By Alex Gault
Watertown Daily Times
ALBANY, N.Y. — Emergency medical services in New York are increasingly becoming a responsibility of county governments, as costs increase and local providers struggle to make the finances work.
A new report from the state comptroller’s office found that ambulance companies or EMS divisions of local fire departments are struggling with low pay, reliance on volunteers and increasing numbers of patients. As the issues become more widespread and significant, providing services has largely fallen to county governments, funded by property taxpayers, to cover the gaps.
“The stakes are too high and the issues too complex for counties and other local governments to have to address this on their own,” the report reads. “The current circumstances call for direct state involvement to support the efforts of counties and other local governments to turn fragmented and ad hoc responses into comprehensive solutions.”
The comptroller’s report details a number of systemic issues facing emergency medical service providers in New York. Most EMS providers in New York are nonprofit corporations, representing 54% of the EMS industry. This includes organizations like the Thousand Islands Emergency Rescue Service in northern Jefferson County, which uses a combination of paid and volunteer staff.
The next largest group is fire districts or fire companies that provide EMS services alongside their firefighting outfits. These can also rely on paid or volunteer staff. Cities, counties, towns and villages together provide 18% of the state’s EMS services directly — all have paid staff, while towns and villages occasionally have volunteers.
A tiny 1.6% of EMS agencies in New York are provided by the state or federal governments, which include agencies like the Fort Drum Directorate of Emergency Services.
Only 9.1% of EMS providers in New York are for-profit companies like Guilfoyle Ambulance Service in Watertown — something EMS providers say will grow increasingly rare as the financial realities of providing ambulance services get even more difficult.
Of all providers in New York , only 19.6% rely on a fully paid staff, with about 49% relying exclusively on volunteer staff.
Between 2019 and 2022, New York lost an average of 17.5% of its emergency medical staff, including emergency medical technicians, advanced and critical care EMTs, and paramedics. In 2019, there were more than 40,000 EMTs and paramedics in New York. There are now just over 33,000.
According to the report, as qualified staff have disappeared from New York, many agencies and local governments have looked to hire more paid staff to replace volunteer staff, with the hopes they will be able to shore up their staff counts. But both volunteer-driven and paid organizations have reported similar struggles with finding enough qualified staff, paid or unpaid, to run their services effectively and respond to calls in a timely manner.
Part of the problem is low pay. In the Watertown - Fort Drum area, the median wage for EMTs is $32,880 a year, just about minimum wage. Paramedics had a median wage of $45,630, while firefighters and police officers both had a median of at least $20,000 more than a paramedic. The Watertown — Fort Drum area, the only sector of the north country to get a median wage comparison in the comptroller’s report, is the lowest-earning sector in the state. The next-lowest earning region is the Utica - Rome area east of the Syracuse.
Beyond staffing concerns, the comptroller’s report lays out how funding streams for EMS agencies are in many cases insufficient to cover the costs of operation. The report said that many reimbursements provided to EMS companies from insurance providers both public and private often only reimburse for transit, rather than covering the costs of providing medical treatment to a patient at the scene and in-transit. Medicare reimburses up to 80% of the approved amount, with the Medicare patient meant to cover the remaining 20% of the cost.
But EMS providers have long said the approved amount is often insufficient to cover the costs of treatment and transport, and Medicare patients are often unable to pay their 20% share. For privately insured individuals, EMS providers were only this year empowered to start billing insurance companies directly if they aren’t “in network” with that company. Before, they were required to bill the patient, who would seek reimbursement from their insurance company, although EMS providers have long said that process rarely results in payment.
At the same time, EMS calls are not always reimbursed at all. If a patient refuses treatment or transport, nobody pays for the EMS staff who responded to the call, the equipment costs or any other costs of the trip. If an ambulance is called to a scene where no emergency medical care is actually required, nobody pays for that trip. When multiple EMS agencies respond to the same call, only the agency that physically transports the patient gets paid, regardless of what work the other agencies did on the call.
EMS companies are all required to treat and transport patients regardless of their ability to pay or insurance coverage status. In 2026, the law permitting town- and village-provided emergency medical services to bill patients for service will expire.
According to the comptroller’s office, much of the critical information that could help leaders and EMS providers scale their operations and provide effective service is difficult or impossible to find. There is no central repository for information on ambulance response times, dropped calls where service cannot be rendered, cases where one EMS agency has to assist another agency with a call, provider compliance with license and credential rules, or cases where patients refuse to be transported.
Absent much of that data, the comptroller’s report uses a number of other metrics, including the financial information it obtains from local governments and nonprofit fire districts or EMS agencies, to draw the conclusion that counties and towns have started to pay more for EMS services in their budgets, Counties have seen EMS-related costs shoot up at a rate of 16% per year, while the other groups that run EMS services have seen an annual increase of about 4.4%.
Counties have historically not spent much on EMS, with towns, villages and nonprofits picking up almost all the costs until recently. In 2012, the counties of New York spent a combined $1.8 million on EMS, while the other EMS providers spent about $103.2 million. In 2022, the counties were spending $8.2 million on EMS, a change of 348%, while the other providers were spending $158.9 million on services, an increase from 2012 of only 54%.
Information in individual counties is spotty as well. Jefferson County and St. Lawrence County spend almost nothing on EMS in their county budgets, according to the comptroller’s report, while Lewis County finances EMS directly, spending about $3.39 per person in 2022 on EMS funding.
Some counties spent much more than that — Livingston County spent $44.77 per person on EMS funding in 2022, and Schoharie County spent $36.05 per person. There were 21 counties spending money on EMS in 2023, up 3 from 2022 and up 17 from 2000, when only four counties provided EMS funding.
While the comptroller’s report indicates that more intensive study is required to get a full financial reality of EMS providers and local government involvement, its conclusion calls for the state to step in to both shore up the data collection needed and begin providing more financial support to EMS providers across New York.
“While regional EMS councils and local government providers should conduct regular needs assessments, solutions need to start at the state level and include better statewide data collection, management and analysis to help EMS agencies identify where services are falling short and provide options for improving response times and outcomes,” the report concludes. “Better centralized guidance from the state about funding sources can help local officials make more informed decisions about how to pay for these services.”
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