Author: Matt Zavadsky

You can access a copy of the Rural EMS Task Force report here.

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NY’s rural EMS system on ‘brink of collapse.’ Inside the fight to save it

Emily Barnes

USA TODAY Network-New York

March 12, 2026

https://www.lohud.com/story/news/politics/2026/03/12/ny-rural-ems-system-is-collapsing-what-that-means-for-public-safety/89097779007

Rural emergency medical service agencies across New York are in need of funding and systemic changes to continue helping save lives, a newly released report about the state’s EMS system reveals.

The New York State Rural Ambulance Task Force, created in 2021 to evaluate the state’s rural ambulance services, released its inaugural report in January, asserting that the reliability of the system continues to decline.

“The rural EMS system in New York State is teetering on the brink of collapse,” the report stressed.

“The cascading consequences of these issues manifest in prolonged EMS response times, exposing patients in crisis to heightened risks of serious medical and traumatic complications,” the report added, noting the crisis was “further stressing the healthcare system as a whole and robbing communities of their neighbors.”

Here’s how some Albany lawmakers are proposing to address the growing issue.

How many rural EMS agencies are there in New York?

There are 1,157 rural EMS agencies across 44 counties in New York, the report shows, noting counties with populations under 200,000 are considered rural under federal standards.

What often sets rural agencies apart from urban ones is that cities and larger towns are able to sustain private ambulance agencies, resulting in better wages and benefits and more personnel, the New York State Association of Counties says.

In Greene County, for example, there are multiple independent town agencies and two nonprofits running their EMS system, Greene County Administrator Shaun Groden said during a news conference held in Albany on Wednesday, March 11.

“Because they’re all independent, we have varying wage and benefit packages,” Groden said. “And you have EMTs who work for multiple agencies in order to earn sufficient annual revenue, sometimes working 70-80 hours a week.”

“I don’t want to be the patient who would be attended by an EMT on hour 80,” Groden added.

The lack of financial support for smaller community EMS agencies has led to what the task force is calling a “patchwork system” of differing approaches to provide EMS coverage throughout the state, leading to longer response times, staffing issues and sometimes even the closure of an ambulance service.

The stakes of fixing the problem have been highlighted across local media reports and industry trade studies in recent years.

Ambulance services in the Town of Enfield in Tompkins County saw an average response time of over 20 minutes in 2021, up from just more than 12 minutes in 2017, The Ithaca Voice reported. And in the Hudson Valley, where scores of communities lean heavily on volunteer ambulance services, county officials learned of hundreds of cases where patients found alternative ways to get to hospitals due to delayed ambulance responses, USA TODAY Network reported.

Patrick Quinn, Vice President of McNeil & Co., the insurance firm that represents the state’s fire and EMS services, said 10 fire and EMS facilities closed across the state in 2025 and four have already closed in 2026.

Rural services are also unique in that they often have much longer distances to travel to transport those in need to area hospitals. Greene County, which has a population of just over 47,000 as of 2023 doesn’t have a hospital, according to Groden. The closest hospitals — Columbia Memorial Health and Cobleskill Regional Hospital — are in neighboring Columbia and Schoharie counties.

What problems need to be addressed to strengthen the NY’s EMS system?

The most immediate concerns are funding shortfalls due to outdated insurance reimbursement systems and lack of revenue being generated in the time between calls, as well as less EMS practitioners amid rising system demands, the new report states.

“The Task Force report confirms what many of us have been warning about for years; that EMS services, especially in rural areas, are at risk,” Assemblywoman Donna Lupardo, a Southern Tier Democrat, said. “Our highest priority is to acknowledge that the current funding model is unsustainable, with Medicaid reimbursement rates woefully inadequate.”

Medicaid reimbursement rates are a topic actively being considered by lawmakers in the fiscal year 2027 budget.

According to local and state officials, EMS agencies in New York receive less than half of what it costs to take the Medicaid-insured call. For example, a Greene County fire chief specifically said his town of Catskill department receives around $290 in reimbursement from Medicaid for a call that costs them $650.

For future consideration, Senator Michelle Hinchey, a Hudson Valley Democrat, said a grant program similar to the V-FIRE Grant Program initiated in 2023, which provides critical funding to strengthen volunteer fire departments and districts statewide, could be beneficial for the EMS system as well.

