While the challenge of resource availability in emergency medical services (EMS) has long been acknowledged, a more pointed concept has recently gained attention: the "ambulance desert." Defined in a 2023 study by the Maine Rural Health Research Center as “locations that are more than a 25-minute drive from where an ambulance is stationed,” these deserts expose alarming gaps in equitable access to emergency care. The study found widespread disparities, particularly in rural regions, documenting that eight of the 41 states studied had fewer than three ambulances per 1,000 square miles.
The underlying causes are complex: chronic underfunding, inadequate reimbursement models, workforce shortages, the high cost of maintaining EMS readiness, and policy frameworks that fail to recognize EMS as the essential public service it is. As rural hospital closures accelerate, the need to establish sustainable EMS funding and reimbursement mechanisms becomes not just important but essential to ensuring timely, life-saving care in every ZIP code.
The disproportionate impact on rural communities signals an urgent need for targeted policy solutions. States must take a comprehensive approach to understanding and addressing the root causes of ambulance deserts. This can be done through their offices of emergency medical services, rural health or other relevant entities. Substantive action is needed: States must invest in data-driven strategies, support struggling EMS agencies, and ensure that they are equipped to respond to all calls in a timely manner.
Some states have already taken meaningful steps: Maine’s “Plan for a Sustainable EMS System,” for example, is helping to stabilize services statewide, backed by a $31 million funding initiative. Another example, this one from Minnesota, saw Gov. Tim Walz sign legislation allocating $30 million to support rural emergency medical services for the 2024–2025 period. This funding included $24 million in short-term emergency aid and $6 million for a “sprint medic” pilot program aimed at improving EMS response in rural areas through the use of roving paramedics.
To turn awareness into action, policymakers at the state level must consider a multipronged approach:
Designate EMS as essential: Many states still do not recognize EMS as an essential public service, unlike fire or law enforcement. Appropriate statutory designation, with funding and function explicitly outlined, would ensure that EMS is prioritized not only in funding but also in workforce planning and infrastructure development.
Develop statewide EMS sustainability plans: Encourage or mandate the creation of blueprints that assess system gaps, establish performance benchmarks and outline long-term funding strategies. A good example of this comes from Colorado, which in 2022 established an EMS Sustainability Task Force to evaluate the current state of EMS and develop recommendations for a sustainable statewide system.
Fund EMS for the cost of readiness: EMS agencies are expected to be prepared to respond to an emergency at any moment. To meet these goals, EMS agencies must have personnel and ambulances available that are not already on emergency calls. An EMS agency does not generate revenue for this level of readiness, and insurance payers do not reimburse for this specific cost. Policymakers should explore supplemental funding mechanisms — grants, subsidies or block funding — that support EMS readiness, particularly in low-volume rural areas.
Expand Medicaid reimbursement pathways: Encourage state Medicaid programs to broaden what is reimbursable, such as treatment in place, non-transport responses and community paramedicine. Some states, including Georgia, Mississippi, Tennessee and West Virginia, have expanded Medicaid in this manner, creating new revenue streams for EMS agencies.
Invest in EMS workforce development: Support recruitment and retention through tuition reimbursement, scholarships and rural incentive programs. California, Michigan, Pennsylvania and Texas are among states that have implemented programs targeted to strengthen the EMS workforce.
Fixing ambulance deserts won’t come from patchwork efforts or temporary fixes. It requires deliberate policy action, sustainable investment and — most importantly — a shift in how we view EMS. Emergency medical services are not optional. They are core infrastructure, particularly in rural America. An ambulance desert isn’t just a gap in coverage. It’s a public health emergency hiding in plain sight.
Governing’s opinion columns reflect the views of their authors and not necessarily those of Governing’s editors or management.
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