Congress didn’t ban shocking ambulance bills, leaving rural patients especially vulnerable
Many Americans can’t afford an unplanned $400 expense, yet when Washington cracked down on surprise medical bills, it opened a loophole big enough for a Southwestern Pennsylvania ambulance to drive through.
(Original photo by Stephanie Strasburg/Pittsburgh's Public Source)
Congress didn’t include ground ambulances in surprise billing regulation because they found the emergency transportation too complex to regulate, so Americans are paying the price —- literally.
And it will only get worse in communities like my rural hometown of Waynesburg, Pennsylvania, as hospitals close under the financial strain of historic Medicaid cuts, leaving patients to fend for themselves during emergencies with longer —- and consequently, more expensive —- ambulance rides to the nearest hospital.
In Greene County, where Waynesburg is located, access to ground ambulance services is scarce, especially following Southwest EMS’s 2024 cessation of operations due to financial constraints. The result was longer response times and an increasingly limited number of ambulances available to service three counties split across two other EMS service bodies. What follows is higher operating costs for EMS agencies and greater risk for patients, exacerbated by surprise billing.
The No Surprises Act (NSA), which took effect in 2022, is designed to protect consumers from surprise medical billing —- that is, when patients are billed out-of-network charges for care at in-network facilities or with certain ambulance service providers. Under the NSA, those with private health insurance are protected against the most common types of surprise bills (e.g., anesthesiology). Uninsured patients and those not using insurance must receive a good-faith estimate upfront.
However, this policy’s scope is narrower than many patients realize: Not only is it restricted to those enrolled in group health plans, ACA marketplace plans, and the federal employees health benefits program (leaving out traditional and managed Medicare and Medicaid), but it only applies to air ambulance service providers, excluding ground ambulance services altogether.
The patchwork of billing, municipal handouts and the occasional grant can no longer sustain local EMS services amid rising costs and steady calls. Regional cooperation, such as the newly formed Alle-Kiski Emergency Services Authority, could model a way forward.
Clearly, American pockets are bearing a cost that is all too often insurmountable. So, why not include these services in the No Surprises Act?
The significance of this issue did not escape Congress, which convened a committee to study ground ambulance coverage. Yet, nearly four years later, no meaningful action has been taken
This lack of progress reflects deeper structural challenges stemming from the patchwork nature of ground ambulance services. Run by an amalgamation of fire departments, municipalities, hospitals, and private operators, funding and service capabilities vary widely. It is difficult to craft a regulation that encompasses this variation within and across states.
Additionally, there are stark urban-rural disparities in ambulatory care. Rural ambulances travel farther and make fewer trips, thus costs are harder to spread across calls and result in much higher operating costs.
Ambulance breakdowns can cost lives. Pittsburgh’s EMS leaders have been so concerned about old vehicles with six figures on the odometer that they’ve used tragedies that happened elsewhere to appeal to city officials.
This will only be amplified by the One Big Beautiful Bill Act. This act constrains rural Americans’ —- disproportionately Medicaid recipients —- access to healthcare. Millions of rural Americans will soon face not only surprise medical bills, but broader barriers to care. Hospital closures will compound these challenges as rural hospitals face rising uncompensated care.
Taken together, these trends emphasize the widening gap between policy protections and realities faced by rural patients. While the complexity of ground ambulance systems may explain Congress’s hesitation, it does not excuse continued inaction. Congress has already shown through broader surprise billing protections that fragmented areas of healthcare can be effectively regulated. Ground ambulance billing should be no exception.
Vivian Greenwood is a recent University of Pittsburgh School of Public Health graduate who will attend Carnegie Mellon’s Heinz College to pursue a Master of Public Policy and Management in the fall. She can be reached at vivianggreenwood@gmail.com.
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Congress didn’t ban shocking ambulance bills, leaving rural patients especially vulnerable
by Guest Commentary by Vivian Greenwood, Pittsburgh's Public Source July 24, 2026
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Congress didn’t ban shocking ambulance bills, leaving rural patients especially vulnerable
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Congress didn’t include ground ambulances in surprise billing regulation because they found the emergency transportation too complex to regulate, so Americans are paying the price —- literally.