“This is one of the most important issues that we can be talking about right now,” Hinchey said during the news conference. “We have to do more … We have a responsibility to show up and stand up for (EMS workers) so they can continue to do that work and so that we, in our rural communities but across the entire state, have access to healthcare. This is a life-or-death issue.”

If enacted, Colorado will join a list of states that require insurance coverage for treatment in place (TIP) services. It’s interesting that the commercial insurers wanted to be excluded from the initiative, especially with the fiscal note showing savings to the Medicaid program of $2.1 million in the first fiscal year, starting in July 2026, $4.6 million in the following fiscal year, and $4.9 million in future years. This is the financial information agencies can use to help promote more legislative efforts to make TIP a covered service.

Click here to view the bill.

Click here to view the fiscal note.

Ambulance services would get funding boost while saving Colorado millions under new bill

KUNC | By Lucas Brady Woods

March 4, 2026

https://www.kunc.org/politics/2026-03-04/ambulance-services-could-get-funding-boost-while-saving-the-state-millions-under-new-bill?_amp=true

State lawmakers are working on a bill that they say would create much-needed funding for Colorado’s emergency medical services and save the state millions of dollars a year in health care spending.

The measure, House Bill 26-1069, would expand the list of services that EMS agencies can bill to the Colorado Department of Health Care Policy and Financing, which administers the state’s Medicaid program, or to private insurance companies.

Ambulance services in Colorado have been struggling with funding for years. A 2023 state study found that many EMS agencies in Colorado were operating without enough funding in large part because insurance reimbursement rates, from both the state and from commercial insurers, are significantly lower than the agencies’ actual costs.

Democratic state Rep. Katie Stewart of Durango, a former EMT, is sponsoring the bill and says funding issues continue to threaten Colorado’s emergency medical services, especially in the state’s rural areas.

“We are already seeing the effects of this lack of funding and this lack of support,” Stewart said. “The ramifications of not supporting our folks in EMS means that we will not have these workers to show up when you dial 911.”

Other sponsors of the measure are state Rep. Lisa Feret, of Arvada, and state Sen. Kyle Mullica, of Thornton, both Democrats.

Currently, ambulance services in Colorado must be reimbursed only when they transport a patient to an emergency room. Under the bill, they could also be reimbursed for treating someone on-site without transporting them, a practice commonly called treatment in place.

Scott Sholes, EMS Chief of Durango Fire & Rescue, called the current system “a historical funding pitfall” during his testimony to lawmakers in support of the bill.

“We get some of the reimbursement only when we transport patients using the most expensive means – ambulances – to the most expensive destinations – that’s the hospital emergency rooms,” Sholes said. “But we don’t get reimbursed for providing clinically appropriate treatment, rendering ambulance transport unnecessary.”

A number of other states already allow EMS agencies to bill for treatment in place, and Congress is considering legislation to expand federal reimbursements for it.

The measure would also require Colorado, but not private insurers, to reimburse emergency medical responders when patients are taken to behavioral health clinics instead of emergency rooms or if telehealth services are used during an emergency call.

An earlier version of HB-1069 would have required private insurance companies to reimburse EMS agencies for such situations and would have allowed ambulance services to reimburse for transportation to other locations as well, like urgent care clinics.

But Stewart said those provisions were removed to appease health insurance companies, which originally had concerns about the bill.

“As introduced, House Bill 1069 did raise some substantial concerns for our members,” said Kevin McFatridge, Executive Director of the Colorado Association of Health Plans, during a legislative hearing on the bill. “We appreciate these efforts and believe they reflect meaningful progress toward addressing many of the operation and affordability concerns raised by carriers.”

Stewart also assured lawmakers during the committee hearing that nothing in the bill would prevent ambulances from taking patients to emergency rooms.

“This will not stop anyone from being transported to an ER if that is what they want or need,” Stewart said. “Instead, this will empower EMS and patients to make the smartest decisions about their care.”

Apart from providing funding for EMS agencies, the measure would likely save Colorado millions of dollars a year in health care spending because it would result in fewer emergency room and hospital visits. Any savings are particularly significant this year as lawmakers struggle to balance a billion-dollar budget deficit driven largely by the cost of health care.

Nonpartisan legislative fiscal analysts project the bill would save $2.1 million in the first fiscal year, starting in July 2026, $4.6 million in the following fiscal year, and $4.9 million in future years.

