Reading this quote stopped me in my tracks while sifting through qualitative data for a research project. As a resident, I had heard from patients before that they avoided calling 9-1-1 because ambulance costs were too expensive. But this idea of a complete lack of access to emergency medical services (EMS) was both new and frightening.

A quick Google search of “EMS shortage” reveals headlines expressing emergent care shortages in New York, Southern California, Wisconsin, Iowa, New Jersey, North Carolina, Maine, and Indiana, all within the first set of results. Even in Boston, a medical mecca, on-time EMS response rates declined to 58% at the end of 2021.1 In rural areas, depletion of resources exacerbated by the COVID-19 pandemic and hospital closures have translated into a dire dearth of emergency services for regions throughout the county, as described by our rural focus group participant above.2,3 

What is causing this crisis?
To start, emergency medical technicians’ (EMT) and paramedics’ salaries are grossly insufficient. The U.S. Department of Labor Bureau of Labor Statistics stated the median wage for EMTs and paramedics in May 2021 was $35,470 and $46,770 respectively.4 Per hour, average EMT pay is $17.76.4 Limited wages has prompted many EMS staff to leave the field, with no likely salary increases on the horizon. EMS agencies are strikingly underfunded, and report that their private and governmental insurance reimbursements do not cover the cost of providing services. Donald DeReamus, the Legislative Chair for the Ambulance Association of Pennsylvania, stated in a March 2023 interview that if an ambulance call cost an EMS agency $550, the agency may only receive $350 in reimbursement.2 EMS funding is also often associated with regional call volumes, leaving rural areas at further disadvantage, and increasingly reliant on volunteers and local fundraising efforts, such as bake sales.3

Considering these extreme shortages, 40 state legislatures in 2022 considered bills in relation to increasing state-funding for EMS. The Centers for Medicare & Medicaid Services are to examine a new payment model to increase funding for EMS services, but this process is still underway. 

I carried these ruminations into my primary care clinic the next day, and with a no-show on my schedule, I had extra time to spend with my next patient who arrived early. He and his wife travel more than an hour and a half across state lines to see me. He had recently called EMS after experiencing dyspnea at home alone. We reviewed his hospital stay and his medication changes, but at the end of our encounter he sensed I had another question to ask him. 

“Doc, what’s on your mind?”

“Mr. P, how long did it take for the paramedics to get to your house?”

He laughed. He told me he couldn’t remember exactly, but he stated “Where I live, I know better than to wait to call.”

The structure of EMS agencies, run either by private/for profit companies or by the local municipalities they serve, propagates inequity in sparsely populated and underfunded parts of the country. Reliance on either the free market or, alternatively, on safety nets improvised by neighbors and volunteers, is woefully inadequate when lives are on the line. 

This begs the question: how can we ensure just and equitable allocation of EMS resources? First, we must understand the EMS crisis as a microcosm of the systemic failures in American healthcare. As a country, the United States spends more of its gross domestic product on healthcare than any other country while experiencing higher rates of chronic disease and hospitalizations from preventable causes.5 Americans’ out-of-pocket spending and the private sector’s spending on healthcare is also higher than other first-world countries.5 The end result is a disorganized healthcare system rife with misaligned incentives in which Americans pay more but get less. 

Our system supposedly relies on interconnectedness, but physicians’ siloed awareness has prevented us from appropriately acknowledging the EMS crisis and from advocating on behalf of our EMS colleagues and patients. 

Our advances in healthcare, particularly emergent care, are futile if patients cannot reach us to receive them. 

I wish to acknowledge Gaetan Sgro, MD, for his thoughtful review of this manuscript.