Author: Matt Zavadsky

This commentary is notable because it takes an issue the ambulance industry has been raising for months and places it squarely in the broader national health policy conversation.

CEPR explicitly connects restrictions on Medicaid supplemental and state-directed payments with the financial sustainability of ambulance services, warning that the consequences could include fewer staffed ambulances, longer response times, service reductions, and even agency closures.

Importantly, it also recognizes that these effects extend well beyond Medicaid beneficiaries, when an ambulance disappears from a community, it is unavailable to everyone who needs it.

The article reinforces what the profession’s own cost data have demonstrated: Medicare and Medicaid reimbursement already falls substantially short of the actual cost of providing ambulance service, leaving little capacity to absorb additional reductions.

While we may not agree with every political characterization in the commentary, having an independent economic policy organization describe EMS as potential “collateral damage” of these policies significantly broadens the audience, and strengthens the case that this is a healthcare access and community infrastructure issue, not simply an ambulance reimbursement issue.

NOTE: PWW|AG has a prepared a free toolkit that agencies can use to help assess and prepare for the potential impact of the CMS Proposed Rule impacting Medicaid Ambulance Supplemental Payment/GEMT programs.

You can access the toolkit here.

Collateral Damage: How the One Big Beautiful Bill Act Threatens the Future of Emergency Services

Sep 11, 2026

By Eileen Appelbaum

https://cepr.net/publications/collateral-damage-how-the-one-big-beautiful-bill-act-threatens-the-future-of-emergency-services

On  the 25th anniversary of the horrendous 9/11 terrorist attacks, a grateful nation is celebrating the bravery of the EMTs, emergency medical technicians who ran into fire and smoke-filled collapsing buildings to rescue and treat victims. It’s a moment to contemplate, as well, the less spectacular lifesaving rescues emergency ambulances and their crews make every day, coming to the aid of car crash victims and people suffering health emergencies in their homes. 

But few of us are aware of the perilous financial situation facing emergency medical service (EMS) companies, made worse this year by provisions in H.R.1, the One Big Beautiful Bill Act, that limit how states can top up woefully inadequate Medicaid payments for services provided to people on their rolls. The number of emergency ambulances, the services EMTs provide, and the geographic areas served are in danger of being reduced, and some EMS companies have even had to close.

When President Trump signed the Republican-passed One Big Beautiful Bill Act (OBBBA) into law, there was plenty of attention paid to the more than $900 billion in cuts to Medicaid, the program that provides health insurance for low-income and disabled people. But there was little talk of the wider damage those cuts would have on health care services that millions of Americans not on Medicaid rely on. 

Republicans were focused on a desperate need to offset massive tax breaks in the OBBBA for wealthy individuals and corporations that will reduce federal revenues by more than $3.5 trillion over 10 years. Republicans saw cutting Medicaid spending as an opportunity to reduce the federal budget deficit created by the tax giveaway at the expense of people they mischaracterized as illegal immigrants or able-bodied folks too lazy to work. If Mehmet Oz and others in the administration responsible for carrying out health policy knew enough to understand the fallout the bill’s provisions would create in other parts of the US health system, they raised no alarms. But it seems safe to assume that most Republicans voting for the Medicaid cuts had no idea that they would threaten emergency ambulance services and deprive Americans with no relationship to Medicaid of a quick response in an emergency.

To understand how cuts to Medicaid can threaten the nation’s emergency services, it’s necessary to take a brief detour into provider taxes and state directed payments.

State Provider Taxes

Medicaid payments to providers are often drastically below the cost of providing necessary medical services. One way that states and municipalities reduce this shortfall and retain critical services is through provider taxes that fund state-directed payments for these services. States are allowed to tax hospitals, clinics, emergency ambulance companies, nursing homes, Medicaid managed care organizations and other institutions that treat Medicaid patients and to use the proceeds to fund state directed payments to these providers to help fill the gap. Medicaid is a joint state-federal program and, like other state payments for the care of Medicaid beneficiaries, they are matched by the federal government, which picks up its share of Medicaid costs.

Prior to the passage of OBBBA, these taxes were limited to 6 percent of a provider’s net patient revenue. New provisions in OBBBA banned new provider taxes or increases in the rate of existing provider taxes.

In the states that expanded Medicaid coverage as part of the Affordable Care Act (expansion states), it ratcheted down the amount of net patient revenue that states could tax from 6 percent to 3.5 percent by 2034 with a few exceptions. This reduces the funds states have available to supplement Medicaid payments. Cutting provider taxes and state directed payments to Medicaid providers reduces federal spending on its match of these payments. These provisions are projected to reduce federal spending on matching funds by nearly $225.7 billion over 10 years.

On the state-directed payments side, OBBBA requires expansion states to reduce the size of these payments to providers to the Medicare payment rate and to 110 percent of Medicaid rates in the other 10 states by 2029. In some cases, Medicare payment rates fail to come close to covering providers’ costs. OBBBA applied these limits to hospital inpatient and outpatient services, skilled nursing facility services, and qualified practitioner services at academic medical centers. However, in May the Centers for Medicare and Medicaid Services (CMS) proposed a rule that went beyond these four categories and applied the limits to all services and providers by 2029. CMS projects its rule will reduce Medicaid spending by $775 billion over 10 years, with the federal government reaping two-thirds of the savings. In August, CMS finalized the rule extending these limits.