A separate proposal working its way through the legislature, House Bill 26-1238, would define emergency medical services as essential in state law. The change would allow ambulance services to receive state funding reserved for public safety, emergencies, or disasters.

Legislative committees unanimously approved both bills and they now await consideration in the House.

In EMS, clinical excellence depends on operational readiness — and readiness starts long before the first patient contact. From supply chain disruptions to expired medications, missing equipment, and inconsistent restocking practices, logistics and materials management can quietly determine whether field teams are prepared… or scrambling.

This AIMHI webinar will explore best practices for building a resilient, efficient, and accountable logistics system that supports high-performing mobile healthcare operations. Participants will learn how leading organizations manage inventory, standardize equipment readiness, reduce waste, improve vendor coordination, and create systems that ensure the right resources are available at the right time — across diverse response environments.

Designed for EMS leaders, logistics professionals, and operational decision-makers, this session will highlight practical tools, emerging innovations, and proven strategies that enhance both patient care and financial sustainability.

Attendees will leave with actionable approaches to strengthen supply workflows, improve compliance, and ensure operational teams can focus on what matters most: delivering care.

Key Topics Include:

                • Inventory control and standardization across mobile units

                • Medication and equipment lifecycle management

                • Reducing supply waste and managing cost pressures

                • Technology solutions for tracking and accountability

                • Aligning logistics operations with clinical performance goals

Panelists:

Josh Duffy joined REMSA Health in 2005 and has held a variety of roles, including AEMT, supervisor, and manager. He is now the Director of Support Services, overseeing product supplies and vendor relationships, logistics and fleet operations for more than 75 ambulances and support vehicles, and facilities maintenance across all locations. He holds an Associate of Applied Science and a Bachelor of Science from Columbia Southern University, is a Certified Professional Purchasing Manager (CPPM), and maintains multiple industry licenses and certifications.

Dusty Edwards is a Logistics Manager with Mecklenburg EMS Agency, bringing extensive experience in field support operations and resource management. Since joining the agency in 2005, he has been committed to improving operational efficiency, supporting frontline clinicians, and ensuring mission-critical readiness across the organization.

Jonathan Washko is a healthcare executive with 40 years of EMS experience. Currently Assistant Vice President at Northwell Health Center for EMS and Assistant Professor of Emergency Medicine at Hofstra/Zucker School of Medicine, he’s a recognized expert in EMS system design, high-performance EMS, and mobile integrated healthcare. He consults internationally, driving innovation in telehealth and community paramedicine. A prolific author, researcher, and speaker, Mr. Washko transforms healthcare through technology and innovative, patient-centered solutions.

The Academy of International Mobile Healthcare Integration (AIMHI) is pleased to announce the appointment of Douglas R. Swanson, MD, FAEMS, FAMPA, FACEP, as its inaugural Medical Advisor to the Board of Directors.

Dr. Swanson brings more than 25 years of experience as an EMS physician leader and currently serves as Medical Director of the Mecklenburg EMS Agency (MEDIC) in Charlotte, North Carolina. He is also Professor of Emergency Medicine at Wake Forest University School of Medicine and is board certified by the American Board of Emergency Medicine in both Emergency Medicine and Emergency Medical Services.

Dr. Swanson completed his emergency medicine residency at Carolinas Medical Center in Charlotte after earning his medical degree from the University of South Florida College of Medicine. He subsequently completed an EMS fellowship and has since dedicated his career to advancing high-performance EMS systems at the local, state and national levels.

Rob Lawrence, President of AIMHI, welcomed the appointment “We are delighted to welcome Dr. Swanson as our Medical Advisor. His wide experience as an emergency medicine and EMS physician will further guide the association in its mission to improve the efficiency and effectiveness of mobile healthcare. Dr. Swanson’s wisdom in the creation and delivery of high-quality, patient-centered care will be invaluable as AIMHI continues to champion system performance, clinical excellence and innovation across our member agencies.”

Throughout his career, Dr. Swanson has demonstrated sustained leadership in organized medicine and EMS governance. In addition to his long-standing role with MEDIC, he has served on the North Carolina EMS Advisory Council representing the North Carolina College of Emergency Physicians, co-chaired the NCCEP EMS Committee, and served as President of the North Carolina Chapter of the National Association of EMS Physicians. Nationally, he is the Immediate Past President of the Air Medical Physician Association and has represented AMPA on the Air Medical Transport Conference Education Committee for the past 15 years.

