He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
> Society should find a better way to pay for ambulances
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
And the US also pays a TON of tax dollars to a broken, overregulated system.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
>It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
I had an accident where I had a concussion and other injuries that put me in a lot of, and the people I was with called an ambulance for me, and I wasn't really in a state to decline, but if I had been, and knew how much it would cost, I would have. The ambulance ride was, of course, out of network. As were some of the doctors that treated me once I got to the hospital. It was the first time I dealt with a major medical expense as an adult, and it came as quite a shock when the bills came several months later, that said I was responsible for about $10,000 for the ambulance (plus a lot more for the hospital), and a good chunk of it didn't even count towards my deductible because it was out of network. I later learned I should have contested that since it was an emergency, and insurance is supposed to cover out of network service in an emergency, but I was young and inexperienced with dealing with health insurance companies. Oh, and it was about a 10 minute ambulance ride.
I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.
Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.
Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.
For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.
Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.
But humanitarian values are out of fashion, because they were never achieved globally.
So the only right people care about increasingly is their right to own property.
>> We scale it down depending on income and type of event. We're not massive sticklers about it.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.
Consent for treatment is a core principle of medical practice.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
The author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.
As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
> The average ambulance transport costs $2,673 to provide
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.
Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.
TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....
I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.
Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.
I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.
Stand by cost are about 154 euro/hour. E.g. for sport events.
ICU transport is about 2500. All are law mandated.
The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.
Some of your estimates on this seem fine, but not this:
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).
[1] Oh, holy crap, I just got why ambulances are called that
Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.
> We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Given you find this is _normal_ for a six mile ambulance ride: "and $11,670 as a “base rate.”"
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
"Medicare pays too little" is based on the "fee for service" model; it only makes sense if you believe the group of people who actually use the ambulance should pay its full cost.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
>The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
That 150k figure I believe is quite outdated. New ones are running 300k or more. The ambulance vehicle providers have been bought up by private equity and the lead times are now years to get one.
You’re right. The cost of the service not matching the direct cost is something we’re familiar with - that’s just fixed cost and entirely normal (happens with books, movies, etc).
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
> As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.
I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.
Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.
From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.
I dislike sentences like 'you still have to wait months for an exam or years for surgery'. Depends on the exam or surgery.
- Blood test: wait time (after your 12 hour fast) is likely 15-30minutes in most of Europe (even eastern Europe. I should know, I do one every 3 month).
- pet-scan/x-ray: at most a few hours if your area is truly underserved, in my experience, less than an hour (but I needed it 4 times, so it might be small sample size).
Specialists will make you wait for sure if it doesn't sound life-threatening for deeper exams, and especially exams that requires surgery, but the only example I have on hand is my mother's boyfriend who got his in less than two weeks, and his cancer removal surgery was planned within 3 months after the tumor biopsy (you need to change your diet at least a month before surgery to prevent complications and improve healing, so the true delay caused by wait time is ~2 month). They also explicitly said that if his cancer was more aggressive they would have given him a month to prepare according to my mom.
But yes, in Europe especially, convenience surgery can take a year (my intern lips and teeth took 17 months) (and you pay a bit out of pocket), when in the US you can be done within days.
What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.
If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.
Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.
You have free healthcare for children (up to 18 years old), pregnant women and registered unemployed. Moreover, any working person can (for free) add their spouse and parents. Plus people can apply for free health insurance if they have very low income.
Not sure, that's why I specified "from what I understand".
BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.
I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.
I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.
I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
> discovered the "life hack" of having an extremely inadequate network
The article covers this. Ambulance providers are strongly incentivized not to join insurance provider networks, and as a result more than 80% of ambulance rides in the US are “out of network”. So the inadequacy of the network is probably not the insurer’s fault.
Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
I had a very similar experience. Except unlike you I wasn't aware of that requirement at the time, and ended up paying all of it. I did complain to the insurance company that the amount I owed didn't seem right, and they told me it was my fault for using an out of network ambulance.
You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.
The last thing I want at that time is to have to reason about any of this.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
This applies to other things as well - retirement and education come to mind.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.
Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.
The law you've cited only applies for "emergency transport".
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least. Wild.
> My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.
Would your wife have been in a different location if you had made the call?
Yeah, my family was hit by two ambulance bills in California in 2024, and tried to balance bill us contrary to the law.
It was a really frustrating experience trying to get them follow the law. One of the ambulance companies waited an entire year to even file paperwork and still tried to get insurance and me to pay.
Last view of life: slowly bleeding out in the back of a waymo that has gotten trapped in the traffic circle in front of the ER and won't unlock its doors until it reached its destination.
I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.
I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)
A 5 minutes ride cost 1500.- (more or less the same in USD)
Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.
In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.
Yeah, I had a Canadian friend who was in a motorcycle accident. He could see the hospital from where he crashed. He begged the paramedics to let him walk, but they judged he should not.
He was billed 600$.
The paramedics' judgment as to whether he should or shouldn't have isn't the debate here. They likely made the safe call.
We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
I'm volunteering to help build out a nonprofit EMS authority that will tax residents and businesses in our local six boroughs to spread out the costs for ambulance transports.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
> most of the world has solved it by making ambulance (EMS) funding similar to fire...
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
Thanks for the response, it's been awhile since I used an ambulance. I've got to say, I was willing to believe, what with free Qld buses and all that jazz, but alas like WA it's "qualified":
There's no cost for ambulance treatment and transport for Queensland residents. This includes treatment and transport that takes place in other parts of Australia.
and
If you don’t live in Queensland, you’ll be charged for ambulance treatment and transport. If you have ambulance cover in another state it may cover the cost for you.
You know we can have volunteer supported services be very effective, right?
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
I think we are all villains here. Good healthcare coverage is just another status symbol to be attained. If the poor have it then it becomes less of a value. To some degree we are all wired this way and we all
suffer because of it.
>I think we are all villains here. Good healthcare coverage is just another status symbol to be attained.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.
SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.
Many makes it seem like this is common. But it extremely uncommon in the US to get a bill after a fire. There are some rural volunteer fire departments that are funded through memberships and they will bill you if you aren’t a member. But these are not common.
Story up thread is about an ambulance ride by the San Francisco Fire Department charging a grand. So in essence the EMS funding is the fire department funding and it’s still unsolved.
Health care in general has been solved by state sponsored medicine in most industrialized nations. And when it isn't solved by directly state sponsored medicine, it's solved by formally and informally regulated monopolies. In fact, US health care in the 1960s was made reasonable by the Blue Shield regulated monopoly.
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
Very much so. We could fix this. We continue to choose not to, and will for some time into the future.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties.
Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington.
Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
The city with the most funds per capita in the USA is SF. It's entirely run by dems. They can't pull it together or make the numbers work any better than repubs
There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.
We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.
US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.
What metrics are you using for that? The US ranks fairly close to the top for out of hospital heart attack survival, which is a good proxy for emergency medicine in general.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.
> The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.
> “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year
And even if you don't pay this it still isn't that expensive - US$12873 is more than a helicopter transport would cost here. US healthcare companies somehow get away with charging insured patients 10x more than civilised countries charge uninsured ones.
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
There is no need to be condescending to me and be arrogant despite you being ambiguous over which definition of the word you were using. You could simply end the conversation, realizing we were talking past each other but instead you decided to take jabs such as implying I am ESL, implying I am bad at English, and assuming I'm early in my career in order to attempt to belittle me.
Virginia has a long-established local dog license taxes on dog ownership and recently proposed a tax for, among other things, walking dogs. Clearly the liberals have their priorities wrong as usual. But hey you get what you vote for.
Foreigner from the socialist Nordics here, so perhaps I'm brain washed or something, but I don't get it. After some brief Googling it appears that you mean they have proposed a tax on a service that for some reason used to be tax-exempt.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency
“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
Yeah you're always free to decline medical services. Nobody can make you go to the hospital (unless you're unconscious or in delirious but then you aren't deciding anything).
> There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.
This isn't sustainable. You really want every person who is dealing with this bureaucracy to manage negotiating between their insurance and their EMS? After they've just had a significant accident/health issue?
The genius part is that the negotiations that determine how much they can get away with charging completely excludes the consumer. Two for-profit entities, with no mandate to actually provide care, decide how much they should pay each other.
Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.
This was a fun read, however, I feel that the actual essence is quite thin.
It can be summarized in a short sentence: The cost comes from being always prepared with teams and equipment, and few privately insured riders subsidizes everyone else, getting very high surprise bills - this can and should be a shared community tax which would effectively allow free ambulance rides to almost everybody.
It's an excellently written post though. I suspect people read this author for the experience, more so than actual information. I just wonder if they should just do prose and go wild with their skill instead of coating a few predictable facts with so many layers of color.
The article explains why; regulators sometimes can't foresee that their decision to consider something fee for service will eventually prevent it from being considered as a communal expense.
Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday
Years ago i slid down a bannister at a dance club, caught my foot, flipped over backwards, and landed on a barstool. Having grown up poor as dirt, i knew that calling an ambulance would be at least a grand if not double that. I called an uber to take me the 15 blocks to the hospital.
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
There is a gigantic business called "NEMT" "Non-Emergency Medical Transport" that has been filled by taxis and rideshares for decades. I first discovered this service when I broke my leg in 2006, and Medicaid was paying for taxi vouchers so that I could travel to far-flung orthopedic appointments over the span of 9 months. Otherwise I'd be on the bus, on crutches: ouch!
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
Because America healthcare is stuck in the middle - it is semi socialized. You get both the negatives of socialized and free market ones. Either make it full socialized or remove all state money (this includes tax breaks and incentives) and allow competition.
Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"
> In 2020, Congress passed the No Surprises Act, which banned surprise balance bills for most parts of emergency care. But by necessity, it exempted ground ambulances from the law: actually restricting the practice would have rendered much of the EMS industry insolvent.
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
I've treated people with panic disorder who, if there were no cost involved, would probably have called an ambulance monthly for suspected heart attacks.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
i think i read many warnings or jokes about this: when go to usa, dont call an ambulance because it's so fucking expensive..to compare, in china, it usally cost less than 100USD.
