He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
> Society should find a better way to pay for ambulances
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
>> We scale it down depending on income and type of event. We're not massive sticklers about it.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
> The average ambulance transport costs $2,673 to provide
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.
Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.
TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....
I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.
"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.
Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.
I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Some of your estimates on this seem fine, but not this:
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).
[1] Oh, holy crap, I just got why ambulances are called that
Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.
> We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Given you find this is _normal_ for a six mile ambulance ride: "and $11,670 as a “base rate.”"
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
That 150k figure I believe is quite outdated. New ones are running 300k or more. The ambulance vehicle providers have been bought up by private equity and the lead times are now years to get one.
"Medicare pays too little" is based on the "fee for service" model; it only makes sense if you believe the group of people who actually use the ambulance should pay its full cost.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
>The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
You’re right. The cost of the service not matching the direct cost is something we’re familiar with - that’s just fixed cost and entirely normal (happens with books, movies, etc).
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
> As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.
I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
> discovered the "life hack" of having an extremely inadequate network
The article covers this. Ambulance providers are strongly incentivized not to join insurance provider networks, and as a result more than 80% of ambulance rides in the US are “out of network”. So the inadequacy of the network is probably not the insurer’s fault.
Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.
The last thing I want at that time is to have to reason about any of this.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
This applies to other things as well - retirement and education come to mind.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.
Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.
My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least. Wild.
> My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.
Would your wife have been in a different location if you had made the call?
The law you've cited only applies for "emergency transport".
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
Yeah, my family was hit by two ambulance bills in California in 2024, and tried to balance bill us contrary to the law.
It was a really frustrating experience trying to get them follow the law. One of the ambulance companies waited an entire year to even file paperwork and still tried to get insurance and me to pay.
Last view of life: slowly bleeding out in the back of a waymo that has gotten trapped in the traffic circle in front of the ER and won't unlock its doors until it reached its destination.
This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday
We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
I'm volunteering to help build out a nonprofit EMS authority that will tax residents and businesses in our local six boroughs to spread out the costs for ambulance transports.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
> most of the world has solved it by making ambulance (EMS) funding similar to fire...
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
You know we can have volunteer supported services be very effective, right?
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
I think we are all villains here. Good healthcare coverage is just another status symbol to be attained. If the poor have it then it becomes less of a value. To some degree we are all wired this way and we all
suffer because of it.
>I think we are all villains here. Good healthcare coverage is just another status symbol to be attained.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.
SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.
Many makes it seem like this is common. But it extremely uncommon in the US to get a bill after a fire. There are some rural volunteer fire departments that are funded through memberships and they will bill you if you aren’t a member. But these are not common.
Story up thread is about an ambulance ride by the San Francisco Fire Department charging a grand. So in essence the EMS funding is the fire department funding and it’s still unsolved.
Health care in general has been solved by state sponsored medicine in most industrialized nations. And when it isn't solved by directly state sponsored medicine, it's solved by formally and informally regulated monopolies. In fact, US health care in the 1960s was made reasonable by the Blue Shield regulated monopoly.
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
Very much so. We could fix this. We continue to choose not to, and will for some time into the future.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties.
Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington.
Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.
We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.
US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.
What metrics are you using for that? The US ranks fairly close to the top for out of hospital heart attack survival, which is a good proxy for emergency medicine in general.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
> The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
Virginia has a long-established local dog license taxes on dog ownership and recently proposed a tax for, among other things, walking dogs. Clearly the liberals have their priorities wrong as usual. But hey you get what you vote for.
“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
Yeah you're always free to decline medical services. Nobody can make you go to the hospital (unless you're unconscious or in delirious but then you aren't deciding anything).
This isn't sustainable. You really want every person who is dealing with this bureaucracy to manage negotiating between their insurance and their EMS? After they've just had a significant accident/health issue?
Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.
> There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.
The genius part is that the negotiations that determine how much they can get away with charging completely excludes the consumer. Two for-profit entities, with no mandate to actually provide care, decide how much they should pay each other.
The article explains why; regulators sometimes can't foresee that their decision to consider something fee for service will eventually prevent it from being considered as a communal expense.
Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
Years ago i slid down a bannister at a dance club, caught my foot, flipped over backwards, and landed on a barstool. Having grown up poor as dirt, i knew that calling an ambulance would be at least a grand if not double that. I called an uber to take me the 15 blocks to the hospital.
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
There is a gigantic business called "NEMT" "Non-Emergency Medical Transport" that has been filled by taxis and rideshares for decades. I first discovered this service when I broke my leg in 2006, and Medicaid was paying for taxi vouchers so that I could travel to far-flung orthopedic appointments over the span of 9 months. Otherwise I'd be on the bus, on crutches: ouch!