The Case of Emergency Services

The revenue for most EMS systems comes from billing insurers (commercial insurers, Medicare, Medicaid) and patients. The reimbursements from Medicare and Medicaid are dramatically short of covering actual costs. Much of the difference is made up from taxes (general revenue and property taxes as well as provider taxes and state-directed payments). Average payments by public insurers — Medicare (traditional fee-for-service and Medicare Advantage) and Medicaid — do not come close to covering the costs of emergency ambulance transport. Much higher payments from commercial insurers bring average revenue closer to average costs.

In December 2024, CMS released the first report on the Medicare Ground Ambulance Data Collection System (GADCS) based on an analysis by RAND Health Care. The report is based on survey data collected from 3,694 ambulance agencies for the years 2022 and 2023. It presents aggregate costs and revenues for Emergency Medical Services documenting the extent of the shortfall. The RAND report also breaks down aggregate costs into its component parts. Labor costs are the largest category. In 2022-2023, they were 69.4 percent of the $27.2 billion of aggregate ground ambulance costs for the agencies included in the survey. Labor costs include administration facilities staff as well as EMTs and EMT-paramedics. Median aggregate ground ambulance labor expenses were $551,000 while average ground ambulance labor expenses were many times larger at $3.65 million. This is likely due to a small number of EMS organizations with labor costs that were much higher than the typical organization.

The high share of labor costs doesn’t mean that EMTs are highly paid workers, however. On the contrary, despite their skills and the stress of their jobs, their pay is quite modest. The Bureau of Labor Statistics’ (BLS) Occupation Employment Survey (OES) reports that median pay of EMTs was just $38,930 in May 2023. 

A January 2025 webinar that featured the lead author of the RAND report presented average costs and reimbursements for ambulance transport and documents the gap between these costs and reimbursements to EMS agencies. RAND found that nationally, the average cost of an ambulance transport across all types of emergency medical systems was $2,673. The average reimbursement was $1,147, an under-reimbursement of $1,526 per transport. Medicare reimbursements were much lower, averaging just $329 — an underpayment of $2,334.

Data for New York state from the American Ambulance Association drives the disparity home. While Medicare reimbursements are higher in New York than the national average, they are still far below the costs of emergency ambulance transport. Medicare reimbursement for a basic level emergency service (BLS) was $507 in 2026 and for an advanced level emergency service (ALS) was $602. Importantly, the table below also presents Medicaid reimbursements for the two levels of emergency services: they are $250 and $296, respectively. This is just under half the Medicare reimbursement rates, a drastically low payment rate.

As the reimbursement rates show, the situation was already dire for emergency ambulance services before the development of new CMS rules in the OBBBA — rules that are even more draconian than called for in the legislation. Emergency ambulance deserts were already becoming apparent as EMS agencies closed, especially in rural and super rural areas where they are especially needed and often function as the only medical facility people can access in a medical emergency. They may become more prevalent as states’ ability to supplement Medicaid reimbursements is reduced.

Emergency ambulance services provide a sense of security in rural areas devoid of the medical resources available in cities. The limits on how states supplement Medicaid payments mean that some EMS agencies will be collateral damage as the Trump administration shreds the social safety net and cuts programs that provide essential health services that the US can well afford. Reductions in supplemental payments may lead ambulance agencies in rural areas to cut services or the number of ambulances, increasing response times when minutes may mean the difference between life and death. Emergency ambulance services may even find that they can’t make the math work and close down.

JD Vance, who cast the deciding vote for the OBBBA, ignored the effects of cuts to Medicaid on health care for the many folks in Appalachia and elsewhere who rely on the program. But he probably didn’t consider the effect of the cuts on the wealthy people with second and third homes in remote scenic areas. These people, too, may find there isn’t an ambulance with a crew of EMTs available to stabilize them after a traumatic event.

Interesting ED wait time data from CMS, which could be used by innovative EMS systems to help make the case for funding and implementing alternate disposition models such as:

Dispatch Triage: With ED visits averaging more than 2½ hours, EMS should expand clinical dispatch triage and secondary nurse/clinician review to identify patients who may not need an ambulance or ED. The best opportunity to avoid an unnecessary ED visit may be before the ambulance is ever dispatched.

Treatment in Place & Alternative Destinations: ED overcrowding strengthens the case for treatment in place, telehealth, and transport to appropriate non-ED destinations. Every safely avoided ED transport reduces demand on an already-congested system while potentially giving the patient a better care experience.

Mobile Integrated Healthcare: As patients delay routine care and increasingly reach crisis points, MIH can intervene upstream through high-utilizer management, post-discharge follow-up, and care navigation. The most valuable EMS response may be the 911 call and ED visit that never have to happen.

Americans spend more than 2.5 hours in the ER

Maya Goldman

8/25/26

https://www.axios.com/2026/08/25/americans-er-wait-times-data

Patients now spend an average of more than two and a half hours in hospital emergency departments, and visits have been getting longer in nearly half of the states, new federal data shows.

Why it matters: Forthcoming insurance eligibility and cost changes could lead people to put off care until their health reaches a crisis point, sending even more patients to an ED.

