08/18/2026
One of the dumbest things we have managed to accomplish in American healthcare is this:
Everybody wants an ambulance sitting five minutes away when their chest starts hurting.
Nobody seems particularly interested in paying to keep the damn thing sitting there.
That right there is the whole EMS financial system in a nutshell.
Out here in rural Arkansas, ambulances do not grow wild in soybean fields.
Before that truck ever backs out of the station, somebody had to buy it, insure it, fuel it, maintain it, put a cardiac monitor on it that costs about what my first house did, stock it with enough drugs and equipment to open a small clinic, and then locate two qualified human beings willing to climb aboard at three in the morning.
And those two human beings have developed this irritating habit of wanting paychecks.
Apparently they have mortgages and light bills.
Selfish bastards.
All of that costs money before the ambulance ever turns a wheel.
Then somebody calls 911.
We drive twenty miles down a county road, dodge three deer, one possum with poor decision-making skills, and somebody in a Nissan Altima doing ninety-seven miles an hour with one headlight.
We evaluate the patient.
We treat the patient.
We use equipment.
We use supplies.
We document everything down to which direction the mosquito was flying when we arrived.
Then the ambulance service sends the bill to the insurance company.
And according to the August 2025 EMS Financial Index, 26.2% of ambulance claims submitted to commercial insurance resulted in the insurance company paying...
Nothing.
Zero.
Not a dime.
Now that's impressive.
Imagine taking your truck to the mechanic, having him replace the transmission, and then saying, "I have reviewed your claim and determined I owe you zero dollars."
You would probably leave the shop wearing that transmission.
But somehow in healthcare, we've built an entire financial system around exactly that kind of logic.
And I don't blame the patient.
Not one bit.
Folks buy health insurance because they think health insurance is supposed to pay for healthcare.
Crazy concept, I know.
The same report found that patients accounted for 16.6% of the reimbursement ambulance services received on commercial insurance claims, often because of deductibles, coinsurance, or insurer underpayment.
So the patient gets sick, calls 911, gets an ambulance bill they weren't expecting, and wonders why insurance didn't cover more of it.
Meanwhile, the ambulance service is staring at payroll wondering which kidney is bringing the best price this month.
Everybody loses except the system that designed this mess.
Medicare Advantage isn't exactly arriving on a white horse carrying sacks of cash either.
In this report, Medicare Advantage represented 56.9% of Medicare ambulance claims, while its average ambulance reimbursement was $25 less than traditional Medicare.
Twenty-five dollars doesn't sound like much until you multiply it by thousands of transports.
Then somebody in administration starts looking at the budget and asking why we're still using cardiac monitors instead of just putting our ear against the patient's chest.
And then we get to Treatment in Place.
Sometimes EMS can safely evaluate and treat somebody without hauling them to an emergency department.
That ought to be good for everybody.
Patient stays home.
ER doesn't get another patient.
Ambulance gets back in service.
Healthcare system saves money.
So naturally, we found a way to screw that up too.
The Financial Index found only 38.8% of Treatment in Place claims were reimbursed nationally. Among the paid claims, the average reimbursement was $398.
I'll come back to Treatment in Place because that deserves its own discussion.
But underneath all these numbers is something we've got to get through our heads.
The expensive part of EMS isn't just the ride.
It's readiness.
It's having somebody available when your daddy collapses in the kitchen.
It's having an ambulance available when your child quits breathing.
It's having a paramedic available when somebody wraps a pickup truck around a pine tree twenty miles from the nearest emergency department.
It's having enough trucks spread across a rural county that when your worst day finally shows up, somebody answers the radio.
That's what you're paying for.
Or at least that's what we ought to be paying for.
Instead, we have built a reimbursement system that treats EMS like some kind of medically equipped taxi company.
No ride?
Maybe no payment.
Insurance doesn't like the claim?
Maybe no payment.
Treat the patient successfully at home and avoid an unnecessary emergency department visit?
Congratulations. You may have just saved the healthcare system thousands of dollars.
Now kindly go back to the station and eat your financial bag of air.
That's the part people outside EMS need to understand.
Ambulance services aren't closing because somebody forgot how to balance a checkbook.
They're being asked to provide an expensive, 24-hour emergency service while operating inside a reimbursement system that frequently doesn't pay what it actually costs to provide that service.
You cannot keep an ambulance staffed with good intentions.
You cannot put diesel in it with community appreciation.
And eventually you run out of duct tape, overtime, exhausted employees, and miracles.
We don't have an ambulance-cost problem nearly as much as we have a system that refuses to admit what an ambulance actually costs.
Everybody wants that truck sitting there when they need it.
It's about time we built a reimbursement system willing to pay for keeping it there.
-- East Arkansas Paramedic