I had an ambulance ride on Thanksgiving Day last year. And the punchline was that with my ACA insurance, the "ambulance run" co-pay was $1,200. (Of course my total ambulance bill was around $1,310.)
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
Yeah I would bet the vast majority of ambulance rides are never paid for. Homeless, street people, the impoverished, the uninsured, the unemployed... none of them will ever pay a dollar much less thousands for an ambulance ride. And in many areas those are the people who disproportionately use ambulance services.
The piece is actually quite concise, but you're right in the other respect. You definitely didn't read it. Private equity as an explanation is explicitly rejected.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
The cost isn't about the actual mileage though, it's having two paramedics each earning about 100k/yr per ambulance, while having coverage 24x7x365. So fully loaded, the labor for one ambulance might be in the high six figures to seven figures.
I think the answer is very simple. Regulation. If there was no regulation or very little then anyone could open up an ambulance service and the cheapest costs and the best service would win.
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked
The idea that everything gets better if we remove all regulation is one we know doesn't work. It's the model we've tested repeatedly, before each piece of regulation, and it always leads to negative outcomes.
> The standard answer is greed
The article is interesting, but it doesn't actually sufficiently dismiss this; it's the route cause of it all.
He refused to go in an ambulance the first time. He could have refused the second ride. You can refuse transport or medical care at any time as long as you are able to make rational decisions.
As an EMT if you're A&Ox4, alert to time, place, person and event, you make the choices. You do sign a release so we have proof we didn't abandon you, but you make the choice. If we move you without your approval, it's kidnapping or entrapment (not hit me up law arguers). To do that we either need implied consent (minor no parent, not A&Ox4, or Law Enforcement).
My department, a small rural one with a small tax base which happens to cover a lot of injuries because we have 20 miles of dangerous mountain pass freeway and a ski and mountain bike area, only charge for calls if we transport. I think a transport is around $900. Our minimum transport is 37 miles. We scale it down depending on income and type of event. We're not massive sticklers about it. We're just trying to cover wear and tear on big expensive vehicles for all the non-transports, winter driving, equipment, uniforms, training, etc. Most of our "business" comes from "transients" eg folks who don't live there, eg those skiing, hiking, biking, or driving over the pass.
This is also very much not the norm. But should explain a bit about those who do pay are covering those who don't.
We don't want a chilling effect on calling 911 for precautionary stuff. We'd rather show up 99 times and check people out and let them go than miss the impending cardiac event. And we get those. It's very interesting just how much going over a 4k foot pass stresses people on the edge. Many of our medica calls are people driving to seattle for deeper care and things exacerbating when they get to 4k feet.
I don't think the question is "Should ambulances be a thing?" though. It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
The (fairly obvious) answer to that no one should be in that situation. It's horrible. Society should find a better way to pay for ambulances. Most of the world has accepted that some system to spread the cost among everyone is better than putting people in that situation.
> Society should find a better way to pay for ambulances
Society has this figured out, at least a decent solution that works until we find a perfect one. Only the US society seems to be unable to find a solution.
And the US also pays a TON of tax dollars to a broken, overregulated system.
IIRC if you look at the cost of Medicaide, Medicare, VA, and other federal and state spending it's the same as most other countries per capita or as a percent of GDP. The US taxpayer pays about as much as Canadians to fund their public system, then pays the same amount again for private cover since it's not universal.
No I'm not making a typo. Medicare, Medicaide, and the US system is such a rip off that per capita Americans are paying similar tax dollars to their joke of a public system.
But no one wants to fix it. US doctors are overpaid. US nurses are over paid. Dug companies. Admin. Lawyers. Everyone who makes the system work, and everyone who makes the system a mess are paid a fortune for it.
Is this the common cost or is this an outlier blog story that hit it off. Talk real data to me. I don't get excited about any individual anecdote (unless it's me personally of course).
No people shouldn't be bankrupted for a short cab ride that's not needed. I'm not arguing that.
It’s pretty common.
I know that John Oliver is a bit of a “lightning rod,” for many folks, but he (or his staff, really) does his homework. He did a segment on it, some time ago: https://youtube.com/watch?v=Ezv8sdTLxKo
>It's a question of "Should someone in a situation where they need an ambulance have to balance the potentially life-threatening impact of saying no versus the potentially financially ruinous impact of saying yes?"
Yes, you want to make that choice rather than shirk it off. Anything else is a perverse incentive. Making poor medical choices that prioritize your own well-being over the financial solvency of those you care for, those around you, is a shitty thing to do. But, some people like to pretend that if they can just make sure those people are the 300 million Americans rather than a more immediate circle of family, that the problem goes away. It doesn't, it becomes worse.
Most decent people would rather croak than ruin their own family. But those same people, through one false rationalization or another, are more than happy to ruin the entire country. Even if doing so won't result in net benefit. If I'm going to live, it's because the cost of keeping me alive is less than the net benefit of my increased lifespan. That calculation has to be the same no matter how you want to "spread the cost among everyone" or it all falls to shit. And since you're incapable of making rational decisions when it's spread further than your own family, well... things are going to continue to go downhill.
Your argument leads me to assume you think everything that causes to someone need an ambulance is the result of their choices.
Victim of a violent crime? You shouldn't have left your house.
Run over by someone else? You shouldn't have left your house.
Caught an infectious disease? You shouldn't have left your house.
Fell down the stairs? Why were you in your house!?! Don't you know how dangerous it is?!?
I had an accident where I had a concussion and other injuries that put me in a lot of, and the people I was with called an ambulance for me, and I wasn't really in a state to decline, but if I had been, and knew how much it would cost, I would have. The ambulance ride was, of course, out of network. As were some of the doctors that treated me once I got to the hospital. It was the first time I dealt with a major medical expense as an adult, and it came as quite a shock when the bills came several months later, that said I was responsible for about $10,000 for the ambulance (plus a lot more for the hospital), and a good chunk of it didn't even count towards my deductible because it was out of network. I later learned I should have contested that since it was an emergency, and insurance is supposed to cover out of network service in an emergency, but I was young and inexperienced with dealing with health insurance companies. Oh, and it was about a 10 minute ambulance ride.
I guess my point is, sometimes you don't have a choice, but you still end up with a massive bill. And also, that experience definitely had a chilling effect on me calling 911.
Treating medical care like this, similar to a racketeering scheme, should not be a thing anywhere.
Instead of punishing people for seeking medical care (or plainly requiring it), it would be preferable to have a robust protocol for rejecting patients that do not require care, whether at the hospital or before the ambulance ride.
For this, people would need to want medical care be a humanitarian right and basic pillar of a functioning society, not a business or a bureaucratic system to perform a selection process decreasing the life expectancy of less-affluent people.
Ironically, when there is free medical care and universal insurance, there are also perverse incentives. For example unneeded expensive procedures, prescribing patented, newer drugs where cheaper ones would work, providing ineffective or even detrimental services, etc.
But humanitarian values are out of fashion, because they were never achieved globally.
So the only right people care about increasingly is their right to own property.
As someone who is not American, $10,000!!!!!! That's hard to conceive where I live. We even have a specifically free ambulance service here.
> but you make the choice
No US doctor would ever tell you how much any procedure would cost (even though they know, at least "in-network" doctors).
But if in your EMT you inform the patient of the potential costs of the ride, then yea, I agree they make an informed choice.
>> We scale it down depending on income and type of event. We're not massive sticklers about it.
That touches on another very american problem. The injured person now does not know how much the tansport/treatment will cost. And the only persons on the ground cannot quote a price. If they say yes they enter into that zone of having another random health care bill comming in the mail. Is it 900, or 9000? Will my insurance cover this? Is this outside my deductable? ... this is math that no person should have to do while bleeding beside a highway.
The physician can mandate ambulance transfer.
Really? Where I live a patient is always able to refuse any medical procedure or treatment, unless they’re unconscious or otherwise mentally unable and the procedure is considered necessary to save their life. They certainly can opt for a non-ambulance transfer, though here it would be free even though a regular ambulance service typically isn’t.
Consent for treatment is a core principle of medical practice.
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
The author does not understand how private equity extracts money. The high-liability and heavily scrutinized business is intentionally left with little profit: the actual profits are funneled up the supply chain. This is why private equity buys "nonprofit" hospitals - they can now control who that nonprofit buys services and equipment from.
As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted. The article starts off by noting about how ambulance is an "option" for a rescue, but even though the analogy might vaguely work, it's not really needed to answer the question. That can be answered far more simply: "medicare and insurance companies pay them too little, so they have to charge everyone else more". Or, from the article:
>This meant that the payment structure and the cost structure were increasingly mismatched: and so ambulance services had to pay for their round-the-clock readiness by billing for individual rides. [...]
>And notably, the fees that Medicare sets run far below cost. The average ambulance transport costs $2,673 to provide; Medicare pays only about $329 of that. A typical ambulance ride for a Medicare patient, in other words, loses theambulance service thousands of dollars.
> The average ambulance transport costs $2,673 to provide
I think this ignores the 400 pound gorilla in the room. Why does an ambulance transport cost thousands for the operator? This is a short trip in an automobile, essentially a fancy uber ride. At first one might say that's flippant - obviously ambulances are specialized vehicles, and you have paramedics, and they need to get to locations quickly, and so forth, but let's consider those costs.
A new, fully equipped ambulance is about $150k. Of course this is more than a regular car, but by a factor of 5, not 50. Let's be generous and presume the ambulance fully depreciates in 2 years. Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr. Again, not orders of magnitude more expensive. Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year. Throw in money for gas and wear and tear, which should be quite comparable to other automobiles, and it costs about $1600 to own and operate an ambulance for 24 hours.
Now the other side of the equation is utilization. Taking the arbitrary example of Philadelphia Fire Department, they have 60 ambulances that handle on average 700 ems calls per day, and approximately 70% of ems calls lead to transport, so that's about 8 transports per ambulance per day. So distributing this all out, the actual cost to the ambulance operator, ignoring overhead, ought to be somewhere around $200.
