By Steve Wirth, Matt Zavadsky, PWW Advisory Group
The One Big Beautiful Bill Act (OBBBA) has the potential to cause a seismic shift in how prehospital care is funded and delivered. On July 15, the consultants at PWW Advisory Group, in partnership with EMS Management and Consultants (EMS|MC), conducted a national webinar highlighting seven key aspects of the 870-page law that are likely to impact EMS in some way or other.
While the Act’s broader goals are aimed at deficit reduction and structural Medicaid reform, its cascading impact on EMS agencies — particularly those already walking the tightrope of financial sustainability — requires urgent attention and coordinated action by EMS agency leaders and advocacy groups.
Here’s a summary of the bill’s most critical provisions that have the potential to impact EMS agencies and recommended specific, strategic action steps EMS leaders should take to prepare for what could be the most disruptive fiscal environment in EMS history.
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1. Medicaid changes: A tectonic shift in payer mix
The OBBBA includes significant changes to Medicaid eligibility and cost-sharing that could drastically reduce Medicaid beneficiaries and increase the uninsured population:
- Work requirements (Dec. 31, 2026)
- Eligibility restrictions for immigrants (Oct. 1, 2026)
- More frequent re-determinations and reduced retroactive coverage (Oct. 1, 2026 and Jan. 1, 2027, respectively)
- Mandatory co-pays for adults Medicaid beneficiaries covered through Medicaid expansion (Oct. 1, 2028)
These provisions are expected to push many current beneficiaries out of Medicaid, likely shifting EMS patient populations from insured to uninsured. With Medicaid already a significant payer for ambulance services in many communities, the result could be substantial revenue reductions.
Action steps:
- Conduct detailed payer mix and economic impact modeling
- Partner with state officials and community organizations to forecast coverage loss
- Improve real-time eligibility verification systems and field documentation
- Advocate for state reimbursement and alternative funding strategies
- Explore evidence-based, patient-centric system delivery changes that reduce costs and increase efficiencies
2. Potential threats to Medicaid supplemental payment programs
Several provisions in the OBBBA could severely restrict the funding mechanisms states use to bolster Medicaid payments to EMS agencies and other healthcare providers:
- Moratorium on new provider taxes (effective immediately)
- Cap on state-directed payments to no more than the Medicare rates (2028)
- Reduction of Safe Harbor Provider Tax threshold from 6% to 3.5% (2028-2032)
Programs that are designed to provide supplemental payments to providers, like Ground Emergency Medical Transportation (GEMT) programs, could see drastic revenue reductions — an especially critical issue for agencies in states where GEMT funding is integral to operational stability. New programs approved locally but not submitted to CMS for approval as of the OBBBA’s effective date will likely not be authorized.
Action steps:
- Evaluate your state’s impact of provider tax reductions
- Educate policymakers on how reduced payments threaten service delivery
- Explore evidence-based, patient-centric system delivery changes that reduce costs and increase efficiencies
3. Commercial insurance market disruption and exchange enrollment limits
Provisions in the OBBBA also aim to scale back Affordable Care Act (ACA) Exchange enrollment through shorter windows for enrollment, eliminating auto-enrollment features and reductions in premium subsidies. This could result in many patients currently covered by commercial insurance through enrollment in ACA exchanges becoming uninsured or utilizing Medicaid, further altering the financial landscape for EMS.
