, but those agreements were never formalized. In July 2024, residents rejected a $1,600 contract proposal from the East Millinocket Fire Department that would ensure those services continued.

Just eight of the 62 people who live in Macwahoc voted on the proposal.

It was not rejected because of the cost, but because a contract simply wasn’t how things were done before, Assessor Roger Pratt said. For his whole life, people there just picked which town’s ambulance they wanted to respond to emergencies and didn’t understand why that needed to change.

Macwahoc signed a $9,400 contract with Lincoln after Rachel’s death.

But no arrangement guarantees help will arrive as fire departments lose staff and ambulance providers try to rein in growing costs.

The number of volunteer firefighters has plummeted nationwide, with the service losing a quarter of its members in 15 years, according to the National Fire Protection Association. That means even if a town has its own department or a contract for services, there may not be enough first responders available to go to multiple emergencies at the same time.

It’s also expensive to operate an ambulance. Buying the vehicle alone can cost up to $500,000, and running it can cost $400,000 a year, Lee Fire Chief Jay Crocker said. MaineCare reimburses ambulances at a fixed rate, and nationwide the money recouped from insurance providers is a fraction of the actual cost, a federal study found.

The average reimbursement is $525 per person transported, said Ed Moreshead, interim lead for Northern Light Medical Transport, who has worked in EMS in Maine for nearly 40 years. That means an ambulance needs to run about 2,400 calls a year to break even, given that not every patient is transported and billed. Many rural areas do not have enough calls to support the service.

Two years ago, Northern Light Health shocked towns it provides ambulance service to when it started charging $17 per person for an annual contract. The service had previously been free, relying solely on reimbursements. The growing costs for these services become harder for taxpayers to tolerate as property taxes surge throughout the state.

“You’re not seeing services go completely out of business yet,” Moreshead said. “I think that that’s coming.”

A $350 million crisis

The Legislature has passed several laws intended to improve emergency services in recent years, but they fail to provide what the commission said is needed most to fix the crisis: money.

The commission’s first recommendation in its 2022 report was for the state to provide $350 million in funding across five years to support existing EMS services. A second report from the commission in 2024 suggested raising reimbursements so that ambulances can recoup the money that they spend.

Instead, the Legislature allocated a one-time $31 million boost to EMS agencies across the state, three-quarters of which has been distributed. It also approved additional reimbursements for ambulances, such as providing payment even when a patient isn’t transported to a hospital. That didn’t eliminate the funding gap.

A state law passed this year requires communities to publicly post whether they have a contract for ambulance services. It does not force towns to provide ambulance services to its residents, which would require an amendment to the Maine Constitution.

Beyond that, the Legislature has approved the creation of more commissions and reports, none of which guarantee changes will be made. They include the Maine Emergency Medical Services Commission, which is tasked with filing a report on the system’s funding needs by Jan. 1, 2027. A report on the number of firefighters in Maine is expected to be finalized this fall.

Getting the Legislature to close the gap between what insurance pays and what delivering EMS costs has been the biggest struggle for Sen. Chip Curry, D-Belfast, who worked on both commissions.

“I continue to be pretty concerned and continue to think that we’re not in a long term sustainable, financial system for emergency medical [services],” Curry said.

Local legislators disagree about the severity of the crisis facing rural Maine.

Making towns submit an EMS plan is a step forward, said Senate Minority Leader Trey Stewart, R-Presque Isle, whose district includes Macwahoc Plantation. Stewart also pointed to the Maine EMS commission and upcoming funding report as improvements.

But for Sen. Mike Tipping, D-Orono, the rapidly rising costs of EMS require a more sustainable path than being funded primarily by property taxes.

“I think there is a lot more still we need to do to make sure that when you call 911 someone answers and gets to your house in time,” said Tipping, whose district covers Lincoln, Burlington and Orono.

With no changes, emergency services in rural Maine will be spread more thin in the coming years.

Maine’s population of people over the age of 65 is predicted to surge to 400,000 by 2028, up from 276,000 a decade prior, a report from the state economist found. Those people are more likely to call 911 than their younger counterparts, according to a study published in Prehospital Emergency Care.

Over the same period, the number of people in the state who are between 20 and 64 years old — the group most likely to provide emergency care — is expected to drop nearly 8%.

The only path forward that makes sense for rural Maine is regionalizing EMS, multiple people told the BDN.

In that model, small towns could work with a regional agency while larger communities run their own departments, similar to how county sheriffs or state police operate.

There’s already an example of this in Howland. More than 10 communities in Penobscot and Hancock counties merged their emergency services into one district in 2024. The Central Maine Highlands Fire & EMS District 1 is run by a board of directors and covers about 500 square miles, providing coverage to more than 4,500 people.

Such partnerships are more effective than a system where local agencies maintain strict control, O’Neal said. The Maine EMS commission’s upcoming report must include how much the adoption of a regionalized system would cost.

‘My whole life has changed’

For years, Michael would joke with Rachel that he would die before her.

Michael, now 67, was 10 years older than Rachel and had endured health issues, including diabetes, leading him to believe he’d be the “one to go first.” Rachel told Michael that he’d outlive her.

The pair spent 21 years together. They met in 2001, married five years later, briefly divorced and then got back together. Hunter still called Rachel his wife, even though they never officially remarried.

“She was the love of my life,” Michael said.

Now Michael lives in their house alone. A forearm tattoo of a yellow hummingbird — Rachel’s favorite — serves as a reminder of what he lost.

“My whole life changed,” Michael said. “I won’t go to a restaurant and eat because I won’t go in and sit by myself.”

No one from the state reached out to Hunter or to Macwahoc officials after Rachel’s death. Pratt, the Macwahoc assessor, thought maybe someone running for office would bring it up this year, using the state’s rural emergency services crisis to stump for votes.

“But evidently it’s not that big of a deal,” the 75-year-old said.

Pratt doesn’t think anything will change for rural EMS service. When asked if he thought someone else would die, Pratt said, “Oh that’s going to happen, there’s no question around it.”

But to Michael, there’s no change that could be made now that will make a difference to him.

“I don’t trust EMS,” Michael said. “I never will.”