Ambulance deserts — 2.3 million people in rural counties are more than 25 minutes from an ambulance station

What is happening?

An ambulance desert is a place more than 25 minutes from where an ambulance is stationed. In the last national count, which covered 41 states using 2021-2022 data and was published in May 2023, 4.5 million people lived in one, and 2.3 million of them lived in rural counties — a share the report prints as 52 percent. No national count has replaced it since.

What has been measured more recently is the consequence. A study of 64.6 million emergency medical services calls recorded between January 2023 and January 2025, presented at a surgical conference in October 2025, found that the average total call time in rural communities was 92.8 minutes against 74.1 minutes nationally. Rural calls were also sicker: 39.3 percent were high-acuity against 26.4 percent nationally, and for high-acuity patients taken to a specialty center the rural figure was 155 minutes against 114 minutes nationally.

The gap persists because in most states nothing requires anyone to close it. As of an April 2024 tally, 14 states and the District of Columbia had enacted legislation designating emergency medical services an essential service. In the remaining states an ambulance service is run by an operator — a private company, a hospital, a volunteer squad, a city fire department working outside its own borders — and an operator can stop.

Whose problem is this?

The decision that ends a service is made by one operator, and in most states the duty to replace it sits with no one at all.

Where does this problem end?

The boundary matters because what is drawn here is a map, not a performance record. A single call can run fast or slow for reasons that have nothing to do with geography, so the line is set at where a truck is stationed, and a distance nobody is assigned to close is a different object from a distance somebody is late in closing.

What is the state now, and what should it be?

Now

Needs a new measurementthe target state. No federal or national standard was found in these sources for how far a person may live from an ambulance station. The 25-minute figure is a measurement threshold chosen by the researchers, not a required maximum that any authority has adopted. What state-level advocates ask for instead is a legal duty to provide the service and a payment level that covers the cost of standing ready.

How big is it?

The affected population is between 2.3 million and 4.5 million people, and both ends are counted rather than modeled.

The lower end is the number of ambulance desert residents living in rural counties. The upper end is the number of all ambulance desert residents in the same study, rural and non-rural together. Both come from one chartbook covering 41 states with 2021-2022 data.

Nine states were never measured, so neither end covers the whole country. The range is not a confidence interval — it is the distance between a narrow reading and a wide reading of a single count, and it is four years old.

Under what conditions does it arise?

1. No unit of government owes the service. In most states no unit of government is required to provide an ambulance service, and none is required to replace one that stops. A 2026 report on South Dakota states the position plainly — that state does not require counties, townships, or municipalities to provide ambulance service. 2. Payment follows transport rather than readiness. Reimbursement arrives when a patient is carried to an emergency room. A place with few calls therefore has few paid events while carrying the full cost of a crew and a vehicle available around the clock. Alabama operators told legislators in March 2026 that the rate insurers pay had gone eight years without change. 3. The fixed costs do not scale down. One new basic ambulance cost $200,000 to $300,000 as of September 2023. The Rapid City Fire Department says it needs $800,000 to keep covering the unincorporated areas of Pennington County, and those areas produced about 2,655 calls in 2025. 4. The workforce is thin where it was counted. A 2016 survey found 92 of the 95 rural ambulance services in South Dakota facing difficulty recruiting and retaining volunteers, and a 2021 study found one-third of rural EMS agencies at risk because they cannot cover the cost of operations. Both figures were still being carried forward in February 2025 reporting on the failed South Dakota bill, and no newer count of either was found here.

What has been tried?

Attempts fall into two groups — those that create a duty and those that send money without one. The only bill read here that would have created a duty is the South Dakota bill, and it was the one that failed.

What was found?

Why is it still unsolved?

Supply disparity — the ambulances exist in the country but not in the places that need them, and nothing in law moves them.

The reason the distribution does not correct itself is that nobody is assigned to correct it. Police and fire coverage is a duty of local government almost everywhere. Emergency medical services carried that status in 14 states and the District of Columbia at the April 2024 tally, which leaves most of the country in a position where the service is supplied only for as long as some operator chooses to supply it. When the Rapid City Fire Department set December 31, 2026 as the date it stops covering unincorporated Pennington County without a funding agreement, no statute obliged any other body to step in.

Where the duty is absent, payment decides, and payment is built around carrying a patient rather than around being ready to. Low call volume therefore produces low revenue against a cost that barely falls, since a crew and a vehicle have to be available whether or not the phone rings. That is why the thin places are the ones that go dark, and why they are the same places that already have the longest distances.

