When someone needs law enforcement, the officer who shows up will almost certainly be a public employee – working for a municipal police department, county sheriff’s office, state police agency or specialized unit such as transit or university police.
The same holds true for firefighters: Outside a handful of industrial or campus settings, American fire departments are municipal functions.
Emergency medical services (EMS), however, straddle both sides of the public vs. private line. Your local ambulance service might be run by the fire department or by a stand‑alone government “third service,” but in many communities the 911 ambulance contract is held by a private EMS provider.
Why does EMS have this difference – and what does it mean for patients, taxpayers and city leaders? This article unpacks the critical distinctions between public vs. private EMS and ambulance operations.
What is a private ambulance service?
A private ambulance service or private EMS agency is owned and operated by a nongovernmental entity. Most are for‑profit corporations, although nonprofits and hospital‑based systems also fall under the private umbrella. Instead of being funded by local taxes, private EMS agencies earn revenue primarily through user fees and third‑party billing.
Municipalities may contract with these companies for primary 911 coverage or for narrower roles such as nonemergency and interfacility transports, specialty critical‑care transfers and standby coverage at special events. In some tiered systems, private ambulances handle low‑acuity calls while fire‑based paramedics cover high‑acuity emergencies, or vice versa.
What is the difference between public and private ambulance services?
Public EMS is operated by city or county governments – often within fire departments – and funded largely through tax revenue supplemented by transport billing. These agencies answer directly to elected officials, follow public‑sector labor rules and generally share dispatch, training and incident‑command systems with police and fire peers.
Private EMS, by contrast, is an external contractor. It negotiates performance‑based agreements, absorbs more financial risk and enjoys greater flexibility in purchasing, staffing and deployment. This public vs. private split shapes nearly every operational decision, from response‑time guarantees to data transparency.
How many EMS providers are private?
The 2020 National EMS Assessment estimated U.S. agency ownership at approximately:
- Fire department-based/public: ~39 %
- Private EMS (for‑profit and nonprofit): ~34 %
- Municipal third service: ~11 %
- Hospital‑based: ~6 %
Private participation is especially notable in large urban markets with high call volumes and in resource‑sparse rural areas where local governments lack the tax base for full public coverage. A 2018 survey of U.S. cities over 300,000 population by the Cleveland Association of Rescue Employees reflected a similar mix: 36% cross‑trained fire, 24% contracted private ambulance and 18% third service.
Who are the biggest private EMS providers?
The biggest private EMS providers in the U.S. are:
- American Medical Response (AMR): 37,000-plus employees, 8,000-plus ground units.
- Acadian Ambulance: 5,300 employee‑owners, 650-plus ground units.
- Falck USA: Around 2,800 U.S. employees, 1,000-plus ground units.
These firms illustrate the national scale and consolidation possible on the private EMS side of the public vs. private divide.
Why does EMS have private providers?
Historically, ambulance services evolved later than police or fire. Before the 1970s many communities relied on funeral homes, hospitals or volunteer squads for transport of their sick and injured. When formal EMS systems emerged, some cities simply upgraded those existing private ambulance contracts.
The ability to bill Medicare, Medicaid and private insurers also makes EMS uniquely suited to a private EMS revenue model – unlike police or fire, which have no fee‑for‑service component.
What are the advantages and disadvantages of private EMS?
Advantages of private EMS include:
- Cost shifting: By billing insurers and patients directly, private EMS moves part of the burden off taxpayers.
- Procurement agility: A private ambulance provider can add vehicles or specialty units (e.g., neonatal, bariatric, critical‑care) without lengthy municipal purchasing cycles.
- Scalability: National firms spread overhead across many markets, lowering per‑unit cost.
Disadvantages of private EMS include:
- Lower wages: Pay often lags fire‑based EMS, affecting turnover and experience.
- Cost‑cutting pressures: Profit motives can influence staffing and readiness.
- Data silos: Proprietary systems may limit public transparency.
- Limited competition: In single‑provider franchises, workforce conditions and performance can suffer.
How does pay compare between public vs. private ambulance jobs?
The Bureau of Labor Statistics lists a 2024 median wage of $41,340 for EMTs and $58,410 for paramedics. Fire‑based paramedics typically earn 30%–40 % more than peers in private EMS roles, and they often enjoy pensions, overtime and longevity incentives.
Are there differences in care and performance between public vs. private EMS?
State licensure ensures identical minimum competencies, and national accreditation makes no distinction between public and private ambulance providers. Some studies show municipal crews reach urban patients faster and perform more interventions; others find no significant difference in mortality. The evidence is mixed but underscores the need for robust contract oversight when cities choose the private EMS path.
Are there differences in training, staffing and deployment between public vs. private EMS?
State EMS offices set identical prerequisites regardless of employer. Optional advanced training and internal quality assurance programs, however, may vary widely between public and private EMS agencies.
Fire‑based systems typically staff dual‑role firefighter‑paramedics on 24/48 shifts, keeping ALS units in quarters. Private EMS fleets often surge units to peak demand and redeploy them dynamically, which can stretch off‑peak response times.
Can a private ambulance run 911 calls in my city?
Yes. No state bans private EMS outright. Local officials choose the delivery model that best fits community needs. Public vs. private decisions typically hinge on cost, performance guarantees and political philosophy.
Private ambulances can also operate alongside public EMS in non-911 roles.
How does public vs. private ambulance billing and costs to patients differ?
Because private ambulances must recover full cost plus margin, their transport charges often exceed those of tax‑subsidized municipals. Ground transports also remain outside the federal No Surprises Act, so out‑of‑network private EMS bills can still result in balance‑billing (unless state law forbids it).
What are the key questions for city leaders weighing public vs. private EMS?
City leaders weighing the public vs. private EMS decision should consider:
- Total cost of ownership, including taxes, overhead and pension liabilities.
- Contract enforcement, including the ability to audit, fine and renegotiate.
- Response‑time guarantees and surge capacity.
- Workforce stability, including turnover and wage competitiveness.
- Transparency and data access: Public dashboards vs. proprietary reporting.
Market conditions matter: Rural areas with a single bidder may lose leverage, while urban regions can foster competition among multiple private EMS vendors.
America’s ambulance landscape is a blend of public vs. private models. Understanding how private EMS and public EMS differ – in funding, accountability and patient impact – helps communities choose the right mix for their needs.
This article, originally published on Oct. 23, 2017, has been updated with new information.
