Stefan Hofer's ambulance company, West Traill EMS, in Mayville, North Dakota, has received only one or two calls that weren’t related to Covid-19 over the past two months. But he said the case count has ballooned by 20 to 30 percent because of the pandemic. At the same time, the company's expenses have mounted, its revenue has cratered and its workforce is being decimated by the virus.

The company — which is private and supported by volunteers, a few employees and four trucks — covers more than 1,500 miles of North Dakota prairie and serves about 10,000 people on the far east side of the state.

Private EMS services, both in urban and rural centers across the country, collectively received $350 million in Covid-19 relief funds in April, but those companies said that money ran out within weeks. Months later, the need remains great as they face another coronavirus surge.

Hofer said he doesn’t know how long his company can keep up its current pace — much less how it will manage the increase in cases they expect from the Thanksgiving holiday — if ambulance services like his don’t receive additional federal aid. He said he may lose employees soon. That could mean answering fewer calls, too.