In 1966, the document that created modern EMS highlighted one argument above all others: that moving people was killing them.
The white paper, “Accidental Death and Disability: The Neglected Disease of Modern Society,” described a country where ambulances were often run by funeral homes, where the people inside them frequently had little or no medical training, and where the entire model was built around transportation rather than treatment. It found that a seriously injured person sometimes had a better chance of survival on a battlefield than on an American street. The reform it launched was, at its core, a single idea: stop being a transport service. Become a medical one.
That is the founding purpose of this profession. We exist because someone proved, with data, that transport without treatment was a public health failure.
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The great irony is this: for all the clinical sophistication EMS has built since, including paramedicine, advanced airway management, and prehospital stroke and STEMI care, the system that pays for it still files us under exactly the thing we were created to escape: transport.
The code that’s worth nothing
Here is how literal this is. When a Medicare patient calls 911 and an ambulance crew arrives, assesses them, treats them and stabilizes them, but the patient doesn’t go to the hospital, it is coded as A0998: “ambulance response and treatment, no transport.” The code exists. The clinical work is real. The documentation is required.
And the code is worth nothing. Under the Medicare Physician Fee Schedule, A0998 carries a status indicator of “I,” meaning it is not valid for reimbursement. The care happened. The payment doesn’t.
This isn’t an oversight. It’s the architecture. Medicare’s entire ambulance fee schedule is built around “loaded mileage,” the number of miles a patient is transported. No transport means no loaded miles, which means no payment, no matter how much clinical care was delivered.
The reimbursement model doesn’t pay for medicine. It pays for motion.
As with everything else, there is an exception, and it highlights the problem. If a patient dies after EMS is dispatched but before transport begins, Medicare allows a modifier that makes the response payable despite no completed transport. The system built a mechanism to pay when a patient could not be saved, but never built one to pay when a patient was successfully treated and stabilized in place.
To be fair, the payment system isn’t entirely blind to clinical acuity. The fee schedule does pay differentially by level of service, distinguishing basic life support, advanced life support and specialty care transport. But notice what that distinction is attached to: transport. Whether the crew delivers ALS-level care or BLS-level care, a patient who doesn’t need the hospital is reimbursed exactly the same: zero.
The consequences are predictable. EMS clinicians routinely assess, treat and stabilize patients who don’t require transport, work that demands trained personnel, supplies and the ambulance, and receive nothing for it under traditional Medicare. Industry survey data suggests only about one in ten agencies bill for treatment in place at all.
What gets measured becomes what you are
There is a principle every operations leader knows: what you measure is what you optimize, and what you optimize is eventually what you become.
When the only reimbursable unit of EMS is the transport, the transport becomes the identity, not by anyone’s intention, but by the gravitational pull of the payment structure. Budgets get built around transport volume.
Performance gets measured against response times, because that’s what the contract specifies. The clinical work, the assessment that prevented an unnecessary ED visit, the de-escalation that resolved a behavioral health crisis, generates no line item. So, it generates no recognition.
This is how a profession founded to deliver medicine gets categorized as a delivery service. The most commoditized thing EMS does, the physical act of moving a patient from point A to point B, becomes the thing the entire system is organized to count. And once you are defined by your most commoditized function, you are managed as a cost to be minimized rather than an expertise to be valued.
That is the cost-center trap, and it doesn’t stay in the billing office. It follows EMS everywhere: into how hospitals see us, how policymakers fund us and how the broader professional world reads our resumes.
The trap has a voice, and it sounds reasonable
The most honest version of the cost-center trap doesn’t come from administrators or policymakers. It comes from inside EMS, and it sounds like pragmatism.
The argument, paraphrased fairly, runs something like this: EMS is the entry point to healthcare, not healthcare itself. We provide rescue medicine and safe transport to facilities where the real, organized care happens. So, we should stop seeking acknowledgment from a system that doesn’t serve us and focus on our own specialty.
There is truth in parts of it. EMS is a distinct discipline. But look at where that logic leads. If we accept that we are fundamentally the transport, our entire improvement horizon collapses into one question: how do we transport better? Faster response times, smoother handoffs, lower cost per mile. We optimize the cage instead of leaving it.
And we would be doing it at a particularly costly moment. Much of the healthcare system is organizing around a principle EMS is positioned to deliver: the right care, for the right patient, at the right time, in the right place.
Value-based care, treatment-in-place programs, mobile integrated health, and hospital-at-home initiatives are all moving away from transporting everyone to a central facility. Each leans instead on distributed, in-the-field clinical judgment EMS has practiced for decades, often without being paid for it.
To respond by doubling down on transport is to step back from a seat just as it’s being offered.
Getting better at transport is not the ceiling. It is the floor we were supposed to leave behind.
The structure is finally being challenged
The architecture is starting to crack, which suggests it was a policy choice, not an unchangeable fact of healthcare.
At the state level, several Medicaid programs have moved to reimburse EMS for treatment without transport, according to industry reporting. Minnesota Medicaid has recognized and paid for it for years. Georgia Medicaid began doing so in 2018. Oregon worked with the Centers for Medicare and Medicaid Services on a state plan amendment to raise its treatment-in-place reimbursement during the pandemic.
Maine took a related step in 2023, when Gov. Janet Mills signed a law requiring private insurers, not Medicare, to reimburse EMS, regardless of transport.
At the federal level, two bipartisan bills have now been introduced in consecutive sessions of Congress. In 2024, Senators Joe Manchin and Susan Collins introduced the Improving Access to Emergency Medical Services Act, which would have directed Medicare’s innovation center to test a treatment-in-place payment model. In 2025, Sens. Collins and Peter Welch introduced a successor, the CARE Act, which would require a 5-year treatment-in-place model under Medicare. Its sponsors point to a pandemic-era pilot that one analysis found saved Medicare more than $500 per patient encounter. Neither bill has become law, but two bipartisan attempts in back-to-back sessions signal this is no longer a fringe idea in Washington.
The advocacy around the CARE Act echoes this argument closely. The American Ambulance Association described the legislation as recognizing that EMS organizations provide critical prehospital medical care, not just transportation. The National Association of Emergency Medical Technicians framed its support around providing the right care in the right place at the right time. That is national EMS leadership, on the record, making the case that EMS is not a transport service.
Every one of these changes is a small admission of the same truth: EMS was never really a transport service. It was always a medical one that happened to arrive by vehicle. The payment system is slowly and unevenly catching up to what the 1966 white paper already knew.
But reimbursement reform alone won’t undo 60 years of category error. The rest is on us: to stop describing ourselves in the language of transport, and to present our work in terms the broader healthcare world recognizes.
Out from under the file
We were created to escape transport. We have spent six decades proving we are something far more complex than a ride to the hospital. And we have let a payment structure quietly file us back under the one word our profession was founded to move beyond.
The work now is to climb out of that file: in how we bill, in how we measure, in how we talk about ourselves, and in how we show up in the rooms where the categories get assigned. History is on our side. What is required is that we stop accepting a definition written by a fee schedule and start insisting on the one written by the work.
We are not a transport service. We never were. It is time the file caught up.
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