• Longer visits may also mean longer waits to see a clinician — a driver of negative experiences and increased costs for the health care system.

Driving the news: The median time spent in the emergency department was 162 minutes during the year ending Sept. 30, 2025, according to the Centers for Medicare and Medicaid Services.

• Washington, D.C., had the highest median visit length at 303 minutes. North Dakota had the lowest, at 110 minutes. The national median visit length stayed the same from the previous year.
• The data also shows that an average of 2% of patients nationwide left the emergency department before being seen.

Median visit lengths increased in 24 states and D.C. compared with the prior 12-month period, per Axios’ analysis of the CMS data.

• Oregon and Arkansas each saw a 15-minute jump in visit times. Twenty states saw decreases.

Between the lines: More than 20% of patients spend more time waiting for an ED visit than recommended for their triage level, according to the most recent data from the Centers for Disease Control and Prevention.

• Reducing ED wait times is one focus in a federal effort to improve health care by 2030.

Zoom out: Once patients are seen in the ED, they can face more long waits before they’re actually admitted to the hospital.

• The vast majority of emergency departments report overcrowding, and nearly a quarter of people requiring inpatient care have to wait at least four hours for a bed to open up, according to a study published last week in JAMA.
• The Agency for Healthcare Research and Quality convened a summit in 2024 to address what happens to patients who are sick enough to require inpatient care.
• But the health services research agency has been gutted since the Trump administration took office last year, and the Department of Health and Human Services didn’t respond when asked if the emergency room improvement work is continuing.

The big picture: Hospitals are facing a perfect storm of changes that could make it hard to focus on emergency visit and wait times, including Medicaid funding cuts, scrutiny of the federal discount drug purchasing program and a shift toward site-neutral hospital payments.

• “Beneath the surface of longer emergency department wait times, there will be a range of impacts from delays in accessing care to a loss of services,” Beth Feldpush, senior vice president of advocacy and policy at America’s Essential Hospitals, told Axios.

What we’re watching: AI-powered technologies have already started to help lower emergency room wait times, a 2025 review found.

• But data quality issues, biased algorithms and ethical concerns could make it hard for emergency rooms to adopt the technologies widely.

Stakeholders should be cautious when using the term “Essential Service” designation.

Designation of emergency medical services (EMS) as an “essential service” is important because it recognizes a basic public policy reality: communities depend on EMS for immediate access to lifesaving medical care, just as they depend on other core public-safety services. But the term essential service can mean very different things in state law, and that distinction is critical when evaluating the practical value of an essential-service designation.

The CO passed legislation is essentially a proclamation that the legislature appreciates EMS. Like the majority of other states that ‘state’ EMS is an essential service, it DOES NOT require local jurisdictions to assure EMS IS provided in their jurisdiction.

A recent review of state “EMS Essential Service” laws by PWW Advisory Group (PWW|AG) reveals that many states have enacted statutes or resolutions recognizing EMS as “essential,” “vital,” or important to public health and safety without actually imposing an obligation on local government to ensure that EMS is available or financially sustainable. For example, Alabama declares EMS to be an essential public service performed for a public purpose, while Colorado describes EMS as an essential service and an integral part of the state’s healthcare infrastructure. Neither, however, requires local jurisdictions to provide or fund EMS. Similarly, Maine recognizes EMS as essential to a well-functioning health system, and Nebraska calls EMS an essential healthcare service that can mean the difference between life and death or permanent disability, but neither designation creates a local obligation to provide or fund the service.

Of the 22 states that have passed ‘essential service’ designation for EMS, only 7 (HI, NC, PA, SC, TN, UT and WV) require that jurisdiction assure EMS is provided in their jurisdiction.

For example, here’s the language in the TN “Essential Service” legislation:

“(a) Ambulance service is hereby designated as an essential service in the state of Tennessee. (b) All county governing bodies are authorized and directed to make provisions to ensure that at least one (1) licensed ambulance service is available within their county. This may be provided as a county service, but can also be accomplished through other means, including, but not limited to: providing a license or franchise to a private company; contracting with a public, private, or nonprofit entity for the service; entering into an interlocal agreement with one (1) or more local governments; or entering into an agreement with a hospital or other healthcare facility. A county is not required to appropriate county revenues for ambulance service if the service can be provided by any other means.”

Click here for an updated chart, with source links, to a summary of “EMS as an Essential Service” legislation.

Colo. law recognizing EMS as an essential service goes into effect

HB 26-1238 covers ambulance and air ambulance services while clarifying that off-duty EMS providers are not required to respond

August 14, 2026

https://www.ems1.com/legal/colo-law-recognizing-ems-as-an-essential-service-goes-into-effect

Ambulance agencies and advocacy associations should pay close attention to the renewed congressional interest in revisiting the No Surprises Act.

If insurers and employers succeed in opening the law for legislative changes, they may also see an opportunity to press Congress to finally address ground ambulance balance billing, potentially including a federally mandated payment methodology, or adding ground ambulance to the current NSA. That could have significant reimbursement implications for ambulance providers.

As we know, the insurance industry has been very active recently in state-level statutes, in some cases, successfully proposing language in the statutes that cap commercial reimbursement for ambulance service at 180% – 200% of the Medicare Ambulance Fee Schedule.

A summary of the current state patient protection/balance billing laws prepared by PWW|AG can be found here.

