The median ambulance ride costs $1,340. Collections cover $625.

An ambulance shows up, and somewhere behind it is an accounting problem nobody chose.▸ Ground-ambulance agencies bill Medicare, Medicaid, private insurers, and patients directly, and for years no one — not Congress, not the Centers for Medicare & Medicaid Services (CMS) — had reliable, system-wide data on what a transport actually costs versus what gets paid. Congress ordered CMS to find out in 2018. The first real answer, published by CMS in December 2024, is not close.

CMS built the Ground Ambulance Data Collection System (GADCS) to make agencies report their actual books — labor, vehicles, facilities, equipment, everything — in standardized categories for the first time.▸ Summed across the 5,317 organizations in the first two reporting cohorts, total ground-ambulance operating cost came to $27.2 billion. The breakdown holds no surprises for anyone who has run a crew: this is a labor business.

Labor is 69.4 cents of every cost dollar — salaries, benefits, and training for the people on the truck.▸ Response crews (EMTs and paramedics) alone account for 90% of that labor spending; administrative and facilities staff take the rest. Vehicles, the next-largest category, are a tenth of the total. There is no fat here to trim that doesn't come out of a paycheck or a truck that has to run.

Here is the part that doesn't hold up.▸ CMS also had these same organizations report their revenue — from Medicare, Medicare Advantage, Medicaid, commercial insurers, and patients directly — per transport. Across roughly 5,000 transporting organizations, the median total cost per transport was $1,340. Median total revenue collected per transport was $625 — 47 cents on the dollar. Traditional Medicare accounts for about a quarter of that revenue and Medicare Advantage another sixth; Medicare, Medicare Advantage, and commercial insurers together bring in roughly 75% of what agencies collect. None of the major payers, individually or combined, closes the gap.

The shortfall is not evenly spread.▸ Because so much of the cost is a crew on shift and a truck ready to move, agencies that run fewer Medicare transports can't spread that fixed cost over enough runs to bring the per-transport price down — and low-volume agencies are disproportionately small, rural, and volunteer-dependent operations, the ones already hardest pressed to compete for staff.

The lowest-volume agencies post a median cost of $1,980 per transport — more than triple the $608 median at the highest-volume agencies.▸ Scale buys efficiency here the same way it does anywhere else; the agencies that can't reach it are stuck eating both the widest revenue gap and the highest underlying cost.

None of this stays contained to a balance sheet.▸ The American Ambulance Association's 2024 Ambulance Employee Workforce Turnover Study, run with Newton 360 — a survey of nearly 20,000 employees at 258 EMS organizations, the largest of its kind for the private EMS industry — found overall turnover among paramedics and EMTs running 20 to 30 percent a year. The association has since asked Congress to fund recruitment, training, and mental-health support through the PARA-EMT Act (H.R. 2220), calling the shortage "crippling" and citing longer 911 response times as the visible symptom. An industry that collects less than half of what its core service costs to run is not well positioned to out-bid hospitals, who are hiring paramedics to offset their own nursing shortages, for the same workers.

Cost and revenue figures come from the GADCS Year 1 and Year 2 cohorts — organizations sampled from 2017–18 Medicare claims data, each reporting a 12-month collection period starting January or July 2022; the report is the first of its kind and CMS has not yet published Year 3 or Year 4 data. Turnover figures are industry-reported, not government data, though drawn from the largest private-EMS turnover survey publicly cited.