I'm sure there are some additional costs I haven't included in this back of the envelope calculation, and maybe some of the numbers I pulled off google are off a bit, this should be taken as a very rough estimate. But even if you significantly increase the cost, the medicare payment amount seems quite reasonable to cover the expenses with a healthy profit margin. Unless you want to claim that operating an ambulance is less than 10% of the cost of ambulance transport, and that the estimators with Medicare are absurdly out of touch with reality, whence cometh $2,673?
There’s the cost of supplies used during transport. Also the cost of maintaining potential supplies like blood even if they go unused. EMTs may make $23 but they are also getting benefits and have other overhead, making their real hourly cost probably closer to $50/hr minimum. There’s insurance, which I bet is out the wazoo expensive for ambulance. Ambulances have to be maintained and I would guess have much more regular service than your car at home. Ambulances have to be stored somewhere and secured-access parking isn’t cheap. Many ambulance rounds-trips can be well over an hour considering so many of us live far away from urban centers.
Is it $2600? Probably not. But I think you are low-balling pretty significantly.
Put another way, just getting a plumber to vibe to your house is gonna cost you $200 easy. It’s within reason that an ambulance ride might cost much more than that.
I don't disagree with what you're saying but I want to point out that it's rather unusual for (American) ambulances to carry blood, and probably more of them should.
https://www.redcross.org/about-us/news-and-events/news/10-wa...
Correct. The only ambulances that typically will stock blood are specialized NICU ambulances and HEMS (helicopter). Although more progressive agencies are looking more and more at part blood products.
EMTs are like veterinarians. Lovely people who get ruthlessly exploited. Benefits are garbage unless you’re a unionized public employee.
Yeah, every EMT I know was way underpaid for how crazy stressful it was. Especially considering how expensive the ride was
EMT now is often used as a stepping stone to a career with a liveable wage, like physician.
Medical supply costs for transport are very small. The labor overhead costs are overhead. Insurance is included in the estimate.
A plumber charges you $200 to come to your house, it costs the plumber $20 to come to your house. The latter value is what we're discussing here.
TIL getting an elevator tech to just come out to look at your building's elevator is about $1600. If it's an easy fix, that's all you need to pay. If it's not, it goes up significantly....
He wouldn't be much of an elevator repairman if it didn't go up considerably.
To be fair, if you pay the repairman, your elevator also goes up :)
Don’t they need to sign something legally binding, the moment they adjust even one minor internal part?
I'm not going to claim that elevator malpractice isn't possible, but no elevator is designed with a single point of failure for any safety critical system, so I don't think it's easy or likely to make a mistake that would cause a safety issue.
Most people live in urban environments. Approaching zero are over an hour. As with most people being in urban environments most ambulance rides are in urban environments and go to the nearest hospital meaning that most rides should be under 10 minutes.
There is zero reason to compare cost of ambulance rides to a plumber and "vibe" on how much more expensive an ambulance ride instead of actually looking at the component costs. They aren't remotely related and one tells you nothing about the other.
Both the actual analysis you responded to and this one are also missing the fact that the ambulance is already subsidized and that usage fees aren't actually paying for the ambulance which makes the fees charged more onerous yet.
It might be instructive to look at what Canada charges non-residence as non-residents pay the unsubsidized rate of about $400-$600 Canadian.
https://www.cma.ca/resources/healthcare-real/answers/healthc...
"We mark it down based on [income]".. Obviously it's profit first (I don't mind if you don't pretend that profit is a cost). It unfortunately seems cheaper to be uninsured for many cases if you're willing to pick up a phone and discuss prices and take the risk that it may not always work out (but then again dealing with insurances has its own set of annoyances and steadily rising costs).. Not a recommendation but clearly my observation.
Replying to myself as a followup:
https://digitechcomputer.com/costs-of-ems-readiness/
Looks like of the $1954 they estimate for a transport (already quite a bit below TFAs $2673), $1582 is salary. Given that we established the crew in the ambulance are taking home about $140 per transport between them, this seems bonkers. Capital, medical supplies, and fleet maintenance are a whopping 6% of the "cost".
You need more than the crew in the ambulance.
Dispatch, maintenance, janitors, HR, managers.
They also need continuous training, and that is also a large salary cost for training staff (you have to pay them and the trainer).
+1. The base price for US healthcare is entirely removed from the cost of the service provided. And you can of course just look at other countries to figure out that the cost is much higher than it should be.
I think the main expense you are missing is medication and disposable equipment and insurance for the ambulance and medical malpractice.
Otherwise, yeah, I suspect the other major cost is the "It's the mayor's brother's business" cost and the "private equity has figured out how to extract maximum value" cost.
That said, there's no reason the patent should be charged anything. It should be entirely a tax burden of the citizens. It's crazy to make some decide between death and crippling debt.
Insurance is included.
12k for insurance is not enough.
Normal commercial insurance is much more expensive, let alone ambulances.
And don’t forget, the EMS employees need malpractice insurance and the company needs liability and workman’s comp insurance above the normal commercial levels
Probably an obvious/dumb thing to say on HN, but I just want every medical service to have this exact type of breakdown. And then we can at least somewhat pierce the veil of health care costs. The thing I can't figure out is why this doesn't already exist, or, if it does, why it's not more widely known amongst laypeople. Everything from ambulance rides to MRI's to surgeries can be baselined and then we can talk about unique situations that can push that baseline price higher, but at least have a baseline. Seems like a good thing for an LLM actually if you could trust it.
As to your specific $200 quote, which others have attempted to refine, it can't be a coincidence that you come up with that number and the Medicare number is $300+, which, if your $200 is even somewhat accurate, seems like a perfectly fair gross margin on what's being delivered. Imagine if the government actually reimburses for cost plus a decent profit margin! Unthinkable the gov could somehow be accurate in their reimbursements.
Edit: spelling
> I just want every medical service to have this exact type of breakdown
Check out the "No Surprises Act"
https://www.cms.gov/priorities/key-initiatives/hospital-pric...
Here in the Netherlands it is 877 euro for an A1 call (emergency, no delays), and 384 for B1 calls (non emergency, planable). You also get a 4.83 euro per km cost. You pay up to 375 euro if you haven't had any medical cost that year, otherwise zero.
Stand by cost are about 154 euro/hour. E.g. for sport events.
ICU transport is about 2500. All are law mandated.
The total cost might be more as the insurers also put in undisclosed amounts and some cost is shared with the emergency departments at the hospitals.
Some of your estimates on this seem fine, but not this:
liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Insurance on my SUV is close to $3,000 a year, but with the understanding I drive it about 12k miles, and I'm not allowed to speed or run red lights whereas they're guaranteed to be speeding, and driving it around all day and maybe all night. And the ambulance is worth 5x as much as my car is. So I'd be shocked if the combo of their auto insurance + insurance against being sued for rescuing someone wrong is that cheap.
The 12k per year includes medical liability insurance.
It may also be telling to figure out why no startup is offering $400 ambulance rides and dominating on volume.
Almost certainly regulations. Anything even vaguely medically-related tends to be very, very highly regulated.
I for one would love to see a startup called say, "Trauma Team International" or "Docwagon"...
Ambulnz by DocGo
You forgot the cost of insurance when you get sued by the passengers or when you get into an accident since you're racing down the road hoping people are paying attention and get out of the way. No idea what it costs but it's arguably more than an uber driver. 2x? 5x?
There are a ton of other costs. You're not paying for one employee. You're paying for many since ambulances run 24/7. They are also driven hard which means they require more maintenance. The ambulance is also full of expensive equipment and supplies.
My LLM of choice says it actually costs $1000-$2500 per ride to the company for operational costs on top of per-ride costs. You can probably ask one for a breakdown and see if it makes sense to you
"My LLM of choice" is like when the news reporter says "confirmed by someone not authorized to speak publicly". It's not a meaningful report.
It's arguably more reliable than some rando above doing napkin math and zero actual experience or evidence
Your point about LLMs aside, I'd trust the inside source over whatever carefully baked misrepresentation the PR department doles out.
I didn't forget the cost of insurance.
> Typically an ems crew will be two paramedics. Average paramedic wage is about $23/hr.
Paramedics and EMTs aren't the same thing. Private ambulance crews running "dual ALS (advanced life support, i.e. paramedics)" are _exceptionally rare_. Normal staffing is Paramedic and EMT, and most often there are crews that are dual EMT.
Average EMT wage is actually about $18/hr (and in much of the south you can be looking at $15-16/hr).
However where wages do go up, but not in a good way, is overtime. The agency I worked would happily schedule you for 36 or 48 hour _shifts_ and had no weekly hour limit beyond "You must take an 8 hour break after 60 hours of shift", I kid you not - and many people will regularly work 72-96 hour weeks.
The big thing is that private EMS writes off a lot of bills and pushes the balance on everyone else. The holy grail for private EMS agencies is "inter facility -out- of a hospital", as oftentimes the hospital pays the ambulance bill and charges the patient.
You also have to be careful looking at FD provided _transport_ as billing for this is often subsidized by property taxes. There are FDs who will charge for treatment and for transport, for transport only (not for treatment), or for neither (my FD did not charge - but there were also differing policies on when we transported, not by default, so you had people literally - and understandably - peeking out their window to see if it was a red FD ambulance/medic unit outside, or a white private ambulance).
Even above and beyond that, there are a LOT of disposable costs you never recoup. Bedding, blankets, gloves, etc.
> This is a short trip in an automobile, essentially a fancy uber ride.
That is a little flippant, as you acknowledge... good way to offend any paramedic or EMT. I've delivered babies en route to a hospital, including breeches. CPR. Emergency airways.
> A new, fully equipped ambulance is about $150k.
Not any more. Thanks, private equity. You can easily be looking at $400K. And they are vehicles that are driven hard, and cold, and maintenance sucks as a result. No warm up times for engines. Private ambulance, it's common to see rigs with 300,000+ miles on them.
> Then you have liability, both for the vehicle and for the medical treatment; that's about $12k per year.
Not for the medical treatment, no. You can get insurance privately as a paramedic but those policies are generally excess/umbrella style or are specifically "occasional only". The last private agency I worked at with a dozen paramedics and 50+ EMTs had at least mid 6 digit insurance bill.
