Issue 04
August 2026
Buy the Ambulance for the Right Reason
The numbers on what ambulance service actually costs to deliver have been sitting in the
open since December, and departments are still voting on transport without reading them. If
yours runs an ALS first response unit and is having this conversation, start here.
THE NUMBER, AND WHO ACTUALLY RAN IT
CMS and RAND published the expanded Year 1 through Year 4 cohort analysis from the Medicare Ground
Ambulance Data Collection System. It draws on 7,387 ambulance organizations, roughly 70 percent of
those sampled, reporting their own costs to the federal government. Labor came to 71 percent of total
ground ambulance expenses. This is not a survey of the disgruntled. It is close to the whole industry, under
a federal reporting requirement.
What CMS and RAND did not do is tell you whether any of it gets paid for. The report says so directly:
GADCS was not designed to determine Medicare payment rates, and the assessment of payment adequacy
belongs to MedPAC. The authors even caution that their regression models should not be read causally.
They collected the costs. They declined to draw the conclusion.
Matt Zavadsky of PWW Advisory Group drew it. Running the expanded dataset in December, he put the
average ambulance response at a loss of more than $1,000, a 56 percent gap between what a call costs to
run and what it reimburses. For low-volume and public-safety-based agencies, he put the gap above 63
percent.
That inference is his, and it is worth knowing whose it is before you quote it at a board meeting. But the cost
data underneath it is the industry's own, submitted to the federal government by 7,387 agencies, and it is not
going to be argued away.
So sit with the 63 percent. That is not a description of the industry at large. That is a description of the
department you are proposing to become.
YOU CANNOT VOLUME YOUR WAY OUT
The instinct on seeing those numbers is to assume the answer is scale. Run more calls, spread the cost.
That door is closed. Readiness costs are fixed regardless of call volume. The unit, the insurance, the radios,
the narcotics accountability, the training hours, the recertifications, the ePCR license, the billing vendor allexist whether you run 400 EMS calls a year or 1,400. The department running 400 carries nearly the same
burden across a third of the billing events.
Nationally, the top 10 percent of agencies handle about two-thirds of all transports. The economics of this
work reward enormous volume. Volunteer departments do not have enormous volume, and the ones that do
are having a different conversation.
None of this is an argument against EMS, and no chief should read it that way. It is an argument about a
payment model that has never reflected what prehospital care costs to deliver. The people absorbing that
gap are the ones doing the work. New York's Rural Ambulance Task Force said it plainly in March: agencies
receive little or nothing for scene-based treatment that prevents a hospitalization, while 24/7 readiness has
to be funded anyway. The task force warned that rural ambulance service across the state is on the brink of
collapse, and recommended designating EMS an essential service with dedicated municipal funding, wage
floors for EMTs and paramedics, and reimbursement for treatment in place.
That is the correct diagnosis. It is also not going to be fixed before your next board meeting.
“Readiness is the product. Transports are just the billable events that
happen to occur while you are ready.”
THE RIDE-IN
There is a version of this conversation that never makes the trade journals, and it is the one actually
happening in the bay.
Your medic makes the patient. The patient needs ALS. The BLS ambulance arrives, and your volunteer
climbs in the back for the transport, unpaid, while the two providers in the front are on the clock. Your medic
is committed for the transport, the hospital turnaround, and however long it takes to get back to the district.
Your ALS coverage is zero for those two hours. The transport agency bills the call.
Members do that math without being asked to, and it produces the most persuasive argument in the whole
debate: we do the medicine, they get paid, and we lose our medic. Do not pretend that is not a real
grievance. It is.
But look at what it means structurally, because this is the part that gets missed. Whatever the transport
agency's reasons for not staffing a paramedic, and there are good ones, including a labor market that is
punishing everybody and a fee schedule that does not cover the position, the effect of the unpaid ride-in is
the same. Your department absorbs the consequence, so the agency never has to price it. Nobody has to
be acting in bad faith for that to be a bad arrangement. And it looks stable right until your medic is not
available, at which point it becomes clear there was never a reliable ALS transport capability there at all.
That is not hypothetical. That is how these systems fail.
It is also worth saying out loud that when riding in is unpaid, inconvenient, and strands the medic two towns
from his vehicle, the pressure to call a patient BLS-appropriate goes up. That is a staffing problem reaching
into a clinical decision, and nobody wants to be the one to name it.The grievance is legitimate. As a reason to buy an ambulance, it is the most expensive one on the menu.
You would be taking on a 63 percent cost gap to settle what is structurally a contract dispute. A written
ride-in policy that specifies when your medic goes and when the patient goes BLS costs nothing. A
per-ride-in stipend billed to the transport agency costs a stamp. A paid-medic arrangement is a
conversation. Try all three before you spend six figures on apparatus and then discover you still have to staff
it.
THE CASE THAT SURVIVES
Now the argument that does hold up, and it has nothing to do with money.
