This is National EMS Week. Agencies across Pennsylvania are celebrating their EMTs and paramedics—but also warning that staffing shortages are putting citizen healthcare at risk.

These ambulance companies say the key to recruiting more workers is to offer better wages. But that solution opens up a whole other can of worms; namely, ‘how do EMS agencies get paid’?

“Back 30-40 years ago, it was just a ride to the hospital,” said David Basnak, the executive director of EmergyCare. The non-profit agency is one of the largest in the state; servicing a population of up to 400,000 people and answering upwards to 80,000 requests a year.

Ems agencies started out as a public service offered by volunteers. The vocation evolved though, and is now thoroughly regulated by the state. EMTs are held to professional medical standards and ambulances carry the equipment to respond to a wide variety of medical issues.

“It is a mobile ER. So how do you pay for that?” said Heather Harris, the executive director of the Ambulance Association of Pennsylvania.

As these operations evolved, agencies fell back to a fee for service model. For every call they make, they issue a bill to the patient. Most patients then foot the bill to their insurance.

Problems arise with this model. People who don’t have insurance or have high deductibles can’t always pay the bill. Then, when insurance does write a check, the reimbursement rates pay less than what it actually costs to deliver the emergency service.

“Whether it's the cost of an ambulance, or the cost of a cardiac monitor, or the hourly cost of paying folks to answer those calls for us—  all those costs have gone up,” said Derrick Hall, the director for the Greater Valley EMS in Sayre, Pennsylvania. "While most of the reimbursement has stayed the same.”

Ambulance companies want the state to regulate reimbursement rates from private insurance companies be creating a consistent “fee schedule”. The ambulance association wants private insurance rates to reimburse at 350-400% of what Medicare and Medicaid reimburse (the government insurance regulators notorious for having lower reimbursements).

The federal government recently released a preliminary report confirming that ambulance companies are paid significantly less than what it costs companies to provide the service.

Basnak says that the government rates are critical, because citizens on Medicaid or Medicare utilize ambulance services more than those on private insurance.

Beyond reimbursement rates and unpaid bills, there are operational costs of an EMS agency that is not factored into insurance payments. For example, agencies have what’s called “cost of readiness” expenses.

“So we have two crews on duty around the clock at our building,” Hall said. “And some shifts they might run 10 or 12 calls, and other shifts they might only do a couple.”

The agency has to pay workers for the whole shift; an operational cost that no one pays them for.

“The system won't survive on insurance reimbursement alone. There has to be another mechanism,” Basnak said.

Some EMS directors say that because emergency services continue  to be an expected public service, local governments should chip in on the cost of readiness.

Hall said that ambulances help people in individual medical crisis, but they are also expected to show up at public disasters like fires or car crashes.

Having a guaranteed service to transport people from those crisis scenes to the nearest hospital is a community benefit— and the reason EMS was initiated in the first place.

Right now, 28% of municipalities in Pennsylvania give some payment to the EMS agencies that service their communities.

“That’s a low number, for expecting service to be provided 100% of the time when someone calls 9-1-1,” Hall said, “It’s going to take buy in from the other 72%, because they are not used to paying for this."

The issue of how to categorize and fund EMS dates back to a paper published in the 1960s, which said EMS was not properly organized or funded.

“We identified that problem before we even put a man on the moon,” Basnak said, “And here we are, in 2025, with the same struggles. The same narrative. We've come so far in society, but yet we still don't have ambulances funded.”