New York City has an EMS funding problem. Operating expenses are rising faster than revenues, workforce pressures are mounting, and taxpayers are covering a substantial financial gap.
Sound familiar?
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The good news is that New York City has plenty of company. The bad news is that misery doesn’t qualify as a Medicare reimbursement methodology.
On Oct. 16, 2026, the NYC Comptroller released “A system under strain: FDNY EMS operations and fiscal pressures.” Although the report focuses on the Big Apple, its findings should concern EMS leaders, municipal officials and policymakers everywhere. Because the problem isn’t unique to New York. It’s just bigger, louder and comes with more traffic.
The numbers aren’t pretty
According to the Comptroller, FDNY EMS operating expenses increased from $257 million in FY2015 to $434 million in FY2026, a 68% increase. During the same period, EMS revenues increased from $160 million to $254 million, or 59%.
That leaves approximately $180 million in annual expenses (58.5%) not covered by reported EMS revenues.
The report also provides a revealing comparison of ambulance charges and government reimbursement.
To be clear, charges aren’t the same as actual costs. But the comparison illustrates how government payment rates can differ dramatically from what an agency bills. Unfortunately, the electric company doesn’t accept Medicare’s ambulance fee schedule as payment for keeping the station lights on.
The national data tells a similar story
New York City’s experience isn’t occurring in isolation. CMS’s Ground Ambulance Data Collection System (GADCS) provides national information about ambulance costs, revenues, utilization and organizational characteristics.
In its June 2026 report to Congress, the Medicare Payment Advisory Commission (MedPAC) evaluated that data and recommended continuing collection while simplifying reporting requirements.
MedPAC also highlighted an important reality: ambulance organizations operate under dramatically different financial structures. Governmental agencies, nonprofits and private providers have different costs, revenue sources and operating environments.
Many public EMS systems depend on local government funding, taxes and other subsidies to supplement ambulance revenue.
The PWW|AG/EMS|MC “EMS Financial Index” adds another perspective.
Drawing on data from more than 1,500 ambulance services, the March and July 2026 editions document reimbursement and revenue-cycle challenges involving Medicare, Medicaid, commercial insurance and patient collections.
The July report found that commercial claims remaining unpaid by insurers declined from 26.2% to 21.3%. That’s progress, but payments from patients still accounted for nearly 15% of commercial ambulance reimbursement. And as every EMS billing professional knows, sending a bill and collecting a bill are two entirely different hobbies.
Together, these reports point to a fundamental problem: EMS incurs the cost of maintaining emergency readiness around the clock, but much of its reimbursement depends on transporting patients.
The supplemental payment safety net has holes
One particularly interesting NYC finding involves Medicaid supplemental payments. The city anticipated $128 million in federal funding through a proposed Certified Public Expenditure arrangement. However, federal approval remained pending, forcing the city to replace anticipated revenues with local tax funding. Eventually, the city removed the expected federal funding from its budget assumptions.
That’s an important lesson for agencies participating in Ground Emergency Medical Transportation (GEMT) and other supplemental payment programs. These programs can provide essential financial support. But payments depend on approved methodologies, regulatory requirements and program continuity.
Building an EMS budget around money that hasn’t been approved is a little like counting on the hospital to have an empty ED bed when you arrive. It’s possible. Just don’t make it the foundation of your operational plan.
And now insurance coverage is changing
The Commonwealth Fund’s October 2026 survey found that the uninsured rate among working-age adults increased from 8.9% in 2024 to 11.2% in 2026. That doesn’t mean ambulance agencies will experience an identical change in payer mix. But it raises an important question: What happens when more EMS patients lack insurance or face greater out-of-pocket expenses? Unlike many healthcare providers, 911 EMS generally doesn’t get to review someone’s insurance coverage before deciding whether to respond.
The ambulance still rolls. The crew still provides care. The agency still incurs the expense. Whether the bill gets paid is another matter. For agencies already operating with thin margins, even modest changes in payer mix or collection performance can create significant financial pressure.
We need to fund more than the “ride”
Perhaps the most important takeaway is that EMS funding needs to recognize three distinct responsibilities:
- Readiness. Maintaining personnel, ambulances, equipment and infrastructure so emergency medical help is available 24/7
- Patient care and transportation. Reimbursing the actual services provided when EMS responds, assesses, treats and transports patients
- Healthcare beyond transportation. Supporting treatment in place, community paramedicine, post-discharge follow-up, and other services that deliver value without necessarily generating an ambulance transport
The problem is that our traditional reimbursement structure focuses primarily on the second category. It’s a bit like funding the fire department only when something actually catches fire. Communities need to understand the full cost of their EMS systems, evaluate reimbursement by payer, measure deployed unit-hour costs and identify the public funding necessary to maintain expected service levels. That may require a combination of insurance reimbursement, local funding, supplemental payments and healthcare partnerships. There isn’t one perfect solution for every community. But pretending transport revenue alone will support every EMS system isn’t much of a strategy.
New York City is a warning, not an exception
The NYC Comptroller’s report, national GADCS findings, MedPAC analysis, and PWW|AG EMS Financial Index collectively reinforce a message the EMS industry has been delivering for years. Emergency medical readiness costs money, regardless of whether someone gets transported. The question isn’t simply whether ambulance reimbursement should increase. It’s whether communities have sustainable financial models to maintain the emergency medical services they expect.
Because when someone calls 911, they aren’t shopping for emergency medical care. They’re counting on qualified medical help showing up.
And unlike some reimbursement policies, that expectation isn’t optional.
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REFERENCES
- New York City Comptroller. (2026). “A system under strain: FDNY EMS operations and fiscal pressures.”
- Medicare Payment Advisory Commission. (2026). “Assessment of the Medicare Ground Ambulance Data Collection System.”
- Centers for Medicare & Medicaid Services. Medicare Ground Ambulance Data Collection System.
- PWW Advisory Group & EMS|MC. (2026). “EMS Financial Index” — March and July 2026 editions.
- The Commonwealth Fund. (2026). “The state of health insurance coverage in 2026.”