We should therefore be at the table early, advocating that any ground ambulance solution establishes fair, sustainable reimbursement rather than simply extending existing surprise-billing restrictions to ambulance services.

In Washington, reopening a major healthcare law can create opportunity, but it also creates risk for stakeholders who are not actively engaged in shaping the outcome.

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Lobbying cranks up for another surprise billing fix

August 12, 2026

Tina Reed

https://www.axios.com/2026/08/12/lobbying-another-surprise-billing-fix

Providers and insurers are so divided over the process for resolving surprise billing disputes that they can’t even agree on the true size of the payouts. And the blame game is likely to continue into next year.

The big picture: The continued sparring four and a half years after a federal surprise billing law took effect is fueling fresh calls for another congressional “fix” to address a staggering backlog of cases and questions, like which disputed items and services can be lumped together.

• “There’s been a change in the dynamic from even a few weeks ago,” said Jack Hoadley, research professor emeritus at Georgetown’s Health Policy Institute.

Driving the news: Insurers this summer have intensified calls to overhaul the independent dispute resolution process, saying it routinely awards providers big payouts that drive up the cost of care.

• Their arguments were boosted by a Wall Street Journal report on federal data that found the process awarded nearly $15 billion to providers last year — more than triple the total for 2024.
• The Trump administration issued a final rule in May aimed at streamlining arbitration, though some policy analysts predict the changes will only encourage more practices to take claims to arbitration. Insurers and employers both are pressing for more.
• “Action is needed to protect consumers and employers from indefensible and well-documented price gouging by some out-of-network providers and arbitration middlemen who flood the system with ineligible claims to extract exorbitant payments,” said Mike Tuffin, president and CEO of the insurer trade group AHIP.

The other side: Providers say as much as $2.7 billion of the payouts the Wall Street Journal cited appear to be incorrect, and blame the flawed data for contributing to the perception that doctors are gaming the system.

• They point to insurers not engaging meaningfully in the negotiation process by refusing to pay more than 1 million disputed claims or offering rates of less than $1 for some services.

• “If we keep winning, why aren’t insurers coming back to the table with a more reasonable offer?” said American College of Emergency Physicians President Tony Cirillo.
• The general idea was that if either side began to lose too often, it would ultimately change behavior. “And it hasn’t changed,” Cirillo said.

What we’re watching: There’s bipartisan traction for a legislative fix, possibly including penalties for submitting ineligible claims and prompt pay for providers — but it likely won’t happen this year, TD Cowen analyst Molly Turco wrote in a recent note.

• The urgency could intensify if big insurers cite the arbitration process as a drag on their earnings. UnitedHealthcare criticized the process in its second-quarter earnings call, saying it’s one of the reasons commercial insurance rates remain elevated.
• A federal appeals court on Tuesday partially sided with a Texas medical group’s challenge to certain criteria used in the arbitration process, which could also increase pressure for Congress to weigh in.

AIMHI Launches Initiative to Identify the Most Valuable – and Least Burdensome – GADCS Data Elements

The Academy of International Mobile Healthcare Integration (AIMHI) is inviting ambulance agencies across the country to participate in an important initiative aimed at helping shape the future of the Medicare Ground Ambulance Data Collection System (GADCS).

Following the release of MedPAC’s recent report analyzing the first several years of GADCS data, AIMHI representatives met with MedPAC staff to discuss the current data collection process, the value of the information being collected, and opportunities to reduce the significant reporting burden placed on ambulance service providers.

One concept discussed was whether MedPAC and policymakers could obtain the information they need through a smaller, more focused set of high-value data elements, potentially collected more frequently from a rotating sample of ambulance agencies.

Such an approach could provide policymakers with more timely information about the economics of ambulance service delivery while substantially reducing the amount of information individual agencies are required to collect, calculate, validate, and report.

Now We Need the EMS Community’s Help

To help evaluate this concept, AIMHI has developed the GADCS Data Streamlining Workbook, which contains the current GADCS data elements and allows ambulance agencies to help identify which elements should be considered essential to a more streamlined data collection process.

We are asking ambulance agencies of all types, sizes, service models, and geographic settings to review the workbook and identify approximately 25–50 data elements, excluding basic agency demographic information, that meet three important criteria:

1. Value: The information is important for understanding the true costs, revenues, utilization, and economics of providing ambulance services.
2. Accessibility: The information can reasonably be obtained from data agencies already collect or maintain.
3. Sustainability: The data element could realistically be included in a streamlined reporting process without creating unnecessary administrative burden.

This is an expert opinion survey. Agencies are not being asked to compile operational or financial data, only to evaluate which GADCS data elements are most valuable and practical for future national reporting.

The goal is to identify the data that policymakers truly need, and that ambulance agencies can reasonably provide, to create a credible, sustainable national picture of ambulance service costs and revenues.

Most agencies should be able to complete this review in approximately 60 minutes.

Why This Matters

GADCS data are increasingly influencing federal discussions about ambulance reimbursement, the adequacy of Medicare payments, and the financial sustainability of EMS systems.

That makes the quality of the data critically important.

But more data does not necessarily mean better data.

A smaller number of well-defined, consistently reported data elements may ultimately provide policymakers with better and more timely information than an extensive data collection process that requires significant agency resources and occurs only periodically.