In accepting the appointment, Dr. Swanson said “I appreciate the opportunity to contribute to the AIMHI leadership as Medical Advisor to the Board of Directors. Over the course of my career in emergency medicine and EMS, I have been fortunate to work alongside outstanding clinicians and system leaders committed to delivering high-quality, patient-centered care. I look forward to supporting AIMHI’s mission and working collaboratively with its Board and member agencies to advance mobile healthcare integration nationwide.”

The Medical Advisor role was recently established by the AIMHI Board of Directors to provide expert clinical guidance and recommendations related to the Academy’s mission, programs and policies. As a non-voting advisor, the Medical Advisor supports the development and review of clinical education initiatives, advises on emerging standards of care and regulatory considerations, and serves as a liaison to the broader medical community.

AIMHI represents high-performance EMS and mobile healthcare providers committed to clinical excellence, system efficiency and value-based care. Through collaboration, data-driven performance improvement and strong physician partnership, AIMHI members strive to deliver measurable improvements in patient outcomes and community health.

Dr. Swanson’s appointment marks an important step in strengthening the clinical foundation of the Academy’s work and reinforces AIMHI’s commitment to integrating medical oversight with operational innovation.

For more information about AIMHI, visit https://aimhi.mobi

Excellent state-level advocacy by the West Virginia EMS folks.   Interestingly, West Virginia is one of only FOUR states in the country that has a true ‘Essential Service’ designation statute for EMS, that is, requiring that jurisdictions provide and/or fund the provision of EMS for their residents.   To see an analysis by PWW|AG of current ‘essential service’ state statutes, click here.   With the true essential service designation, it’s likely that one of the constituency groups supporting this funding initiative is the trade associations representing the counties, since increased funding from the state likely reduces local tax subsidy burden.

(WV) House Approves Permanent EMS Funding  February 23, 2026 Chris Schulz   https://wvpublic.org/story/health-science/house-approves-permanent-ems-funding/amp/   Lawmakers have taken an important step to funding the state’s Emergency Medical Services (EMS).    The state’s EMS have been struggling for years with dozens of services closing in recent years. Several bills passed by the West Virginia Legislature in 2024 addressed some issues but did not provide stable funding.   House Bill 5168 allocates $12 million from the State Lottery Fund towards supplementing the salaries of, and providing crisis response for, county emergency medical service personnel.   Del. Joe Statler, R-Monongalia, called the bill historic for allocating the first permanent state funding to support EMS workers.   “We’ve had it in there before, under other ways, but this is identified in a permanent manner,” he said. “I think we’re telling our first responders out there that we care. We know that they do a job for us every day they’re out there working, and that we’re willing to reach out to help them, to try and keep them going.”   Several other delegates stood to support the bill, including Del. Hollis Lewis, D-Kanawha, who pointed out that in some parts of West Virginia, EMS is the only medical service available to the community.   “It’s long overdue. We have provided zero state appropriations for this service, which it should be provided for fully,” he said. “So this is a good first step, but it also is insufficient. So moving forward, we need to dedicate more funding, more resources to this essential service.”   Del. Rolland Jennings, R-Preston, said he has been trying to get permanent EMS funding passed since he was first elected eight years ago. He used the example of Secretary of State Kris Warner’s recent car crash to exemplify the need for a robust EMS program in a rural state.   “You don’t really realize how important they are till you dial 911, and then you wonder where they’re at,” he said. “Ask our Secretary of State about it. I asked him about it this morning. Took 12 minutes for them.   He was upside down in his seat belt, and it took 12 minutes for them to get there and get him down, take care of him.”     HB 5168 passed with unanimous support of the 96 delegates present, and now goes to the Senate for its consideration.   [Note: The fund is called the Emergency Medical Services Salary Enhancement, Crisis Response, and Mental Health Treatment Fund.]

Yakima considering $3M EMS levy, raising concerns about compounding tax hikes

Thu, February 5, 2026

https://www.everettpost.com/state-news/yakima-considering-3m-ems-levy-raising-concerns-about-compounding-tax-hikes/

The Yakima City Council is considering another tax proposal to keep a local fire station from closing this summer after resorting to significant public safety cuts to balance the budget.