> Throw in money for gas and wear and tear, which should be quite comparable to other automobiles
For a vehicle that can weigh 10,000lb+, that gets started and stopped often 30 times a day, a lot of time driven "foot to the floor" with an attitude of "it's got to get where it needs to go"? No, although one of the first thing any halfway decent sized agency quickly learns to build out is its own full shop and multiple mechanics (my friend is the Head Mechanic at a local county fire agency and oversees 8 FT mechanics and an auto electrician).
This jumped around a lot, I apologize, and I don't mean to shout you down, at all, but, lest you think I'm defending this state of affairs, I am not, in no way, shape or form.
You can get an ambulance for only $150k? A transit van with a few options is already $75k.
An interesting take on the relative differences of manufacturing (and purchasing) an ambulance in the US and China: https://www.youtube.com/watch?v=8JcCISp5S64
Ambulance crews are almost never 2 paramedics. Most often they transport and do BLS only. If they are it’s because a local government is paying for that service. EMTs make minimum wage.
The people who own ambulances typically have a little cartel like business in a region and print money. They refuse to sign insurance contracts so they are almost always out of network and will not accept direct insurance payments.
When my wife had cancer, she ended up at a hospital that didn’t have the services she needed becuase the ER was full at the trauma center hospital. I was able to arrange a transfer, and paid $1800 for a drive that was approximately 12 city blocks. We had to do that to avoid a complication with hospital admission and coverage. The crew was cool and we did get to honk the siren.
Air ambulance is worse.
Nobody makes (federal) minimum wage these days. McDonalds employees make double that.
I don’t live in a red state so we have a bizarrely low minimum.
We had to move my non-ambulatory[1] father from Mississippi to Virginia a couple of months ago. The vehicle probably didn't have all the staff and equipment of an ambulance but it did have an RN, a crash cart, and some other expensive crap that goes "ping". The cost was $3K for an 800 mile trip (slightly more because I included the "snacks and a DVD player" package).
[1] Oh, holy crap, I just got why ambulances are called that
Ah, but you forgot private equity, that's about $2473 of profit per ride that needs to be accounted for. This high cost is what we must pay to keep our economy dynamic and efficient.
IKON passes don't grow on trees you know.. Someone has to rent out in Aspen.
All in cost of the employee is probably double or more of your example $23 an hour wage, just to flesh out your napkin math
Which would increase the cost to $325, though I was deliberately excluding overhead.
> This is a short trip in an automobile, essentially a fancy uber ride.
We need a regulatory body that can fine people for making analogies this bad
People (like the guy from the article) literally take Uber rides instead of ambulances, so they are a reasonable substitute good in many cases.
> We need a regulatory body that can fine people for making analogies this bad
We need a communal agreement to apply social opprobrium upon people who reflexively propose to solve trivial problems by imposing their will on other people.
Tsk-tsk.
i mean their job is transporting people.
Given you find this is _normal_ for a six mile ambulance ride: "and $11,670 as a “base rate.”"
What on earth would you consider normal for a helicopter ride from Exeter to London?
That's roughly 150 miles as the crow flies. Pilot, co-pilot and a medic, minimum crew for say 1.5 hours. Each way, so 300 miles of fuel and aircraft lifetime and three hours of crew cost, not to mention ground crew etc.
My dad got that on the firm when the shit hit the fan and he needed to be seen by specialists in the Royal Brompton and Royal Devon and Exeter decided that was his best shot at life. That was 15 years ago.
Anyway, the OP's bill looked pretty normal until the 11,000 base rate nonsense. How can that possibly be justified?
> How can that possibly be justified?
They can't make money on some customers (medicare/insurance), so they have to make up the difference however they can. In practice this means screwing over the people who have assets to seize.
This thread is filled with strong arguments that ambulence operators do make money with medicare.
But even more, it's completely false that the reason an ongoing, working business charges a huge price to some people is that some other people are taking money from them. A business charge people huge prices when it can. Businesses make as much money as they can.
It is true that what health care providers charge individuals tends to be their "opening offer" to insurance companies so they do make this exact argument "we gotta make all our profits on you 'cause everyone else is denying us" but that doesn't make such arguments any more reasonable.
Comparable UK costs: https://www.kingsfund.org.uk/insight-and-analysis/data-and-c...
Estimate for an ambulance call is about £450. I suspect the main reason the US costs more is wages.
"Medicare pays too little" is based on the "fee for service" model; it only makes sense if you believe the group of people who actually use the ambulance should pay its full cost.
The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it. The former doesn't imply "everyone else should have to pay for my bad luck"; the latter does. It's effective persuasion.
>The options model matters: if you model an ambulance ride as a roulette wheel, you only expect to pay if you get very unlucky. If you model it as an option, you expect to pay even if you never use it.
There are plenty of services that have high fixed costs but low marginal costs, but we don't use the "options" framing. A movie costs tens to hundreds of millions to make, but otherwise costs very little to deliver. Their price are also fixed, rather than dynamically priced. Yet when a movie bombs, nobody is like "wow I guess they shouldn't have been selling an option for 2 hours of entertainment for $20!". It's a price problem, first and foremost, caused by insurance companies and medicare strongarming them.
I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you; no one is purchasing the right to see a movie regardless of how much it turns out to cost to show. It's the movie maker that would love to buy an option that makes you promise to buy a ticket, even if the movie turns out bad.
>I don't think you fully grasped the concept of an option, which is why it isn't illustrative for you
I perfectly do know what an option is. It's just not relevant to the discussion, or at least not necessary. If you're selling a service that costs $2k of amortized costs to provide for $300, because that's all medicare/insurance companies are willing to pay, that's not a problem because you're offering options, it's an issue because you're charging too little. You're losing money because the numbers simply don't pencil out, not because you sold a bunch of options and sharp jane st traders cleaned you out. In any other situation where you're charging less than what it costs to provide, people just call it "bad business model", not "you're selling options" or whatever.
That 150k figure I believe is quite outdated. New ones are running 300k or more. The ambulance vehicle providers have been bought up by private equity and the lead times are now years to get one.
You’re right. The cost of the service not matching the direct cost is something we’re familiar with - that’s just fixed cost and entirely normal (happens with books, movies, etc).
This just happens to be the case where you must transport people but most people are net losses. In this scenario, the only surviving companies would be those who charge the remainder sufficient enough that the blended population of clients causes a net pay-in. Everyone who doesn’t account for that will just go out of business.
Being available constantly could be helped with a retainer, it’s true, but even with that we should expect that some patients pay a lot if they’re rarer than the loss-makers.
That’s wrong. The poor people who don’t pay are Medicare and Medicaid patients, and both pay for medically necessary transportation.
Those calls essentially cover the base business expenses.
> As much as I like articles that tries to use economics or finance to explain stuff, the "options" analogy is a bit hamfisted
Idk, my takeaway is ambulances look like a solid market for a subscription model. Ideally, one that taxpayers pay for. But also, potentially, as a private one that you can pay e.g. $50/month to know you won't be billed $12,000 by idiots.
One thing I'd like to point out, many of the Airlift companies, like Airlift Northwest, offer $60/year family insurance for Heli EMS. They'll bill your insurance and accept the insurer's payment as "Paid in full". They also tend to have reciprocal agreements with many other HEMS agencies.
This is just insurance, dude
At the end of the day doesnt that just end up being universal healthcare but with more steps?
Here in Australia, you can be 2,000km in the bush and an ambulance will fly out to you and fly you back to the city for free.
That being said, we also have private ambulance companies here that will sting you for a huge bill if you don't have private ambulance cover.
I live in Poland and despite being Europe from what I understand they don't have socialized healthcare. You need to buy insurance from the government, or private (I have both). If you don't have it, you don't have a right to healthcare.
Then, if you go to public doctors or hospital you still have to wait months for an exam or years for surgery. BUT, I've never heard of anyone going bankrupt from getting sick, or being scammed by their insurance not covering costs.
From what people make it sound, in the US you don't have socialized healthcare, getting doctors and exams is quick, but you also get scammed by insurance companies who will try their best to get out of paying, and I've definitely heard about people going bankrupt because they got sick.
I dislike sentences like 'you still have to wait months for an exam or years for surgery'. Depends on the exam or surgery.
- Blood test: wait time (after your 12 hour fast) is likely 15-30minutes in most of Europe (even eastern Europe. I should know, I do one every 3 month).
- pet-scan/x-ray: at most a few hours if your area is truly underserved, in my experience, less than an hour (but I needed it 4 times, so it might be small sample size).
Specialists will make you wait for sure if it doesn't sound life-threatening for deeper exams, and especially exams that requires surgery, but the only example I have on hand is my mother's boyfriend who got his in less than two weeks, and his cancer removal surgery was planned within 3 months after the tumor biopsy (you need to change your diet at least a month before surgery to prevent complications and improve healing, so the true delay caused by wait time is ~2 month). They also explicitly said that if his cancer was more aggressive they would have given him a month to prepare according to my mom.
But yes, in Europe especially, convenience surgery can take a year (my intern lips and teeth took 17 months) (and you pay a bit out of pocket), when in the US you can be done within days.
I'm not sure we're talking about the same thing.
What I meant with "you have to wait months" is that if you go with the government-provided doctors and processes, they put you on a list and you have to wait for your turn. Getting an exam done can take months, and you can wait years for surgery, unless your condition is life-threatening.
If you go to a private clinic, of course you can get test results the same day and schedule any surgery within days.
Most people who can afford it go the private route. I had to do that too, which kind of pissed me off since I pay a hefty amount each month for insurance and I still have to go to private clinics. BUT, using the public infrastructure is just too inefficient. To get blood exams at a reduced price I had to schedule an appointment with my GP (days in advance), she'd send me to a specialist (about 1 week wait to get appointment), then a specialist would give me the paperwork required to get SOME of blood tests I needed covered by my insurance.
> they don't have socialized healthcare
You have free healthcare for children (up to 18 years old), pregnant women and registered unemployed. Moreover, any working person can (for free) add their spouse and parents. Plus people can apply for free health insurance if they have very low income.
Not sure, that's why I specified "from what I understand".
BUT, most people aren't children, pregnant, or registered unemployed/very low income, so from that point of view to me it's still an insurance-centric system.
I pay a hefty amount each month and I was sick in the past and the system was so inefficient that I had to go to private doctors and clinics just to figure out what was wrong with me. I see the public insurance payments as a tax and I have private insurance to cover the costs of private doctors/hospitals.
But maybe that's just me.
that's not true, access to the emergency medicine (and transport) is a constitutional right in Poland, you don't need NFZ coverage for that.
Same as in the USA. They are legally required to treat you in emergency situations there, too.
BUT, they will charge you for their services afterwards--both in the USA and in Poland.
Although I suspect that the bill from the American hospital will be A LOT more...
I spent a lot of time in healthcare finance and across most medical service industries the Medicare rate is actually not a loss. It’s a common thing said as it’s not super profitable, but it’s usually not a huge loss. It’s pretty close to what the cost of care should be. It just doesn’t give the extra padding for extremely fancy clinics, hospitals, admin and executive compensation, and often PE investor margin expectations. It’s usually slightly positive on contribution margin and given the volume of Medicare in the mix there’s enough flow through to cover reasonable overhead and perhaps slim margins. But, whenever I see a claim that the true cost of service is 10x over the Medicare rate, it’s a huge red flag there’s some financial shenanigans at play. Saying that Medicare is a loss, leaves the impression that it leaves a huge hole to fill so other payers need to pick up the bag in a huge way. This kind of lazy analysis blindly perpetuates this misconception. If they wanted to add value here, they should have performed a “what should an ambulance ride cost?” type analysis. You have to really strip out costs that are unneeded, excessive, and account for profit margin similarly. There’s no way $13k makes any sense for the service described. We need sensible cost controls in this industry. The industry hands these people blank checks when they can hide behind out of network, etc. It’s still captive price gouging.
I tell this story every time ambulance costs come up because it might be helpful to anyone. I once lived in San Francisco in the mid-2010s. In SF, the SFFD operates the vast majority of ambulances in the city. As in, 80%+. I once had the need to go to the hospital urgently and called 911. The ambulance that showed up was SFFD. They transported me and I recovered safely. I then got a bill from them saying that my insurance had refused to pay for it - apparently that insurance company (they're lucky I've forgotten which one, as naming and shaming health insurance people is one of my favorite hobbies) had refused to contract with SFFD, making them "out of network." Yes, an out of network ambulance. And remember, there's at least an 80% chance that an SFFD ambulance will show up, and I've never heard of them offering a menu of ambulance companies to the caller who's likely having a heart attack, bleeding, etc!
So of course, my insurance would only pay some small pittance, if anything, and I was sent a ~$1000 bill. I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.
So we have an insurance company which surely knows that law, surely knows what an ambulance is for, but has discovered the "life hack" of having an extremely inadequate network, simply refusing nearly every ambulance claim made in the City, and then only paying the small percentage who know the law and know how to file a complaint. And of course, there's no punishment, the punishment is just having to pay the few times they're caught.
And insurance companies wonder where all that anger (Delay, Deny, Depose, was it?) comes from.
Anyway, practical moral of the story: don't let them get away with doing that if it happens to you or someone you know!
Note: My story is obviously kind of tangential to the actual article which explains why the cost is so high due to everyone who's being subsidized by what they're charging privately-insured patients. However, I have but the world's tiniest violin for those extremely profitable insurance companies who would obviously really like one of their costs of doing business to just go away. Yeah, I'd also like it if I could be paid my full salary, even though I refuse any work I find annoying.
Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.
If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.
The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.
But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.
They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.
I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.
Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.
The insurer is being forced to act as an insurer, by paying the $1000 they're supposed to cover.
Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?
> isn't the California law requiring the insurance company to act as a sin-eater here?
American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.
As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.
The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.
If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.
> or cabulance
I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?
... do they reimburse those charges? Because wtf.
I had a very similar experience. Except unlike you I wasn't aware of that requirement at the time, and ended up paying all of it. I did complain to the insurance company that the amount I owed didn't seem right, and they told me it was my fault for using an out of network ambulance.
Was this Cigna? Same thing happened to me in SF in the same timeframe.
It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.
You don't have to pay them unless they're specific. I got a bill 3 years after being in an accident and I asked them for the documentation they legally have to provide me (itemization, the legal basis, detailed incident record, attempts on their part to contact insurance) of how they arrived at the sum. It's been a year since and they haven't given me anything.
Besides this kind of billing is banned in California now https://leginfo.legislature.ca.gov/faces/billHistoryClient.x...
The insurers just pay the in-network fee and you call it a day.
The last thing I want at that time is to have to reason about any of this.
I think I’m realizing that what I cherish about the healthcare system up here is not just that I don’t pay bills, but that I don’t even see a bill. Not that the bankruptcy inducing costs aren’t wretched, but I just cannot even imagine being put into a fucked up bureaucratic hell while my family is in a life altering crisis.
This applies to other things as well - retirement and education come to mind.
Anecdote: my uncle and BIL are auto mechanics. One in the US, the other in Scotland. Similar lifestyles - both own homes, have mechanical hobbies (vintage cars for one, Harleys for the other) - typical working class lives. The uncle in the UK just has much less mental overhead when it comes to major life planning.
Many here will say that that's the cost of the freedom of choice and speech in the US.
Yea I think this is the bit thats easy to take for granted in nations with rational healthcare systems. Not only do I not get fleeced, but at no point does my healthcare feel like economic activity, a transaction, it feels like healthcare and that the provision of it is being done for the right reasons.
Medicaid is actually like this incidentally. No copays really. Too bad the electeds don't want to roll it out. The a lot of the most expensive risk pools are already on medicaid or medicare.
The law you've cited only applies for "emergency transport".
Falck has found a workaround: Bill emergencies as "non-emergency" so they can balance bill. This is, of course, fraud. I'm sure that enough don't understand the law that this makes them a lot of money.
My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least. Wild.
> My wife had a miscarriage while we were staying at my Uncle's house in New Jersey. I was going to call 911, but instead, he decided he'd call from his landline. Difference between ambulance being free (because it was to a city resident's home) and costing what would have been $5k or so at least.
Would your wife have been in a different location if you had made the call?
Yeah, my family was hit by two ambulance bills in California in 2024, and tried to balance bill us contrary to the law. It was a really frustrating experience trying to get them follow the law. One of the ambulance companies waited an entire year to even file paperwork and still tried to get insurance and me to pay.
Why didn’t you take an Uber?
Last view of life: slowly bleeding out in the back of a waymo that has gotten trapped in the traffic circle in front of the ER and won't unlock its doors until it reached its destination.
Bring a window hammer.
Cleaning fee
I don't get this US medical system. And the more I get to read about it the less informed I feel. Sounds like every involved medical service out there is just to rip the patient off.
I had to call an ambulance in Switzerland where ambulance prices are freely set by the operator (except in a few cantons which are enforcing reasonable flat rates)
A 5 minutes ride cost 1500.- (more or less the same in USD)
Because I had used a good broker to pick my insurance plan, I was left with “only” 500.- to pay out of pocket for the ride.
In Quebec, as a resident, going 3 blocks in the ambulance cost us about 500 CAD if I remember correctly.
Yeah, I had a Canadian friend who was in a motorcycle accident. He could see the hospital from where he crashed. He begged the paramedics to let him walk, but they judged he should not.
He was billed 600$.
The paramedics' judgment as to whether he should or shouldn't have isn't the debate here. They likely made the safe call.
We’re all pretending this is an unsolvable problem when really most of the world has solved it by making ambulance (EMS) funding similar to fire and police departments. Somehow in any emergency I’ve seen, all three show up, often EMS before police or fire dept, and somehow that’s a service that has to be supplemented by insurance billings.
The blog mentions it, but it’s one of those obvious things that somehow isn’t solved yet and blows my mind every time it comes up.
I'm volunteering to help build out a nonprofit EMS authority that will tax residents and businesses in our local six boroughs to spread out the costs for ambulance transports.
We hope to set the rates such that folks won't have to pay at all if they have insurance or will only have to pay the gap amount insurance would have covered.
I'm collecting the data to figure out how many residents, how many businesses, and how many college students there are in the region and match that to the call volume for those same categories so that each group pays a fair share.
We're basing the legal structure in the MESA group from Lancaster PA. Public fee hearings with residents hopefully start this Fall, and then we're hoping to go live Jan 2027.
I will say I've been surprised how extremely expensive it is to run EMS. Even with 25% of our responders being volunteers, the costs are staggering. Insurance, equipment, medicines, payroll, billing, fuel, building maintenance, heating and cooling.
The vehicle maintenance would turn your hair grey. We have a vehicle in the shop almost every single day. And we have two volunteer mechanics trying to do fixes in house. But these ambulances just are absolutely beat to hell 24 hours a day. My partner is one of the mechanics, and she sometimes gets a half dozen vehicle maintenance reports a day! And we only have 7 vehicles!
And then you have to factor in deprecation on an asset that effectively drops to $0 after 5 years. And costs $300k to replace.
We pinch every penny we can think of, but the end effect is that we're trying to provide a service that's extremely expensive and so we hope this model will diffuse those costs across the whole population (which we expect will turn out to be something like $100/year per family).
Cross your fingers because this feels like our best option
> most of the world has solved it by making ambulance (EMS) funding similar to fire...
About 65% of the more than one million firefighters in the U.S. are volunteers, with nearly 19,000 fire departments being run completely by volunteers.
A pretty large number of EMS is also volunteers. Basically wherever you have a volunteer fire department, you'll have volunteer EMS (if it's there).
St. John's Ambulance service in Australia is a hybrid of core paid positions and volunteers (varying by region and demand).
In rural Australia most of the fire, ambulance, and emergency response service are volunteer manned and (locally) run, with federal and state assistance for equipment and costs.
Costwise AU Ambulances are either free (if you're a St. John's member - cheap per annum OR if covered by private / work insurance) or (a decade out of date number) a flat fee of $500.
I don't think this is true everywhere. Queensland has the QAS[1], operated and funded by the state government. There are no (direct) fees.
[1]https://www.ambulance.qld.gov.au/
Thanks for the response, it's been awhile since I used an ambulance. I've got to say, I was willing to believe, what with free Qld buses and all that jazz, but alas like WA it's "qualified":
and https://www.ambulance.qld.gov.au/our-services/emergency-ambu...Yeah. In many countries, EMS is also heavily volunteer-based.
You know we can have volunteer supported services be very effective, right?
I volunteer to give blood. No one is paying me, and yet, someone's life is saved by that.
Some folks believe (in fact, this is the thesis statement of much of anarchist theory) that people would largely volunteer to care for one another if their basic needs were met.
Not everything has to be transactional, you can have a government setting up a scaffold that supports and encourages and organizes volunteers and run an effective service.
But if we fixed it, that might help people who can't afford the ride otherwise. And we cannot have that.
But do they really? Can you point a real, evil villain saying that?
I think we are all villains here. Good healthcare coverage is just another status symbol to be attained. If the poor have it then it becomes less of a value. To some degree we are all wired this way and we all suffer because of it.
I'm not sure I agree. Poor health is not always obvious and your health insurance provider is not conspicuous in most interactions.
I have had VASTLY better free health coverage (OHP, Portland OR via Providence) than the current Kaiser dreck I and employer pay significant sums for.
Healthcare is not a flex, and it my experiences on the west coast, it's an inverse correlation to wealth. :/
>I think we are all villains here. Good healthcare coverage is just another status symbol to be attained.
Seriously? How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other? The extent I've experienced is stuff along the lines of "thank god I had my health plan, because otherwise it would have cost [6 figures]", but it didn't give the impression that they'd be mad if everyone didn't have to suffer that fate.
> How many conversations have you been in where people were bragging about how good their health coverage is and trying to one-up each other
Do imaginary conversations in the shower count?
See everyone who decries student loan forgiveness as an example.
But that is not the topic being discussed. Is it?
Government subsidized sudent loan forgiveness is a regressive tax, though, which makes it quite unpopular in the non educated that on average earn less.
The root cause is still cultural. Nobody wants to pay taxes that are helping someone else. Whether that "other" is in a different economic class, different race, different gender, has different political beliefs, lives in a different state, it's always the same mentality: "I don't want my tax dollars to pay for people I have determined to be 'others' and culturally different from me." Heaven forbid someone who doesn't deserve it or doesn't need it, get help.
Sure, in a given public discussion, lots of people saying that show up. But substantial portion of those are shills, not necessarily people to say but who benefit from the scam. And some people who are paid, public relations people acting on the downlow, etc.
The ambulance that billed me in San Francisco after my accident was run by San Francisco Fire Department.
SF EMS is funded partially through the general fund and other bond measures, with additional billing to cover the rest. I believe it’s like $2K for a ride.
Many fire departments in the US send bills, whether responding to medical emergencies or fires.
Many makes it seem like this is common. But it extremely uncommon in the US to get a bill after a fire. There are some rural volunteer fire departments that are funded through memberships and they will bill you if you aren’t a member. But these are not common.
Story up thread is about an ambulance ride by the San Francisco Fire Department charging a grand. So in essence the EMS funding is the fire department funding and it’s still unsolved.
Health care in general has been solved by state sponsored medicine in most industrialized nations. And when it isn't solved by directly state sponsored medicine, it's solved by formally and informally regulated monopolies. In fact, US health care in the 1960s was made reasonable by the Blue Shield regulated monopoly.
The thing about unfettered private health is that it finds "profit centers" and pumps them ruthlessly. But the problem when scheme/scam gets reigned in (say out-of-plan doctors), another appears (out-of-plan ambulances) and there's no end to the situation. Only actual state sponsored health care can end this.
Very much so. We could fix this. We continue to choose not to, and will for some time into the future.
Tangentially (think in systems), much of the US exists off of volunteer emergency services (fire and emt), which is rapidly evaporating. Average age of these volunteers is mid 50s.
https://www.nfpa.org/news-blogs-and-articles/nfpa-journal/20...
> For generations, volunteers have formed the backbone of the nation’s emergency response system. Roughly half of the U.S. population, some 170 million people, live in areas primarily served by volunteer departments. Unpaid firefighters comprise more than 60 percent of all U.S. firefighters, and more than 80 percent of the country’s fire departments are either all or mostly volunteer.
https://www.ruralhealthresearch.org/publications/1596
> 4.5 million people lived in an ambulance desert (AD); 2.3 million (52%) of them in rural counties. Four out of five counties (82%) had at least one AD. Rural counties were more likely to have ADs (84%) than urban counties (77%). Areas with the highest share and number of people living in ADs include the Appalachian region in the South; Western states with difficult mountainous terrain; coastal areas across the U.S.; and the rural mountainous areas of Maine, Vermont, Oregon, and Washington. Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
> Eight states had fewer than three ambulances covering every 1,000 square miles of land area (the Western states of Nevada, Wyoming, Montana, Utah, New Mexico, and Idaho; and the Midwestern states of North Dakota and South Dakota).
There are some good points above, but I think this one is a distraction. Many of those states on that list have low ambulance densities because they have low population densities.
Have you ever driven through Wyoming or Montana? They have less than 10 people per square mile on average. There are a couple clusters of cities and then miles of empty land.
These statistics need to be based on cities, or at least have population density taken into account. It doesn't compute to set a threshold for ambulances per square mile when the population density differs so much from state to state.
I don’t think it is reasonable to expect to have ambulance coverage across the entire United States. There is a lot of land with very few people.
Choosing to live far away from others is also choosing to live far away from help.
If a service is highly variable cost dependent and is unaffordable for the average individual to pay out-of-pocket it is unaffordable for the aggregate individual as well.
There _should_ be some ambulance deserts.
It's very often not a choice. But also, those rural areas are often the breadbaskets of the united states. Taking care of our farmers is important.
Trying to frame it as a choice also misses a lot. It technically is, but you have to recognize there's a huge cost in uprooting your entire life and moving to a new location.
We give our farmers absolutely insane subsidies already.
It is not the government’s job to “take care of” anybody.
Everything has a cost, staying has a cost, leaving has a cost. The question is how much should the public be taxed to pay for individuals suboptimal decision-making? Or conversely, why am I subsidizing some billionaires remote horse ranch to have daily Postal Service and an ambulance standing by?
Can I move to the wilds of Alaska and then demand the same level of service as New York City? No that would be ludicrous.
W.Australia has a land area three time that of Texas with the bulk of the 2.9 million in population clustered about the capital city Perth.
In the rest of the state there are volunteer Ambulance services subsidised by state and federal government and a fleet of Royal Flying Doctor air ambulances.
RFD(WA) comes in at ~ $80 million AUD / annum in state support (for better or worse - https://www.abc.net.au/news/2024-07-24/rural-gp-slams-royal-... )
They assert to have a "value" to the state of $4.1 billion AUD over 30 years - https://www.flyingdoctor.org.au/wa/
Australia is also going bankrupt just slightly faster than the United States. Looks like deficit spending and debt levels are only trending the wrong direction there as well.
I am all for flight for life as we call it here, but that is different than saying we should have a network of ambulances across massive swabs of mostly empty terrain.
I am willing to hazard that the Australian airlift response is slower than your average ambulance response in Sydney.
> Australia is also going bankrupt just slightly faster than the United States.
Dunno about that, there be weeds. Not to mention the US clown car demolition derby is still in office.
Still, the coronavirus pandemic and associated policy responses led to the largest deterioration in the Australian Commonwealth Government’s fiscal position since the Second World War. That was 2021.
The forecast national net debt has looked pretty shitty since then, but the arc has been one of improvement - last years 2025-26 National Fiscal Outlook has been claimed to be overly grim by the most recent KPMG assessment of the 2026–27 AU Budget and backs the estimates that the Federal Government net debt servicing will return to pre COVID levels by 2029-30.
Yeah, it's f-obvious it takes longer for a plane to cross 600km than it takes an ambulance to cross a Sydney suburb.
Any other insights?
> It is not the government’s job to “take care of” anybody.
That is actually the only legitimate function of government.
Sweet, open the borders then. It's not the government's job to take care of that (we had government long before we had 21st century style closed borders, so it's definitely not a requirement of government). More people = more money coming in.
> It is not the government’s job to “take care of” anybody.
That is literally the only job of government. The entire reason we have a government is to serve the citizens in some fashion or another.
Even for most libertarians, they'll view the government in having a role resolving disputes. That is "taking care of" citizens by resolving conflicts.
Subsidizing farmers so citizens continue to have cheap and consistent access to food is a great thing. Right up there with providing clean drinking water, sewage services, and building roads.
I think what I’m saying is being misinterpreted. I should have been more clear. Everybody’s definition of “taken care of” is different.
The government needs to balance the interest of the public with the interest of the individual. It is not intended to “take care of “people regardless of their asks.
Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
Do you think a beachside penthouse is really an equivalent example to life-saving medical care?
> Otherwise, what if I am only “taken care of” if I have a beachside penthouse in Malibu and also a pony?
That's a false equivalence.
We aren't talking about giving people penthouses. We are talking about providing EMS. Heck, I can even grant "degraded EMS" maybe we don't ensure an ambulance is stocked with the latest and greatest tech because you are rural. Maybe the ambulance is a hand-me-down from a larger city.
But it's not a huge ask to say that rural communities deserve at least some level of emergency health medicine. Less people means less health incidents. That's the primary reason why so many rural locations today are able to get by with volunteer EMS (Something my family participated in. Calls happened roughly once a month at most in my town of 300).
> The government is not taking care of people if it allows the average expenditure per person to eclipse the average tax revenue per person. The economics need to be roughly sustainable at the national state and even rural area level.
I agree, it's smart to make sure the government isn't over spending on frivolous things. I just don't think "EMS" is frivolous. Everyone might need it, it doesn't ultimately cost that much to provide (especially if it were actually ran by the government and not private entities), and it's services buy a lot of good will with citizens. Additionally, it creates economic output. Someone dying or getting a lifetime disability because EMS wasn't available is someone that's not adding to the economy.
Since the 1980s the Republican party had adopted a position of starve the beast, of screwing up these very numbers so that people can make exactly the argument you have.
What happens when half of government acts is bad faith purely to poison the well, one half of government and an entire political party make it so that the numbers don't work (and via the fiscal policy they intentionally inflict/structure/design) purely so that they can promote their policy position of 'the numbers don't work'?
How many unfunded tax cuts have we had recently? Those aren't acts of nature. The numbers you speak of not matching aren't acts of nature. They are intentionally designed to 'starve the beast' in the 1980s Republican way, and in newer ways the party has come up with since. All so the exact argument you gave can be made.
The city with the most funds per capita in the USA is SF. It's entirely run by dems. They can't pull it together or make the numbers work any better than repubs
Why should there be ambulance deserts but not postal deserts?
Directionally, I am also fine with postal deserts or at least different delivery expectations for very rural areas.
But also because Postal Service is much cheaper than an ambulance service?
There is no reason why this should be a blocker to solving the problem though. 80% of the population still lives in an urban area. You could create a system that works for the majority of the country’s population and then can figure out the rest.
We choose not to, because most consumers of ambulance services don't have to pay for it. So those of us who pay out of pocket for an ambulance, like I did ($1700 to go 3/4 of a mile last year) are a tiny minority.
the reverse side of that medal is that in 'most of the world' EMS quality is ass.
US EMS quality isn't exactly something to be proud of. It's been private equityified. Just recently (last winter) I nearly lost an aunt because of our stellar EMS system literally doing a transfer from a hospital to a hospice. The company had only one person working, they parked the ambulance next to a snow bank, tried to wheel my aunt up the snow bank, and had her and the bed flip on them trapping them in the snow.
They were super lucky that someone from the hospice just happened to be leaving at the same time they flipped the bed.
I think this argument is very disingenious for two reasons:
- If you’re comparing to developed nations (or some non developed ones with functioning agencies), the argument doesn’t hold true.
- If you’re comparing to the bottom of the barrel EMS (quality being ass like you said), you’re still not going bankrupt for an ambulance ride.
If you limit it to say the top 20 developed countries how does it look?
Just a quick Google indicates the UK, Germany, US, and Japan all have urban response times in the ballpark of 10 minutes.
And even then they do worse than the average half brained private driver on trauma calls, since for many medical issues speed trumps capability.
Well, here it is often ass AND expensive. I'd take ass and free over ass and expensive.
Haven't yet seen a developed nation do worse than the US. If you prefer to compare against developing countries only, sure, winning by lowering the bar to the ground is an option.
What metrics are you using for that? The US ranks fairly close to the top for out of hospital heart attack survival, which is a good proxy for emergency medicine in general.
The US also has decent EMS response times. If you adjust for population density, the US has fantastic response times.
UK has had some atrocious response times.
Google is telling me that’s not the case… 7 minute target for life-threatening calls, with 90% actual within 15 minutes.
Aside from the funding mechanism being a premium that everyone pays, the other part of the motivating story here that seems downright silly is:
- the patient was _forced_ to take an ambulance to another hospital, but not to be treated for anything in particular.
- the post goes into how the EMS system is expensive b/c you need trained paramedics and expensive medical equipment and such -- but sometimes they really do just need to move a patient, not treat anyone in the field or en route. Saying that you pay for the paramedics even when you're effectively just being moved between facilities _also_ seems wasteful.
Yes, we should share the cost. But once we all share the cost, maybe we should try to spend the public dollars effectively by only using ambulances when they're needed, and distinguishing between "transport patient who can't sit upright and buckle a seatbelt" and "try to stop their arterial bleeding as you speed towards the hospital".
Sharing costs generates institutional incentives to keep costs down. Individualizing costs generates institutional incentives to charge more.
Perverse incentives are the essence of what is wrong with US medical systems.
Its a collective emergency service, which can save lives.
If by law this service is required and you bill only the rides, you get this, high bills per ride.
It would be nice to see a chart of countries with cost of ambulance rides, cost for the patient and average response times.
So what is the practical advice to avoid high costs? Also for foreigners, long ago had a friend visit from Asia and wave away ambulance after a potential serious injury (waiver not to be transported) knowing of the high medical costs.
> The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue. That’s how it’s done in the rest of the rich world. Some places, like the United Kingdom or Japan, simply fund ambulance services directly out of taxes; others, like the Australian state of Victoria, sell memberships in “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year per family.
So there is a solution.
> “Ambulance Victoria,” with unlimited exercise at the cost of about $70 a year
And even if you don't pay this it still isn't that expensive - US$12873 is more than a helicopter transport would cost here. US healthcare companies somehow get away with charging insured patients 10x more than civilised countries charge uninsured ones.
>from everyone the service stands ready to rescue
So compelled health insurance to use an ambulance? You could just as well make it optional and charge people without the insurance the full price.
So everyone's covered unless you explicitly opt-out?
Everyone is covered and you have the ability to pay someone to take on the risk of having to pay for an ambulance.
what happens to the people who don't pay someone to take that risk when they need an ambulance?
Then they pay for the ambulance.
Well then not everyone is covered.
To me covered means that the ambulance will drive to your location.
Hey man, don't worry about it, this is an international forum, English can be difficult. You seem kind of like a more junior/early in your career guy so, I'm happy to help out and explain.
Covered in this case means that they don't have to pay some third party to take that risk for them, they can just get the ambulance as part of the nominal fee everyone pays per year or whatever.
When you outline a problem statement, you want to map out what the person outlining the specs really mean. It takes practice.
There is no need to be condescending to me and be arrogant despite you being ambiguous over which definition of the word you were using. You could simply end the conversation, realizing we were talking past each other but instead you decided to take jabs such as implying I am ESL, implying I am bad at English, and assuming I'm early in my career in order to attempt to belittle me.
But that’s socialism!
Virginia has a long-established local dog license taxes on dog ownership and recently proposed a tax for, among other things, walking dogs. Clearly the liberals have their priorities wrong as usual. But hey you get what you vote for.
Foreigner from the socialist Nordics here, so perhaps I'm brain washed or something, but I don't get it. After some brief Googling it appears that you mean they have proposed a tax on a service that for some reason used to be tax-exempt.
Why was it tax-exempt? Why should it be?
What sets it apart from any other service where you pay someone to do something for you - such as cook you a meal, transport you somewhere or build you a house?
Wait, being transported in an ambulance costs money? Man, every day I learn new things about how shitty the US health system is, and I'm more and more happy to not have to worry about deciding if I'd rather die or be broke in an emergency
My fun ancedotal story about US healthcare:
Kaiser transported me 4hrs in a ambulance to get surgery and I think I just paid the $200 ER fee
But then they would never cover an MRI for an issue with the same leg.
It's like we're almost done with this project guys, come on.
Why won't EMS providers strip down their services to the level where Medicare/Medicaid rates completely cover their costs?
If you remove the $11,000 extortion “fee”, the remaining $1,000 is about the price found in the Western world countries.
“ This time he didn’t have a choice. He was loaded into an ambulance for a six-mile transfer, evaluated without additional treatment, and sent home the same night.”
This is weird, why didn’t he have a choice? I have literally walked out of a hospital with IVs still attached to my arms when I disagreed on course of treatment that included hospitalization for a case of white coat syndrome. They also wanted me to wait one hour to sign a waiver, which I unkindly refused.
Yeah you're always free to decline medical services. Nobody can make you go to the hospital (unless you're unconscious or in delirious but then you aren't deciding anything).
Uber for ambulances, got it. Claude, get to work. We will submit for Apple app review at EOD.
> There are parts of the U.S. that do this already. Ambulance rides are already subsidized by taxpayers in most places, thanks to public funding for fire departments; and a growing number of places have taken this further.
Indeed, in my county that's the case along with a $60/year subscription program to indemnify yourself against further costs:
https://www.wake.gov/departments-government/emergency-medica...
Finding out about this program was such a relief. I haven't worried about the prospect of having to call 911 since signing up.
I think one of the most aggravating things about interacting with the health care system is losing control of cost/risk/reward tradeoffs. The mandatory transfer and ambulance ride in the linked story are an excellent example. I think I'd have walked out against medical advice in that circumstance, but there is the constant danger of being subjected to similar costs, both monetary and physical, when I am less conscious or at a serious informational disadvantage. The need to bring a patient advocate with you to the hospital whose role echoes both doctor and lawyer is becoming quite serious.
"On appeal, his insurance agreed to cover $9,967 of the charge—better than nothing, but it still left him on the hook for about $3,000."
Tell the insurance company to wait to release the funds until you talk to the ambulance company or to release the funds directly to you.
Tell the ambulance company they can take the $9,967 or get zero.
This isn't sustainable. You really want every person who is dealing with this bureaucracy to manage negotiating between their insurance and their EMS? After they've just had a significant accident/health issue?
That seems needlessly cruel to do to people.
Anywhere else in the world it’s possible to do this orders of magnitude cheaper.
But yes, it’s because of “options” and not because of greed.
Some group of people tries to extract as much money as possible. You can call this capitalism. I think it’s a big scam.
In a market where competition isn't relevant, the price of things is whatever you can get someone to pay for it.
The genius part is that the negotiations that determine how much they can get away with charging completely excludes the consumer. Two for-profit entities, with no mandate to actually provide care, decide how much they should pay each other.
And they decide that you'll pay a percentage of what they pay each other. Which you also have no say in.
Seems like rationalization - PE firms establish regional monopolies and jack up rates. They do it with every type of service. Just accept that we're all serfs under the billionaires who extract rents over every aspect of our lives.
Where I live (NJ) you don't pay if your picked up by a town run rescue squad. But you don't always know who's responding... Such a strange system.
> a car hit him; he did, in his words, “a little flip” over the vehicle, landed in the road
He was lucky he was hit by a car.
A slab fronted SUV or pickup would have dragged him underneath and so it goes.
This was a fun read, however, I feel that the actual essence is quite thin.
It can be summarized in a short sentence: The cost comes from being always prepared with teams and equipment, and few privately insured riders subsidizes everyone else, getting very high surprise bills - this can and should be a shared community tax which would effectively allow free ambulance rides to almost everybody.