AIMHI has also encouraged MedPAC to conduct a similar exercise internally by identifying the data elements it considers most important to its analyses. Comparing MedPAC’s priorities with those identified by ambulance providers could help establish a core national ambulance dataset that balances policymaker needs with provider reporting burden.

Help Us Build the Recommendation

Once responses are received, AIMHI will aggregate the results and identify the data elements receiving the strongest support from ambulance agencies.

AIMHI also intends to share the findings with national EMS organizations and explore opportunities to collaboratively develop recommendations regarding the future of ground ambulance data collection.

A broad, consensus-based recommendation from the EMS community has the potential to carry considerably more weight than individual organizations or agencies approaching this issue independently.

This is an opportunity for ambulance agencies to help shape the future of GADCS.

We encourage ambulance leaders, finance professionals, reimbursement specialists, data analysts, and others familiar with their agency’s GADCS reporting experience to complete the AIMHI GADCS Data Streamlining Workbook and add their perspective to this important national conversation.

Download the GADCS Data Streamlining Workbook and help identify the data that matters most.

Download the GADCS Workbook here.

Here’s a great example of a quality dispatch triage systems effectively managing low-acuity 911 “EMS” requests.

Article Themes:

• Dispatch-based clinical triage is safely reducing unnecessary ambulance responses.
• Advanced care paramedics use structured clinical assessment through Priority Solutions, Inc.’s Emergency Communications Nurse System to match patients with the right resource.
• Long-term follow-up and prevention are central to the model.

Dispatch paramedics refer 40 per cent of reviewed 911 calls to alternative options

Anna Ferensowicz

Jul 29 2026

https://www.discoverairdrie.com/articles/dispatch-paramedics-refer-40-per-cent-of-reviewed-911-calls-to-alternative-options

Advanced care paramedics working in Alberta’s emergency dispatch centres referred 40 per cent of close to 6,000 reviewed 911 calls to alternative care options after a new clinical triage model launched May 26, Emergency Health Services Alberta says.

The reviewed calls represented 8.9 per cent of what the agency described as “all 911 demand.”

The July 13 release did not define the geographic scope or precise reporting cutoff for that percentage beyond saying the calls had been reviewed since the program launched.

EHS Alberta also did not provide regional figures, patient-outcome data or before-and-after figures for ambulance response times and emergency department transportation.

How calls are assessed

Following the initial handling of a 911 call, advanced care paramedics may be connected with lower-acuity callers to conduct a more detailed assessment.

The paramedics are stationed in Alberta’s Central Communications Centre and Southern Communications Centre.

They use the Emergency Communication Nurse System, which EHS Alberta describes as a structured clinical assessment tool for triaging low-acuity patients.

The agency said alternatives offered through the program included self-care advice, primary-care referrals, Mobile Integrated Healthcare, taxi transportation and alternative response vehicles.

The remaining 60 per cent of reviewed calls received an ambulance response when clinically appropriate, according to the release.

EHS Alberta did not provide a breakdown showing how many calls were referred to each option or how many were closed without an ambulance being dispatched.

“Our paramedics in dispatch provide self-care advice and reassurance to callers while confirming clinical acuity and priority, ensuring patients who do require EMS receive an appropriate response,” Les Fisher, managing director and chief of EHS Alberta, said in the release.

“Safely identifying cases that can be closed without ambulance dispatch helps keep ambulances available for when they are truly needed.”

Model based on other jurisdictions

EHS Alberta said its model is based on programs used in Saskatchewan, Niagara Region, Wales and New Zealand.

The agency said emergency response vehicles will always be available for patients with high-acuity needs.

Patients with unknown or suspected high-acuity conditions will continue to be transported by ambulance, according to the release.

EHS Alberta said the model is part of efforts to improve response times, reduce unnecessary transportation to emergency departments, improve patient flow and strengthen emergency health services.

The release did not provide figures showing whether those measures have changed since the model began.

EHS Alberta oversees air and ground ambulance services, interfacility transfers and dispatch operations, including services delivered by contracted partners.

This is a great example of MIH in action in Madison, WI. The report highlights 3 key points:

• Community paramedic–behavioral health teams are producing measurable outcomes.
• The program connects patients with the right care instead of defaulting to the ED or jail.
• Long-term follow-up and prevention are central to the model.

Five years in, CARES finds success in diverting people from jail

By Beth Stacey – Jul 29, 2026

https://madison365.com/five-years-in-cares-finds-success-in-diverting-people-from-jail/

When a 911 dispatcher answers a call, traditionally the request for resources goes to the Police Department or the Fire Department.

With their Community Alternative Response Emergency Services (CARES) team, the Madison Fire Department (MFD) takes a different approach, according to Assistant Fire Chief Chris Hammes.

Since 2021, MFD, Journey Mental Health and Public Health Madison and Dane County have collaborated on CARES.  Since then, CARES has served as an alternative to police to respond to emergency and crisis calls for individuals experiencing “behavioral emergencies that are nonviolent in nature.”

CARES allows for a third resource for people in crisis, because many people who call 911 will not benefit from the emergency room or jail, said Hammes. It is important to give that individual the care that best suits their circumstances. Individuals in need may access CARES through a crisis line or through 911 calls.