The officials closed a $9 million budget deficit heading into January, largely by cutting public safety by $6 million. They put a $6 million property tax hike on the ballot last November, hoping to maintain the status quo, but more than 51% of voters rejected the levy.

The fallout included a $1.75 million reduction for the Yakima Fire Department, which planned to offset it by closing Station 92 and redistributing staff to other facilities. Last month, the council responded to concerns by allocating $150,000 in limited reserves for overtime to keep Station 92 open until August.

Fire Chief Aaron Markham returned Tuesday at the council’s direction with details on how an EMS levy could fill the gap. He said a levy of 25 cents per $1,000 of assessed property value could generate $3 million annually; $1.9 million would keep Station 92 open, with YFD using the rest to expand services.

“We have asked the parks to sacrifice. We’ve asked the police to sacrifice, and now we’re talking about increasing the scope of the firefighting,” Councilmember Rick Glenn said, raising concerns given recent struggles to fund basic obligations. “We need these services, but we don’t have an unlimited budget.”

Councilmember Patricia Byers offered similar concerns and hoped to direct any additional revenues to offset cuts to the Yakima Police Department and Parks and Recreation. If they put an EMS levy on the ballot, the city can spend that money only on relevant things, and it can’t supplant existing funding.

Councilmember Juliet Potrykus questioned whether expanding services through a levy would lead to future challenges.

State law limits annual property tax increases to 1%.

Markham acknowledged that, but said any future renewal would require only a simple majority, rather than a 60% supermajority.

“I’m curious if [the EMS levy] will beget another levy at a higher level, over and over,” Potrykus said.

Mayor Matt Brown said he wants to see a plan for how the city would distribute revenue from the levy if it goes on the ballot this year. Byers and Glenn suggested a public safety levy instead, since the city could use it for police services as well. But Potrykus said this levy is still only half of the last proposal.

The officials ultimately voted 4-2 to direct city staff to return with a financial analysis for the EMS levy.

Yakima County also has an EMS levy at the same rate, which expires in 2029. City staff said any EMS levy that the city puts on the ballot must expire at the same time. It typically runs for six years, but in this case, the city would have to run a shorter levy and renew it on a separate ballot from the county.

The council noted that the county will likely go after an EMS levy renewal in 2028, and if it fails, they could try again in 2029. That would push the city’s renewal timeline, potentially leaving a gap year.

If the county raises its levy to 50 cents, the city would receive some of that revenue based on population and other factors, but the city would be barred from setting its own levy due to a countywide cap.

“We’re basically at the mercy of the county,” Byers said. “They have the upper hand in making that decision.”

Great example of grass roots advocacy using DATA to drive decisions… Common response from the Kentucky Association of Health Plans.

And, an example of what information the profession should provide to MedPAC when they say things like ‘there is not an access issue here.’

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EMTs push for reform amid insurance reimbursement crisis

By: Karolina Buczek

Feb 03, 2026

https://www.lex18.com/news/covering-kentucky/emts-push-for-reform-amid-insurance-reimbursement-crisis

FRANKFORT, Ky. (LEX 18) — EMTs from across Kentucky are sounding the alarm about a growing crisis that could leave communities without ambulance services. The problem stems from insurance companies failing to adequately reimburse EMS agencies for their calls, forcing local taxpayers to shoulder the financial burden or local communities to stop ambulance services altogether.

Emergency medical technicians brought their trucks and stretchers to the Capitol Annex on Tuesday urging lawmakers to pass House Bill 447, which would reform ambulance reimbursement in Kentucky.

According to the Kentucky Emergency Response Alliance, insurance companies currently reimburse Kentucky EMS providers only a fraction of their actual costs. The groups says the average cost of an ambulance transport is $1,877, but the average reimbursement from insurance companies is just $635.

This funding gap means taxpayers in many Kentucky counties must cover the difference to keep ambulance services operational.

“Right now, 50, 60, 70, 80% of that (ambulance) bill is being paid by local government taxes offsetting the cost so that the commercial insurance companies can keep more of their money and post higher profits,” Jim Duke of the Kentucky Ambulance Providers Association said.