And it will only get worse in communities like my rural hometown of Waynesburg, Pennsylvania, as hospitals close under the financial strain of historic Medicaid cuts, leaving patients to fend for themselves during emergencies with longer —- and consequently, more expensive —- ambulance rides to the nearest hospital.
In Greene County, where Waynesburg is located, access to ground ambulance services is scarce, especially following Southwest EMS’s 2024 cessation of operations due to financial constraints. The result was longer response times and an increasingly limited number of ambulances available to service three counties split across two other EMS service bodies. What follows is higher operating costs for EMS agencies and greater risk for patients, exacerbated by surprise billing.
The No Surprises Act (NSA), which took effect in 2022, is designed to protect consumers from surprise medical billing —- that is, when patients are billed out-of-network charges for care at in-network facilities or with certain ambulance service providers. Under the NSA, those with private health insurance are protected against the most common types of surprise bills (e.g., anesthesiology). Uninsured patients and those not using insurance must receive a good-faith estimate upfront.
However, this policy’s scope is narrower than many patients realize: Not only is it restricted to those enrolled in group health plans, ACA marketplace plans, and the federal employees health benefits program (leaving out traditional and managed Medicare and Medicaid), but it only applies to air ambulance service providers, excluding ground ambulance services altogether.
Will the ambulance show up? An authority can keep the medics coming.
Surprise bills for ground ambulance transportation are extremely common. Ambulances are dispatched randomly, rendering nearly 80% of all emergency ambulance rides out-of-network and thus resulting in these surprise charges. These surprise bills average $450, but often reach into the thousands. Even if a bill were to amount to that average, nearly 2 in 5 Americans say they would not be able to afford an emergency expense over $400.
Clearly, American pockets are bearing a cost that is all too often insurmountable. So, why not include these services in the No Surprises Act?
The significance of this issue did not escape Congress, which convened a committee to study ground ambulance coverage. Yet, nearly four years later, no meaningful action has been taken
This lack of progress reflects deeper structural challenges stemming from the patchwork nature of ground ambulance services. Run by an amalgamation of fire departments, municipalities, hospitals, and private operators, funding and service capabilities vary widely. It is difficult to craft a regulation that encompasses this variation within and across states.
Additionally, there are stark urban-rural disparities in ambulatory care. Rural ambulances travel farther and make fewer trips, thus costs are harder to spread across calls and result in much higher operating costs.
Ahead of UPMC ambulance deal, Pittsburgh medics rely on makeshift fixes — even using vomit bags to warm cabs
This will only be amplified by the One Big Beautiful Bill Act. This act constrains rural Americans’ —- disproportionately Medicaid recipients —- access to healthcare. Millions of rural Americans will soon face not only surprise medical bills, but broader barriers to care. Hospital closures will compound these challenges as rural hospitals face rising uncompensated care.
Taken together, these trends emphasize the widening gap between policy protections and realities faced by rural patients. While the complexity of ground ambulance systems may explain Congress’s hesitation, it does not excuse continued inaction. Congress has already shown through broader surprise billing protections that fragmented areas of healthcare can be effectively regulated. Ground ambulance billing should be no exception.
Vivian Greenwood is a recent University of Pittsburgh School of Public Health graduate who will attend Carnegie Mellon’s Heinz College to pursue a Master of Public Policy and Management in the fall. She can be reached at vivianggreenwood@gmail.com.
MORE STORIES
This story was made possible by donations to our independent, nonprofit newsroom.
Can you help us keep going with a gift?
We’re Pittsburgh’s Public Source. Since 2011, we’ve taken pride in serving our community by delivering accurate, timely, and impactful journalism — without paywalls. We believe that everyone deserves access to information about local decisions and events that affect them.
But it takes a lot of resources to produce this reporting, from compensating our staff, to the technology that brings it to you, to fact-checking every line, and much more. Reader support is crucial to our ability to keep doing this work.
If you learned something new from this story, consider supporting us with a donation today. Your donation helps ensure that everyone in Allegheny County can stay informed about issues that impact their lives. Thank you for your support!
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