Over the past five years, MFD CARES has responded to over 14,000 calls and 8,500 individuals, including some repeat patients and some who refuse help. 

Of the more than 8,500 individuals that CARES has helped, 60% had their crisis mitigated, with 25% transported to a second location – a detox home, a shelter, a hospital – and only 2% have been incarcerated. 

“There’s a lot of other alternatives that we have in our community that CARES is really plugged into, and can align individuals up with those resources,” said Hammes.

Each CARES team consists of a community paramedic and a crisis worker. Paramedic expertise allows for the team to best assess the safety of the patient and call for an ambulance if necessary. The crisis worker creates a care plan that gives individuals access to a variety of resources.

CARES gives their patients access to case management, behavioral health services,, housing and shelter services, care center, groups homes, rehab resources, ageing and disability resource centers and more, said Hammes. 

“Some individuals that are having these emergencies, they sometimes recognize some of these same CARES team members that arrived,” he said. “That, inherently in itself, maybe brings down that level of anxiety; it just helps deescalate things with a little bit of familiarity. If someone has helped you out in the past, they might be able to help you out in this situation again, right?”

Knowing patients not only helps the situation but the overall care plan, said Hammes. The team can follow up on prior plans, asking if they have worked on what the team suggested, and see if there is another component of life they are struggling with, said Hammes.

Community paramedic is about “having the awareness of what they should be looking for with injury prevention.” It is taking the time to help implement even small changes that could help a living situation, according to Hammes. 

When not responding to calls, the CARES team works on referrals that help implement these small changes, said Hammes. Maybe it’s a handrail down a set of stairs an individual has repeatedly fallen on or a pill organizer for a patient who frequently forgets to take their medication, said Hammes. 

“Once it’s identified that someone out there is struggling with some component of living in the environment that they’re in. If there’s something we can do to tweak that, that’s what our community paramedics get to and really try to center on,” said Hammes

“So we can prevent a bad thing from happening, prevent that next fall which might cause a hip fracture or a head injury that really then puts them in a debilitative state.”

This mitigation from emergency rooms and jails not only relieves strain there but also strain on EMS in general, said Hammes.

“But most importantly, it’s a win for that patient who best benefits from the resources that these care teams can plug them into. That’s going to help them through their event that they’re through. Such a phenomenally successful program that we’re really proud of.”

As trust and need expand, CARES responds to more and more calls, said Hammes. In 2024 they expanded to three full-time teams. In 2025, a pilot program was deployed in Sun Prairie.

“If we get a continued increase of call requests and calls, it’s going to be our challenge to try to meet the need for that demand of service there,” said Hammes.

More information is available on the CARES Data Dashboard.

The Prehospital Blood Transfusion Coalition is celebrating a big milestone: There are now over 400 9-1-1 ground emergency medical services (EMS) nationwide that carry blood products to the scene of life-threatening bleeding. A simple solution to a serious problem: bleeding to death

June 25, 2026 – WASHINGTON, DC. – Over 10,000 Americans die every year from severe blood loss within minutes. Blood loss – or hemorrhage – is the leading cause of preventable death among those suffering traumatic injuries. Nearly half of these patients die before reaching the hospital. Beyond those seriously injured patients, severe bleeding is also a concern for those experiencing post-partum hemorrhage, gastrointestinal bleeding, and more.

Despite years of hard-won military and civilian evidence and rigorous trials showing the efficacy of prehospital blood transfusion, less than 3% of eligible agencies carry blood products. So why don’t all EMS agencies in the United States carry blood?

According to Jon Krohmer, M.D., the Chair of the Coalition and an EMS physician, the answer mainly comes down to funding and logistics. It’s expensive to implement and maintain a prehospital blood program, especially since the cost of blood products is not reimbursed by insurance. There is also a shortage of blood in the U.S. However, EMS agencies are committed to being good stewards of the blood supply by partnering with hospitals to rotate blood products before they expire.

Breaking down the barriers to prehospital blood
“Our goal is to remove the barriers that are preventing a simple solution to a serious problem,” Krohmer said. “We want to see blood transfusions offered by ground and air EMS systems across the country to ensure that every American can receive lifesaving care, regardless of where they live or how far they are from a hospital.”

The Coalition is helping to develop a proposal for EMS agencies to be reimbursed for blood transfusions by the Centers for Medicare and Medicaid Services, as well as working on prehospital blood policy recommendations for Congress and state decision-makers.

Coalition members are actively working to educate EMS personnel, blood suppliers, health care communities, hospitals, and policymakers about the problem of preventable hemorrhage deaths, and the available solution of prehospital transfusion. This past April, the Coalition co-hosted the inaugural Economics of Prehospital Blood Conference in Washington, D.C. to bring together organizations and decision-makers to accelerate progress.

In 2016, approximately 5 ground EMS agencies carried blood products. Over the past few years, there has been an uptick in EMS programs successfully initiating blood programs as the need is recognized and best practices are shared.

“Though our work is far from over, this celebration of over 400 sites serves as a moment for us to recognize the hard work being done at all levels across the country,” Krohmer said. “We want to thank everyone who is advocating for more prehospital blood, from emergency medical professionals to doctors and nurses to industry experts and lawmakers – and most importantly to the survivors who are still here today because of this lifesaving intervention.”