The ALS first response model has exactly one point of failure: somebody else's ambulance. Your paramedic
is only as valuable as the transport that shows up behind him. If that partner folds, your ALS capability goes
to zero overnight, and you are left with a paramedic standing over a patient with no ride.
The partners are folding. New York lost 9 percent of its ambulance services in a decade, from 1,078 to 982.
Active certified EMS practitioners in the state fell 17.5 percent between 2019 and 2022, and only about 44
percent of certified providers are actively delivering prehospital care. This year alone the trade press has
covered a New York EMS support agency shutting down over delayed grant funding, a Pennsylvania service
closing for lack of volunteers, a South Dakota service threatened by workforce shortage, and a regional
provider announcing station closures and layoffs.
Joseph Maruca, chief in West Barnstable, Massachusetts, made this argument in Fire Engineering in 2019,
seven years before the federal data caught up to him. His department transports, not because it profits, but
because nobody else provides comparable ALS response times. His conclusion was that small departments
will not make money on ambulance service and should take it on only when it genuinely serves the
community better than the alternative. He was right, and there are now 7,387 agencies worth of evidence
saying so.
Controlling your own transport is a legitimate reason to buy an ambulance. It is a continuity decision, not a
revenue decision, and the difference is not academic.
“An ALS first response unit is only ever as good as the transport that
shows up behind it.”
TWO QUESTIONS BEFORE THE VOTE
A revenue-motivated program gets pitched to the board as revenue-neutral or better. When it is not, and it
will not be, the chief loses credibility and the program gets cut in year three. A continuity-motivated program
gets pitched from day one as a subsidized essential service, which is exactly what it is, and it survives its
first bad budget.
Revenue logic also pushes you toward minimum crew and maximum billable volume. Continuity logic
pushes you toward reliable coverage in the hours you genuinely cannot staff, which for most volunteerdepartments is weekday daytime, not three in the morning. Same apparatus, completely different
deployment.
So, two questions.
If the transport revenue came out to exactly zero, would you still do it? If yes, you have a real reason, and
you should build a real subsidy line into the budget and defend it out loud. If no, the federal data says you
are about to find out.
And if the transport agency started paying your medic for every ride-in tomorrow, would you still want the
ambulance? If the answer is no, you have a contract problem, not an apparatus problem, and a contract is a
great deal cheaper.
The fire service has spent thirty years quietly absorbing the cost of EMS because saying we cannot afford
this felt like an admission of failure. It was never a failure. It was a payment model that undervalued the work
from the beginning, and the people who filled the gap did it out of obligation to their neighbors. This report is
permission to stop filling it silently. A community that wants ALS transport can have it, funded and staffed
and named as the essential service it is. What it should not have is a volunteer department financing it out of
goodwill and a pancake breakfast.
SIDEBAR: THE VOLUNTEER SERVICE'S QUIETEST FATALITY PROBLEM
NFPA's 2025 fatality report counted 83 firefighter deaths, up 17 percent from 69 the year before. Heart
attacks were the leading cause at 45 of them. Of the 79 municipal firefighters who died, 45 were volunteers.
The volunteer service is where the cardiac deaths are.
Inside that number are two separate problems, and it is worth keeping them apart, because they call for
different fixes and most departments have neither.
The first is who gets on the rig. Of the 45 heart attack deaths, 27 happened on duty. Set that next to a
NIOSH report released this year. In January 2025, a 46-year-old lieutenant in Montgomery County,
Maryland, collapsed on the fireground during his second shift back. He had suffered a stroke the previous
October and carried a new diagnosis of congestive heart failure. He returned to duty through a shift
substitution rather than formal medical leave, which meant he never went through the NFPA 1582
return-to-work evaluation. There was a policy. A scheduling workaround beat it.
That was a career department with an occupational health program and paperwork. Now ask what the same
failure looks like in a volunteer department, where there is no scheduler, no HR, no occupational health, and
often no policy at all. A member has a cardiac event in March, tells his officer he is fine, and in June pulls on
an SCBA and goes interior. There is no gate to fail. Nobody built one.
The regulatory backstop is thinner than most chiefs assume. OSHA's respiratory protection standard
requires a medical evaluation before SCBA use, but federal OSHA does not automatically cover state and
local government employees. Twenty-two State Plans cover both private and public sector workers, seven
cover public employees only, and in the rest, public sector workers have no direct OSHA coverage. Whether
volunteers count as employees varies by state and by how your department is organized. Find out which
column you are in. Most chiefs have never checked.The clinical picture is worth stating precisely. A new heart failure diagnosis or a reduced ejection fraction
means a closed-circuit demand on a compromised pump, under thermal load, in an atmosphere the member
cannot leave quickly. If he is on a beta blocker, his heart rate response is blunted, which means the
fireground indicator you would normally rely on, that he is working too hard, will not appear. And a primary
care clearance to return to work is not a clearance to perform interior structural firefighting. Most members
do not know that. Neither do most physicians. NIOSH specified evaluation by a physician who understands
firefighting demands, and that qualifier is the load-bearing part of the sentence.