In Fayette County, insurance reimburses only 38.4% of ambulance bills, leaving 61.6 % to the local taxpayers, balance billed to the patient, or left unpaid-jeopardizing ambulance service and EMS staff availability. In some areas of Kentucky, like Laurel County, the reimbursement rate is as low as 9, according to Rep. Rebecca Raymer, the sponsor of HB 447.

The lack of adequate reimbursement has created ambulance deserts in almost 92% of Kentucky counties, according to the Kentucky Emergency Response Alliance. This means residents are more than 25 minutes away from timely emergency medical response.

Areas that have temporarily lost ambulance services, like Lewis County, experienced significant stress during the gap in coverage.

“Our dispatchers were stressed when they answered the phones. Somebody called having a heart attack and they could not promise that they were going to have an ambulance there,” Lewis County Judge Executive George Sparks said.

Paramedics say House Bill 447 would require insurance companies to reimburse at the local ground ambulance service rate set by the local governing authority. This change could help keep more ambulance services operational across the state.

Raymer emphasized that many people don’t realize the importance of EMS until they need it themselves.

“You don’t think about EMS until you are the one on the other side of that phone and you need them to come for you or your family member. And then when you experience that and there’s a delay, you’re going to understand what an issue this is,” Raymer said.

The Kentucky Association of Health Plans voiced concern over the reform effort. According to a spokesperson for the group, the state’s actuaries estimate up to an additional $1.27 per person per month in premiums. For a family of 4, that could be another $60.96 a year in health care premiums. The group says this additional cost could be a concern for working families.

This final rule from CMS adopted last week may substantially change how Medicaid Provider Tax programs can be structured.
 
Although “Ambulance” or “EMS” does not appear in the rule, ambulance agencies participating in similar provider tax components as part of a GEMT program should pay particular attention to how this new final rule could be interpreted related to GEMT programs.
 
Link to the CMS News Release:
https://www.cms.gov/newsroom/fact-sheets/preserving-medicaid-funding-vulnerable-populations-closing-health-care-related-tax-loophole-final
 
Link to the published Final Rule:
https://www.govinfo.gov/content/pkg/FR-2025-05-15/pdf/2025-08566.pdf

Preserving Medicaid Funding for Vulnerable Populations – Closing a Health Care-Related Tax Loophole Final Rule Medicaid & CHIP   Section 1902(a)(2) of the Social Security Act (the Act) requires states to share the responsibility of financing the Medicaid program with the federal government, by providing at least 40 percent of the non-federal share of expenditures under the state plan. There are several ways states can finance the non-Federal share, including health care-related taxes under section 1903(w) of the Act. States have historically looked for ways to shift this responsibility more toward the federal government, and both Congress and CMS have sought to address these cases.[1]    On May 12, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would end states’ ability to exploit a health care-related tax loophole currently used by seven states to generate billions in federal Medicaid payments—without contributing their fair share or expanding care for Medicaid enrollees. These states impose higher taxes primarily on Medicaid business of managed care organizations (MCOs), although there are similarly situated current Medicaid loophole taxes on other providers, such as hospitals and nursing facilities. After imposing the tax disproportionately on Medicaid plans or providers, the states effectively reimburse these entities entirely with federal matching funds, while avoiding any state financial cost. This, in turn, allows the states to use the surplus for other purposes—including the expansion of healthcare coverage for illegal immigrants. This effectively means federal money is financing these other interests, instead of enhancing the state Medicaid program.    On July 4, 2025, President Trump signed the Working Families Tax Cuts legislation (Public Law 119-21) and adopted the policies of the proposed rule in section 71117. The legislation also authorized the Secretary to grant transition periods of up to 3 years. On November 14, 2025, CMS issues a Dear Colleague letter outlining the minimum transition periods available under section 71117(c). This final rule, displayed on January, 29, 2026, codifies the proposed provisions adopted by Congress and expands upon the transition periods granted in the Dear Colleague letter.   What the Rule Does  The rule prohibits higher tax rates on Medicaid than on non-Medicaid businesses to ensure states don’t exploit an inadvertent mathematical loophole in the applicable statistical test. The rule also bars the use of vague language or complex designs to disguise taxes that target Medicaid. Based on how recently the state’s tax waiver was last approved and the permissible class, the rule provides States at least until the end of calendar year 2026, and in some cases the full 3 years authorized by Congress.    How the Loophole Works  Tax Differential: Some states view this burden shift as a revenue stream from the federal government.[2]  Some states exploit this loophole by greatly increasing taxes on Medicaid business, but through tax structures that are designed to still pass the statistical test in Medicaid regulations at 42 CFR 433.68(e)(2). For example, in California MCO tax rates are set at $274 per member, per month (PMPM) for Medicaid while comparable commercial member months are taxed at $1.75 PMPM.    States may use these taxes to:  Trigger federal Medicaid match payments,  Repay taxpayers the tax amount, and  Pocket excess funds, which may or may not then go toward Medicaid uses.  These schemes technically pass the current statistical test for permissibility due to an inadvertent loophole but violate the spirit of the law that states must share in the responsibility for financing Medicaid. Apart from the burden on the taxpayers, when states must contribute, they have an incentive to monitor and operate their programs competently to ensure the best value for the dollars that they spend. It further violates the requirement under section 1903(w)(3)(E) of the Act that non-uniform taxes (taxes that do not have the same rate for all payers) be generally redistributive or generally move money from non-Medicaid payers to pay for Medicaid expenditures.    Financial Exposure  Current loophole taxes generate $24 billion in revenue for states. CMS estimates that closing the loophole will save the federal government over $78 billion over the next 10 years.  —————— [1] For example, the Medicaid Voluntary Contribution and Provider Specific Tax Amendments of 1991 (Pub. L. 102-234, enacted December 12, 1991) amended section 1903 of the Act to prevent States from shifting a disproportionate amount of tax burden to entities with a high percentage of Medicaid business, thus shifting the State responsibility for financing of the program to the Federal government.   [2] See for example the California Legislative Analyst’s Office report about California’s MCO tax: https://lao.ca.gov/Publications/Report/4992