About
The Prehospital Blood Transfusion Coalition is a grassroots national nonprofit composed of multidisciplinary experts from trauma and emergency medicine, emergency medical services, blood centers, technology, industry, research, and more.

To learn more about the work of the Prehospital Blood Transfusion Coalition, visit their website, prehospitaltransfusion.org. To see if prehospital blood is available near you, visit their interactive map.

Points of Contact:

• Jon R Krohmer, MD; Chair (jrkrohmer@emsmd.net)
• Randall Schaefer, DNP, RN; President (randi.schaefer@schaeferconsulting.net)

Out-of-hospital cardiac arrest (OHCA) remains one of the most time-critical medical emergencies in modern health care. 

Despite decades of research and operational improvements, survival rates continue to vary significantly between communities.

In January 2026, representatives from fire-rescue departments, emergency medical services agencies, and regional health care partners convened as experienced experts in cardiac arrest response. The purpose of the meeting was to examine current challenges and share successful campaigns that have strengthened community response to out-of-hospital cardiac arrest across North Texas.

Participants shared operational insights, data-driven strategies, and community engagement initiatives designed to improve early recognition of cardiac arrest, increase lay responder CPR, expand public access to defibrillation (AEDs), and enhance coordination across the chain of survival.

This white paper synthesizes those discussions into practical recommendations for EMS systems, public safety agencies, health care leaders, and policymakers seeking to strengthen cardiac arrest survival in their communities.

Click here to view and download “EMS with Heart Out-of-Hospital Cardiac Arrest Case Studies from the Southwest Region“.

Here is a well-done news report from South Dakota Public Broadcasting with an excellent framing of essential service designation and patient protection initiatives by Brian Hambek of the South Dakota Ambulance Association.

Interestingly, of the states that have passed statutes designating EMS as an ‘essential service”, only 9 (HI, NC, PA, SC, TN, UT and WV) actually include provisions that require EMS to be funded by local jurisdictions.

Of note in the article, during their testimony opposing patient protection from balance billing legislation, Wellmark Blue Cross Blue Shield made the ‘claim’ that health insurance premiums would increase. However, when asked if they have specific data or an estimate of how much a bill like SB 211 would raise insurance premiums or increase costs for the insured population, Wellmark did not respond.

As EMS stakeholders advocate for essential service designation, the legislation should specifically require that communities assure funding the level of service they desire. Similarly, when insurers claim that premiums will rise, challenge them to a) prove what % of their healthcare expenditures are attributed to EMS, and b) ask them to prove how much premiums will increase if they paid a fair reimbursement for EMS.

Click here for PWW|AG’s summary of state “Essential Service” laws.

Click here for PWW|AG’s summary of state patient protection from ambulance balance billing laws.

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Ambulance services remain in limbo as lawmakers prepare for EMS funding task force

SDPB | By Delainey LaHood-Burns

June 15, 2026

https://www.sdpb.org/healthcare/2026-06-15/ambulance-services-remain-in-limbo-as-lawmakers-prepare-for-ems-funding-task-force

The Emergency Medical Services Funding Task Force is scheduled to meet for the first time in Pierre on Wednesday.

The task force is studying funding models for emergency medical services and the feasibility of making EMS an essential service in South Dakota.

Unlike law enforcement and fire services, EMS is rarely classified as an essential service that must be provided to citizens and is often funded through governmental sources.

The task force was established through Senate Bill 89 this past legislative session. SB 89 was one of several bills introduced during the 2026 session aimed at helping emergency medical services in South Dakota.

Ambulance providers across the state, and the nation, are facing severe workforce and funding issues. Those challenges have forced organizations to shut their doors, including in rural areas like Isabel and Dupree. More urban services have also been impacted, with the Rapid City Fire Department considering ending ambulance coverage to some surrounding areas in 2027 unless funding agreements are reached.

According to Brian Hambek, executive director of the Spearfish Emergency Ambulance Service and president of the South Dakota Ambulance Association, at the center of the EMS funding issue is inadequate insurance reimbursement rates.

For example, Medicare only pays about 55 percent of the cost for a single ambulance run, and Medicare-aged patients make up the majority of calls that Spearfish Emergency Ambulance takes.

“Financing is like a puzzle for EMS,” said Hambek. “You’ve got one section of that puzzle that’s Medicare, another piece that’s Medicaid, another piece is private insurance. And VA and self pays and that type of thing. And it all has to come together to create that picture and how we can operate within that puzzle.”

An aging workforce and decline in new volunteers is also pushing many ambulance services to the verge of shutting down, particularly in rural communities.

The Emergency Medical Services Funding Task Force will hold up to five meetings during the 2026 interim. Its scope includes:

• Examining mechanisms to fund counties and municipalities for the provision of emergency medical services as an essential service.
• Examining policies for ambulance service payments, including reimbursement standards for out-of-network emergency medical services.
• Seeking input from relevant stakeholders on the provision of emergency medical services as an essential service.
• Providing a report with findings and recommendations for legislative proposals to the executive board no later than Nov. 1, 2026.

The task force will also evaluate using Rural Health Transformation Program funds to support emergency medical services.