The second problem starts when the member goes home. Eighteen of the 45 heart attack deaths happened
within 24 hours of duty rather than on the fireground, and volunteers accounted for 16 of those 18. NFPA's
reading is that volunteers lack immediate medical access once they leave. That is a different failure from the
first one, and no medical clearance program would have caught most of it. A career firefighter finishing a
working fire goes back to a station with a crew, a rehab process, and people who will notice him going gray.
A volunteer drives home alone and goes to bed.
Five things a chief can do without an occupational health budget:
Write a self-report duty. Members notify a named officer after any hospitalization, emergency
department visit, new cardiac or pulmonary diagnosis, or new prescription in those classes. It is an honor
system, but an honor system with a rule beats no rule, and it creates a record.
Give one person the roster. One officer owns the interior-qualified list and has the authority to pull a
member's SCBA status. Not a committee, and not a collateral duty nobody has time for.
Find one physician. You do not need a full 1582 program to have a single doctor in your community
who has been walked through what interior structural firefighting actually demands of a body.
Make SCBA the trigger. If clearance cannot be established, the member works exterior. That is an
operational assignment, not a medical determination, and a chief can make it. Write it into your SOG as a
standing status rather than improvising it member by member, and have your attorney read the SOG
once, so you are not calling counsel every time you use it. Volunteer employment status, disability law,
and any bargaining agreement in a combination department all touch this, and they touch it once, at the
policy level.
Do not let them drive home cold. Formal rehab before release, and a check-in the next morning for
anyone who worked a significant incident. It costs nothing, it is the only control that addresses the 16 of
18, and it is the one nearly every volunteer department skips.
THE OBJECTION, AND THE ANSWER
Any chief reading this has already thought it: volunteer departments are losing people, and adding medical
hurdles will cost you members. That is true.
The answer is that exterior-only status is a retention tool, not a termination. Most departments have no such
category and treat qualification as all-or-nothing, which makes every medical question existential for the
member. So the member says nothing. Build a real exterior role and the self-report becomes survivable. The
department that can say you can still run, just not interior, gets told the truth. The department that cannot,
does not.The career service's failure mode is a policy that got bypassed. The volunteer service's is that there was
nothing to bypass, and that when the call is over, everybody drives home alone. Neither of those is
expensive to fix. Both of them are embarrassing to explain after the fact.
“In a career department, return to duty is a process someone can fail to
follow. In most volunteer departments, it is not a process at all.”
HOMEWORK
Call your PPE vendor this week and ask one question: when PFAS came out of our moisture barrier, what
went in? Get the answer in writing, and ask specifically whether decabromodiphenyl ethane, DBDPE, or any
brominated flame retardant is intentionally added, and at what concentration. A study of used turnout gear
published in Environmental Science and Technology Letters found levels in some newer sets that would
exceed the limits in NFPA 1970, concentrated in the moisture barrier and thermal liner, the layers that sit
against your people. Unlike PFAS, DBDPE is not chemically bound. It is an additive, and additives leach
with heat, wear, and laundering.
If the only answer that comes back is PFAS-free, you did not get an answer. PFAS-free is a marketing term.
It is not a specification, and we should stop buying gear as though it were.
References
EMS Cost and Reimbursement
CMS and RAND, Medicare Ground Ambulance Data Collection System (GADCS), Year 1 through Year 4 cohort analysis,
cms.gov. Source of the 7,387-organization figure and the 71 percent labor share. The report states it was not designed to
determine Medicare payment rates and does not assess payment adequacy.
Matt Zavadsky, PWW Advisory Group, "The data is in, the debate is over, the check is still short," EMS1, December 19,
2025. Source of the per-response loss figure and the 56 and 63 percent cost-to-reimbursement gaps, derived from the
GADCS dataset.
2026 New York Rural Ambulance Task Force Report, released March 2026. Coverage via WXXI News and New York State
of Politics.
Joseph V. Maruca, "To Ambulance or Not to Ambulance?" Fire Engineering, May 2019.
"Volunteer EMS: 10 things to know about billing for services," FireRescue1.
Firefighter Fatalities and Medical Clearance
NFPA firefighter fatality report for 2025. Coverage via Occupational Health and Safety and Fire and Safety Journal Americas.
NIOSH Fire Fighter Fatality Investigation, Montgomery County, Maryland, January 11, 2025. Reported via FireRescue1.
OSHA 29 CFR 1910.134, Respiratory Protection; OSHA State Plans coverage summary, osha.gov/stateplans.
NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.
Protective Clothing
Study of used turnout gear published in Environmental Science and Technology Letters, on brominated flame retardants in
PFAS-free gear. Coverage via FirefighterNation."PPE Supplement 2026: PPE Reimagined," Fire Engineering.
NFPA 1970, Standard on Protective Ensembles, effective 2026.
THE MARGIN • Command judgment for chief officers. • Issue 04 • August 2026