Action steps:
- Collaborate with municipalities and think tanks to assess impact
- Incorporate expected payer changes into your financial planning models
4. Hospital closures and “brown outs:” Operational consequences for EMS
With overall Medicaid and hospital reimbursement facing cuts, safety-net hospitals — especially in rural and underserved urban areas — may reduce services or close entirely. EMS agencies may experience:
- Longer transport times
- Increased interfacility transfer volume (IFTs)
- Higher ambulance patient offload times (APOT)
- Surge in low-acuity 911 calls due to loss of access to basic primary care
Action steps:
- Develop APOT mitigation protocols
- Implement or expand treat-in-place (TIP), telehealth, and mobile integrated health (MIH) models
- Tighten IFT intake procedures, pre-collect payments, and formalize payer contracts
| More: From 73 to 33 minutes: How Sacramento reinvented patient offload times
5. Medicare reimbursement at risk via S-PAYGO
The act may trigger the Statutory Pay-As-You-Go (S-PAYGO) Act of 2010, leading to an up-to-4% across-the-board cut to Medicare reimbursement — potentially hitting EMS agencies already reeling from the Medicaid changes in the act. This is in flux, and Congress has the authority to waive implementation of PAYGO cuts for specific laws, and they have done so in the past. Stay tuned!
Action steps:
- Engage in federal advocacy for a waiver of the S-PAYGO rule
- Model and plan for potential Medicare cuts
6. EMS as employers: HR and tax changes on the horizon
The OBBBA also introduces employer-impacting provisions that require EMS leaders to coordinate with HR and finance departments:
- Overtime pay tax deductions (significant benefit for most employees who are not statutorily exempt from overtime, but it’s not a “raise”)
- Expanded dependent care flexible spending accounts (FSA)
- Permanent paid family medical leave and employer-provided childcare credits
- Student loan assistance exclusion extended
- Tighter I-9 enforcement
While many of these provisions may offer benefits or cost-savings to agencies and their employees, they also require careful implementation and management to avoid compliance issues or staff dissatisfaction.
7. A silver lining? Rural health transformation grants
A promising provision is the $50 billion Rural Health Transformation Program (2026-2030). While primarily aimed at hospitals, EMS agencies may find opportunities in partnerships for infrastructure and care coordination grants, and other sustainability programs, especially in rural communities.
Action steps:
- Collaborate with your rural hospitals now to ensure a seat at the table
- Partner with rural hospitals to secure participation and grant funding
- Collaborate with state officials to ensure EMS inclusion in grant design
Conclusion: The clock is ticking — plan for change NOW!
Many governors and state legislatures are already considering special sessions to respond to the far-reaching effects of the OBBBA. EMS leaders should actively engage with local policy makers, as well as state and national advocacy associations, to stay informed on how the legislative provisions within the Act will be implemented. Agency leaders should also model impacts of dramatic reimbursement changes; educate policymakers; and identify patient-centric, evidence-based options for system delivery changes that enhance economic sustainability and operational effectiveness.
The future of EMS as we know it may depend on the actions we take today to prepare for tomorrow.
Additional resources
Any questions, please reach out to us at info@pwwag.com. We are here to help. We can assist EMS agencies with modeling the impact of many of these changes and the impact they will have on your revenue cycle and operations, and assist in evaluating the overall impact of the OBBBA on your EMS or mobile healthcare agency.
- PWW|AG Webinar recording and handouts: “What the ‘One Big Beautiful Bill Act’ may mean for EMS” (Passcode: 4q5n#gmu)
- Full Text of H.R. 1
- Table of potential EMS Impacts by PWW|AG and NAEMT
- Healthcare provisions
- Paragon report: Addressing Medicaid money laundering
- Paragon report: California GEMT
- Office of Management and Budget (OMB) Letter May 2025 Stating Potential S-PAYGO Trigger
- OMB Letter July 2025 Indicating Potentially No S-PAYGO Trigger
About the authors
Steve Wirth
Steve Wirth is a founding partner of Page, Wolfberg & Wirth. In a distinguished four-decade public safety career, Steve has worked in virtually every facet of EMS – as first responder, firefighter, EMT, paramedic, flight paramedic, EMS instructor, fire officer and EMS executive. He was one of central Pennsylvania’s first paramedics. Steve brings a pragmatic and business-oriented perspective to his diverse legal practice, having served for almost a decade as senior executive of a mid-sized air and ground ambulance service, helping to build the company from the ground up.