Funding Task Force Background: A growing focus on the EMS crisis

In recent years, there’s been growing concern in Pierre over the hardships ambulance services are experiencing. During the 2025 legislative session, state representative Eric Emery, a paramedic and program director for the Rosebud Sioux Tribe Ambulance Service, introduced a bill to designate emergency medical services as essential.

The bill required that local governments provide emergency medical services within their jurisdictions, and established an EMS state fund. It ended up failing, but lawmakers passed a resolution supporting efforts to make EMS an essential public service and a 2025 legislative summer study was created.

That interim committee led to more EMS bills being introduced during the 2026 legislative session. In total, legislators considered four bills this year aimed at improving ambulance services in South Dakota: SB 89, SB 211, HB 1023 and HB 1024.

Senate Bill 89: Another attempt at making EMS essential

Senate Bill 89 was introduced by Senator Tim Reed, who co-chaired the 2025 EMS summer study. Originally, the bill worked to make EMS essential by requiring that counties and municipalities provide emergency medical services within their jurisdictions. Additionally, it created the 2026 Emergency Medical Services Funding Task Force.

However, the bill was amended to just encompass creating the funding task force. This is because legislators wanted to better evaluate how to support cities and counties in funding EMS, before mandating that they provide those services.

Hambek said the push in Pierre this year to make property taxes more affordable also played into the decision to gut the bill.

“With the decrease in property taxes going on this year through the legislature, they didn’t want to have to add that on as another taxing regulation for the citizens,” said Hambek. “And I understand that. I get it. But we’ve still got to make that picture fit. We’ve got to make that picture complete. And that’s where Senate Bill 211 would come into play to help paint that picture even better.”

Senate Bill 211: Protecting consumers from surprise ambulance bills

SB 211 aimed at improving private insurance reimbursement rates to ambulance services, while also protecting consumers from surprise medical bills for out-of-network care. The bill failed on the Senate floor this year, but similar policy is likely to be considered in the upcoming task force.

SB 211 required private health benefit plans to reimburse ambulance providers for out-of-network calls at a specified rate. It also prohibited ambulance services from sending patients the portion of the bill that insurers refuse to cover due to being out of network, a practice called balance billing. Balance billing for most emergency services is banned federally by the No Surprises Act, with the exception of ground ambulance services.

As a result, 22 states have now passed laws protecting patients from surprise ambulance bills through legislation like SB 211.

“It’s a patient protection act,” said Hambek. “It means if insurance is going to pay what it costs us to do that call, then we would have no reason to balance bill a patient for anything over. And that protects them. It protects our patients from getting these surprise bills in the mail. So, it’s a win-win on both sides.”

Opponents to SB 211 argued it would raise insurance premiums, as well as remove incentives for in-network participation. For example, they argued in-network providers may go out of network to get higher mandated reimbursement rates.

In response to the argument that SB 211 would raise premium costs, Hambek countered that premiums are rising either way.

“I’ve got private health insurance coverage and they raise my premiums every year. Last year in 2025, they raised them $300 a month. A month. How do people afford this?” said Hambek. “They’re going to raise premiums anyhow. And here’s another side to this. They’ve done the research on this. What private insurance pays, the amount they pay to EMS nationwide is less than 0.2 percent. That’s nothing. That’s a drop in the bucket. Yet they’re fighting tooth and nail to pay us what it costs.”

Wellmark Blue Cross Blue Shield was one of the opponents of SB 211. Wellmark declined to interview for this story, but said in a statement to SDPB that the approach of Senate Bill 211 “raised concerns about how it could affect costs for South Dakotans over time. The bill would have required health plans to pay 275 percent of the Medicare rate for ground ambulance services, without limits on total charges, a dispute resolution process or incentives for providers to participate in insurance networks.”

When asked if they have specific data or an estimate of how much a bill like SB 211 would raise insurance premiums or increase costs for the insured population, Wellmark did not respond.

Hambek said he hopes a similar bill to SB 211 will be introduced in the future, perhaps one that goes further in improving insurance reimbursement rates to ambulances.

“They realize that these insurance companies are not paying their fair share of this,” said Hambek. “But the way that bill was written, one of the lawmakers that helped defeat it is very much an EMS advocate, and she says, ‘Is this bill enough?’ Which means that they’re looking at bigger changes.”

HB 1023 and 1024: Clarifying state statue to help with workforce shortages

Lawmakers successfully passed two EMS bills during the 2026 legislative session to address ambulance staffing shortages. HB 1023 clarifies that registered and licensed practical nurses can serve on ambulance crews. HB 1024 makes it easier for ambulances to recruit and retain ambulance operators.

Both bills came from the 2025 EMS Interim Committee. Hambek said the bills mainly clear up language from when EMS personnel licensing transferred under the Board of Medical and Osteopathic Examiners.

Looking ahead at the funding task force

With no state law requiring EMS be provided as an essential service in South Dakota, there is no safety net for citizens if an ambulance service shuts down.

Hambek believes lawmakers understand that EMS is at a breaking point. He hopes the funding task force comes up with solutions to keep ambulance services open across the state.

“With the essential service, it requires that the cities or counties have a dedicated ambulance service for their communities, for their residents,” said Hambek. “And I asked the legislators, think about this. How many garbage truck drivers or snowplow drivers or police officers are volunteers? Yet, the county has to supply those services. Why should EMS be any less?”