Thank you for the great discussion and thoughtful questions that followed PWW|AG’s Ground Ambulance Data Collection Systems (GADCS) Webinar. After the session, our team reviewed the questions submitted and pulled together a new resource:

Created by PWW|AG Co-Founder Doug Wolfberg and EMS & Mobile Healthcare Consultant Matt Zavadsky, this Q&A document addresses some of the most common situations agencies are working through, including:

• Why EMS is often left out of shared savings — and how some agencies are changing that
• How Treatment in Place and non-transport billing is being handled nationwide
• What the CMS data reveals about the growing gap between costs and FFS reimbursement
• Key operational and compliance questions agencies are facing today

This resource is designed to help agencies turn cost report data into practical understanding and informed decision-making.

Congratulations to AIMHI member agency REMSA Health on this agreement.

It epitomizes the mission and vision of AIMHI and High-Performance / High-Value EMS delivery!

High-Performance systems like REMSA demonstrate that high-value, innovation, transparency and public accountability – while at the same time, achieving a high level of financial efficiency – is possible, and should be a model for other EMS systems!

New EMS agreement in Washoe County emphasizes patient outcomes and public oversight

January 25, 2026

https://mynews4.com/news/local/new-ems-agreement-in-washoe-county-emphasizes-patient-outcomes-and-public-oversight

The District Board of Health on Thursday approved a modernized franchise agreement with REMSA Health, marking the first significant update to the contract governing emergency medical services in Washoe County in decades.

Board members said the revised agreement is designed to strengthen patient care, improve transparency, and provide long-term stability for emergency medical services, while ensuring uninterrupted EMS coverage for the community.

The previous agreement had not been substantially updated for many years. Under the new framework, the board placed increased emphasis on patient outcomes, responsible cost controls, improved access to data, and stronger public oversight. Officials said these changes are intended to better align the EMS system with current standards and community expectations.

The agreement also establishes a structure for ongoing evaluation and accountability. It includes regular five-year reviews, annual performance assessments, and timelines to further examine emergency dispatch practices. The board also committed to reconvening within six months to consider additional improvements to the system.

REMSA Health has provided ambulance services in the region for approximately 40 years and has operated without reliance on local tax dollars. The updated agreement maintains that model while expanding accountability measures and preserving the ability to study alternatives and implement changes if needed.

Public input played a key role in the discussion leading up to the vote. Board members acknowledged community feedback and said the questions raised helped shape the final agreement and reinforce the focus on patient protection and system stability.

The updated franchise agreement is intended to provide a more flexible and responsive framework for emergency medical services as Washoe County continues to grow.