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"
> In 2020, Congress passed the No Surprises Act, which banned surprise balance bills for most parts of emergency care. But by necessity, it exempted ground ambulances from the law: actually restricting the practice would have rendered much of the EMS industry insolvent.
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
I've treated people with panic disorder who, if there were no cost involved, would probably have called an ambulance monthly for suspected heart attacks.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
i think i read many warnings or jokes about this: when go to usa, dont call an ambulance because it's so fucking expensive..to compare, in china, it usally cost less than 100USD.
I had an ambulance ride on Thanksgiving Day last year. And the punchline was that with my ACA insurance, the "ambulance run" co-pay was $1,200. (Of course my total ambulance bill was around $1,310.)
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
Yeah I would bet the vast majority of ambulance rides are never paid for. Homeless, street people, the impoverished, the uninsured, the unemployed... none of them will ever pay a dollar much less thousands for an ambulance ride. And in many areas those are the people who disproportionately use ambulance services.
The piece is actually quite concise, but you're right in the other respect. You definitely didn't read it. Private equity as an explanation is explicitly rejected.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
The cost isn't about the actual mileage though, it's having two paramedics each earning about 100k/yr per ambulance, while having coverage 24x7x365. So fully loaded, the labor for one ambulance might be in the high six figures to seven figures.
I think the answer is very simple. Regulation. If there was no regulation or very little then anyone could open up an ambulance service and the cheapest costs and the best service would win.
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
No US doctor would ever tell you how much any procedure would cost (even though they know, at least "in-network" doctors).
But if in your EMT you inform the patient of the potential costs of the ride, then yea, I agree they make an informed choice.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
https://www.redcross.org/about-us/news-and-events/news/10-wa...
A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
https://www.cma.ca/resources/healthcare-real/answers/healthc...
https://digitechcomputer.com/costs-of-ems-readiness/
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
Dispatch, maintenance, janitors, HR, managers.
They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Edit: spelling
Check out the "No Surprises Act"
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
Air ambulance is worse.
[1] Oh, holy crap, I just got why ambulances are called that
We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Tsk-tsk.
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
Those calls essentially cover the base business expenses.
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.
Besides this kind of billing is banned in California now https://leginfo.legislature.ca.gov/faces/billHistoryClient.x...
The insurers just pay the in-network fee and you call it a day.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
Would your wife have been in a different location if you had made the call?
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
He was lucky he was hit by a car.
A slab fronted SUV or pickup would have dragged him underneath and so it goes.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
[1]https://www.ambulance.qld.gov.au/
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Do imaginary conversations in the shower count?
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
https://www.nfpa.org/news-blogs-and-articles/nfpa-journal/20...
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
https://www.ruralhealthresearch.org/publications/1596
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties. Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington. Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
There _should_ be some ambulance deserts.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
RFD(WA) comes in at ~ $80 million AUD / annum in state support (for better or worse - https://www.abc.net.au/news/2024-07-24/rural-gp-slams-royal-... )
They assert to have a "value" to the state of $4.1 billion AUD over 30 years - https://www.flyingdoctor.org.au/wa/
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Any other insights?
That is actually the only legitimate function of government.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
But also because Postal Service is much cheaper than an ambulance service?
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
- If you’re comparing to developed nations (or some non developed ones with functioning agencies), the argument doesn’t hold true.
- If you’re comparing to the bottom of the barrel EMS (quality being ass like you said), you’re still not going bankrupt for an ambulance ride.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
So there is a solution.
So compelled health insurance to use an ambulance? You could just as well make it optional and charge people without the insurance the full price.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
But yes, it’s because of “options” and not because of greed.
Some group of people tries to extract as much money as possible. You can call this capitalism. I think it’s a big scam.
Tell the insurance company to wait to release the funds until you talk to the ambulance company or to release the funds directly to you.
Tell the ambulance company they can take the $9,967 or get zero.
That seems needlessly cruel to do to people.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
https://www.wake.gov/departments-government/emergency-medica...
I am shuttled to the airport at 4 am and paid $30.
It did not cost 20k per ride. So ambulance providers charge that much because they can. There is no real competition.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
LAFD has already called Ubers for non-emergency transport to hospitals.
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
the writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.
Everyone in the country needs to read this.
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
Here's a PDF about the No Surprises Act:
https://www.cms.gov/files/document/a274577-1a-training-1-bal...
better to live in uk where nhs takes care of all this compassionately for free.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked