GoKawiilIn July 2023, a 25-year-old man named Jagdish Whitten was out for a run in San Francisco. As he crossed a busy street, a car hit him; he did, in his words, “a little flip” over the vehicle, landed in the road, and dragged himself to the curb. Those who had seen the accident called an ambulance for him. But Whitten waved them off and called a friend, who drove him to a nearby hospital instead: “I knew that ambulances were expensive,” he said, “and I didn’t think I was going to die.”
Whitten was right on both counts. At the hospital, doctors found that he had a mild concussion, a broken toe, and a few bruises—nothing too serious. But because he’d suffered a traumatic injury, they were obligated to send him to San Francisco General, the city’s only designated trauma center. 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.
Over the weeks that followed, Whitten got bills from both hospitals. Everything was roughly what he expected, and all of it would be covered by his insurance plan. But a few months later, Whitten got another bill—this time from American Medical Response, the ambulance provider that had transferred him between hospitals. The ambulance ride, he learned, would cost him $12,873: $737 for the miles traveled, $314 for monitoring his heart on the trip, $151 for infection control, and $11,670 as a “base rate.”
He sent the bill to his insurance provider, which at first denied the claim, saying that AMR was out of network and that the ride hadn’t been pre-authorized. (Whitten, of course, hadn’t chosen the ambulance, or anything else about the trip.) 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. After several failed attempts to contest the bill with AMR, and not wanting it sent to collections to hurt his credit score, he paid the remaining $2,900 or so. The brief ambulance ride from one hospital to another had cost him far more than any other part of the experience.
What Whitten had received was a “surprise bill”—a charge that lands on a patient when they’re treated, without knowledge or consent, by a provider outside their insurer’s network. The insurer pays what they consider reasonable; the provider bills the patient for the difference; and the patient, despite having insurance that’s meant to pay for treatment, is left holding the balance. This is a terrible situation to be in.
It’s also the default way that ambulance billing in the United States works. Each year, roughly three million privately insured Americans take an emergency ambulance ride; about half of them get an out-of-network bill for it, a rate unmatched anywhere else in medicine. And the uninsured have it worse still: with no insurer to absorb any of the charge, they face the full, undiscounted bill on their own.
This has proven quite difficult to fix. When Congress banned surprise billing across virtually the entire healthcare system in 2020, ground ambulances were the great exception. If you’re privately insured and need an emergency ambulance, you’re entering a lottery whose ticket price you’ll learn weeks or months later.
And that’s why so many Americans, like Whitten, avoid ambulances whenever they can. One poll from 2024 found that 23 percent of Americans have forgone an ambulance ride because of concerns about cost.
So why are American ambulances so expensive?
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. Whatever is being extracted from patients like Whitten, it isn’t padding anyone’s pockets.
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