It's an excellently written post though. I suspect people read this author for the experience, more so than actual information. I just wonder if they should just do prose and go wild with their skill instead of coating a few predictable facts with so many layers of color.
I don't understand why taxes can be used to save property but not a person.
The article explains why; regulators sometimes can't foresee that their decision to consider something fee for service will eventually prevent it from being considered as a communal expense.
Fee-for-service doesn't prevent ambulances from being considered a communal expense, it just makes sticky. There is nothing preventing a government from making ambulances equivalent to fire or police except the will.
From the article: "The most efficient way to fund ambulance services would simply be to pay for the option the way that options are normally paid for: with a premium, collected from everyone the service stands ready to rescue". In other words, taxation just like anything else we expect to be available to anybody.
Because we like property.
Sure you do. Most people don’t own property. Most of the taxes are paid by people who do. And elections are decided by people with property.
You've got it. Who makes the decisions? Primarily the folks with the most property.
Taxi / shuttle service also needs trained professionals, high fixed cost investment on specialized equipment, 24/7 availability.
I am shuttled to the airport at 4 am and paid $30.
It did not cost 20k per ride. So ambulance providers charge that much because they can. There is no real competition.
Same from Argentina to Canada? Wow
This is the best article of HN ever, so detailed and explaining, and engaging. I have a message for all US readers, this is simply nonsense. Putting blame on the hurt in the moment of need, discussing money over his own health, is something demons do. I hope you will realize someday
There should be an "Uberlance" - discount emergency pickups by Uber, at Uber prices.
Years ago i slid down a bannister at a dance club, caught my foot, flipped over backwards, and landed on a barstool. Having grown up poor as dirt, i knew that calling an ambulance would be at least a grand if not double that. I called an uber to take me the 15 blocks to the hospital.
Total cost was 70 bucks (10 bucks for the uber, 60 for the er copay).
The number of people here in the US who use uber as an ambulance is waaay higher than you would think.
Uber is already “Uberlance”. Most people take Ubers to the hospital unless they are literally dying (and some even then).
Unlike an ambulance, an uber driver won't be able to keep a hemodynamically unstable patient alive for a 30 minute transport.
LAFD has already called Ubers for non-emergency transport to hospitals.
There is a gigantic business called "NEMT" "Non-Emergency Medical Transport" that has been filled by taxis and rideshares for decades. I first discovered this service when I broke my leg in 2006, and Medicaid was paying for taxi vouchers so that I could travel to far-flung orthopedic appointments over the span of 9 months. Otherwise I'd be on the bus, on crutches: ouch!
So NEMT can cover a lot of use cases where people are stable and just going to PCP or specialist visits. Or even behavioral health appointments. There are now dedicated NEMT providers, like Veyo out of San Diego.
In fact, when I broke my leg, there was talk of calling an ambulance. But I was only about 3 miles from the destination hospital, and there were many wise people nearby, so several of them suggested I just call a cab and take the cab to the E.D. instead, because that was far more efficient. So that's what we did, because really, I didn't need any life support, or blood transfusion, or rescuscitation on the way there.
Since the billing SNAFU last Thanksgiving I also learned about the difference between BLS and ALS. For some reason the ambulance provider billed for ALS even though none of that was necessary. Of course, ALS costs more and bills more and probably profits them more. I should have contested this stupid account trick, but whatever. They haven't even billed me for the "co-pay" yet, so we still need to wait and see how this shakes out.
Because America healthcare is stuck in the middle - it is semi socialized. You get both the negatives of socialized and free market ones. Either make it full socialized or remove all state money (this includes tax breaks and incentives) and allow competition.
Cost in Bulgaria: $0
Check your insurance to make sure you have transport. It's the same in Switzerland - it's an extra line on your insurance.
My wife and also have Rega. They can't legally call it insurance but if we get injured in, for example, the USA they will send us a private hospital jet to bring us home.
And then do what, precisely? Quit your job and find one with better insurance options?
This comment is confusing because it refers to the first paragraph and also assumes when you checked your insurance you didn't find transport there. Since the parent did have transport and good insurance and a second paragraph, it sounds like you're asking "And then do what after your hospital jet flies you home, quit your job and find better insurance?"
This is amazingly coherent and explanatory article!
the writer really went into depth about the problem and...surprise...the answer is almost embarrassingly simple.
Everyone in the country needs to read this.
> In 2020, Congress passed the No Surprises Act, which banned surprise balance bills for most parts of emergency care. But by necessity, it exempted ground ambulances from the law: actually restricting the practice would have rendered much of the EMS industry insolvent.
Right, but air ambulances are subject to the No Surprises Act, and we somehow still have those.
Also, ERs are subject to the No Surprises Act, and they do some pretty damned expensive things. Plus, if you're seen by an out-of-network practitioner in an in-network hospital or ER, no you weren't: No Surprises Act forces them to accept QPA and not balance bill. Somehow all of those out-of-network anesthetists and radiologists are still in business.
Here's a PDF about the No Surprises Act:
https://www.cms.gov/files/document/a274577-1a-training-1-bal...
its horrible to think when u are caught up in something serious that calling an ambulance could ruin your life later.
better to live in uk where nhs takes care of all this compassionately for free.
I've treated people with panic disorder who, if there were no cost involved, would probably have called an ambulance monthly for suspected heart attacks.
I wonder how countries with universal healthcare coverage deal with the lack of a (dis)incentive here. Maybe they just eat the cost?
i think i read many warnings or jokes about this: when go to usa, dont call an ambulance because it's so fucking expensive..to compare, in china, it usally cost less than 100USD.
I had an ambulance ride on Thanksgiving Day last year. And the punchline was that with my ACA insurance, the "ambulance run" co-pay was $1,200. (Of course my total ambulance bill was around $1,310.)
There was a long period of back-and-forth with calls and website visits, where they were insistently billing the wrong insurance, and so forth. But I'm grateful that I used the ambulance at that point in time.
The key advantage to an ambulance ride is bypassing the Triage Nurse. If you're going to an E.D. and you take a ride-share or a friend drives you, then you'll go to the registration desk and then meet the triage nurse. And the Triage window is pretty good at conserving hospital resources, and de-prioritizing you if your issue could be handled by Urgent Care or your PCP on a weekday.
But if the ambulance gets called to your home, it's a foregone conclusion that you really, really want to go to the E.D. and the ambulance crew will Keystone Kops their way to a successful hospital drop-off. They'll take some vitals and ensure that you're stable, because if you're not, they can save lives, and keep you alive during transport. But if you're conscious then they ask that $64,000 question: "do you want to go to the hospital?"
Once a few years ago, a nurse in a clinic had called 9-1-1 on my behalf and it was actually difficult to refuse a hospital transport. The EMS crew put me on the phone with a hospital attending physician and I had to emphatically refuse transport several times, after being advised of all the risks. (My only issue was elevated blood pressure. C'mon, guys.)
One of the troubles with ambulances is that they are really overkill for many calls. If some homeless dude goes unconscious on the curb, they get called. Some neighbor was going to call 9-1-1 because I laid down briefly near the pool. The ambulance and its crew is highly equipped to save lives and respond to the worst trauma cases: multi-GSW, car accidents at 70mph, etc. But I called them because I had a bad headache. And that's why they got to bill so much: they cost a lot! And I bet that a lot of uninsured deadbeats default on their ambulance bills, and the City gets to eat all those costs.
But the times I've transported myself to the hospital, I kinda got blocked by Triage, and it was for my own good. This last time over Thanksgiving, I had a lot of issues, and isn't it always the way that they hit at the beginning of a holiday weekend? So, it was good I went to the hospital.
But I was flabbergasted that my "co-pay" was 92% of the ambulance bill. I don't know why, but that plan has terminated anyway, so there's no arguing about it. At least, my actual hospital bills were well-covered by that plan.
Yeah I would bet the vast majority of ambulance rides are never paid for. Homeless, street people, the impoverished, the uninsured, the unemployed... none of them will ever pay a dollar much less thousands for an ambulance ride. And in many areas those are the people who disproportionately use ambulance services.
TLDR: private equity
The piece is actually quite concise, but you're right in the other respect. You definitely didn't read it. Private equity as an explanation is explicitly rejected.
The article argues the exact opposite:
> The standard answer is greed: rapacious ambulance operators, owned by villainous private equity firms, exploit patients at their most helpless. But I don’t think that’s actually what’s going on. Ambulance providers are chronically unprofitable businesses; margins are thin, crews are underpaid, and operators exit the industry every year.
That paragraph is somewhat incoherent at that point in the article: margins are razor thin — at a price tag of $12,000 per 6 miles or $2,000 per mile.
(Yes, there is some other stuff, much, much, much later that maybe cuts into that …)
The cost isn't about the actual mileage though, it's having two paramedics each earning about 100k/yr per ambulance, while having coverage 24x7x365. So fully loaded, the labor for one ambulance might be in the high six figures to seven figures.
Except the paramedics are actually making mcdonalds wages.
I think the answer is very simple. Regulation. If there was no regulation or very little then anyone could open up an ambulance service and the cheapest costs and the best service would win.
Unfortunately that’s not the case. It’s like day care. Day care is expensive because the government mandates it to be expensive. Otherwise you’d have grandmas down your street would gladly watch your kid but it’s generally not allowed for more than a couple kids.
Same thing with houses. I have half an acre. Could easily put 2 affordable tiny homes on it. Good income for me, cheap rent for someone else, but, unfortunately it’s legally blocked
The idea that everything gets better if we remove all regulation is one we know doesn't work. It's the model we've tested repeatedly, before each piece of regulation, and it always leads to negative outcomes.
When you are bleeding out on the street, you don't have time to shop around for the best deal
Wont matter because nobody is going to be paying 12k for a ambulance ride if there are people doing it significantly cheaper.
I would absolutely not tolerate and unregulated ambulance responding to my emergency.
You don’t have to. You do what you want. I’d prefer to hire a company where the workers make more money. Right now they make a pittance.
Someone who's having a medical emergency is certainly in no position to go comparison shopping for ambulance services.
You would do it before hand of course
When you get your bill, you could just double that as a tip.