The pattern is visible in what happens next. Greene County in Alabama suspended service over a holiday weekend in July 2026 because it could not maintain ambulances that had fallen out of compliance with state standards, and residents were told to expect significantly delayed response times with a single quick response vehicle available. The rescue came as a purchase of two vehicles, not as a change in who is responsible.

What observation would mean it is solved?

Candidates — (a) a refreshed national count, covering all 50 states, showing fewer people in ambulance deserts (b) the number of states designating the service essential rising toward 50 (c) the rural to national gap in total call time closing from the 18.7 minutes measured over 2023 to 2025.

(a) measures stations, not service. The method locates where an ambulance is based. A station that appears on the map with no staffed shift reads as coverage.

(b) can be satisfied on paper. Designation is a label until it carries money — and the South Dakota bill that failed in 2025 was precisely the one that attached a funding mechanism to the duty.

(c) can improve for the wrong reason. That gap narrows if rural times fall, but also if national times rise, and also if services close so that the calls from the farthest places stop being answered and stop being counted.

What is it connected to?

Fills with researchrural hospital closure and the longer transports it produces, critical access hospital finance, the decline of the volunteer fire and rescue model, Medicare ambulance fee schedule policy, and the same distance problem in obstetric care (`us-rural-maternity-unit-closure`). Relation type and evidence grade were not examined in this round.

What these sources do not say

• How many people are in an ambulance desert today. The only national count uses 2021-2022 data and was published in May 2023, and the project page that owns it lists no 2025 or 2026 update. Nine states were never in it. Every current figure in circulation traces back to that one measurement.
• How many ambulance services closed, and when. Individual suspensions and warnings are reported one at a time — Greene County in Alabama, unincorporated Pennington County in South Dakota. No source read here counts closures nationally per year, so whether the map is deteriorating, and how fast, cannot be said.
• How many states designate the service essential now. The most recent figure confirmed here is 14 states and the District of Columbia from an April 2024 tally. The legislature tracker page that would settle the current number could not be opened.
• Whether living in an ambulance desert changes survival. Distance is measured and call times are measured. Deaths attributable to that distance are not quantified in anything read here.
• What the designation actually obliges. The 14 states are counted, but the text of what each law requires, whether it names a payer, and whether any money follows the duty were not examined.
• Whether the $50 billion rural health program reaches this service. The award announcement names four use categories and ambulance services are not among them. Whether individual state plans fund EMS under those categories is unknown here.

See the evidence

No primary dataset was read directly. The national population figure comes from the chartbook publication record rather than from the chartbook itself, and the call-time figures come from a press release describing a conference presentation rather than from a published paper. Two claims were confirmed in two independent places: the 4.5 million count appears in the Maine Rural Health Research Center publication record and again in the 2025 university news item, and the statement that South Dakota imposes no duty to provide ambulance service appears in both the 2026-05 broadcast report and the 2026-07 trade report. The Alabama county figure of 64 of 67 is attributed by the 2026 report to a 2023 study, which is the same body of work as the national count, so it is not treated here as independent confirmation. Two rows carry no URL because the pages refused automated retrieval; neither claim was used to support a number in the body. This is a research-based definition, so observation_refs is empty and provenance_mode is press-derived.

People affected

Estimated range 2,300,000–4,500,000 As of 2021-2022

Sensitivity The range is not a confidence interval. Both ends are measured counts drawn from one study, and the width is the distance between a narrow reading and a wide reading of the same measurement rather than statistical uncertainty. The lower end counts only ambulance desert residents in rural counties, which matches the scope of this problem exactly. The upper end retains every ambulance desert resident in the 41 states because the study classifies by county rather than by settlement, so rural communities that sit inside counties classified as urban fall into the wider figure and not the narrower one. Two limits were not corrected for, and they do not act in the same direction. Nine states lack data on ambulance locations and were never measured, and the report says on that basis that its result is likely an undercount, so both ends are floors for the country rather than national totals. Separately the underlying data are from 2021 and 2022 and no refreshed national count was found as of 2026-08-07; nothing read here establishes which way four years of change moved the figure, so the staleness widens the uncertainty without pointing it up or down. One arithmetic note: the study prints the rural share as 52 percent while 2.3 divided by 4.5 is 51 percent, because both published figures are rounded to two significant digits; the subset count was used here rather than the printed share.

Regional breakdown A state level figure exists for Alabama, where 64 of the 67 counties are described as ambulance deserts affecting more than 300,000 people, but it was read from a 2026 news report citing a 2023 study rather than from the same table that produced the national count, so combining the two would mix sources and reporting years. Dividing the national figure across states by population would be proportional allocation, and it is specifically unfounded here because ambulance deserts are defined by driving distance and terrain rather than by how many people live in a state.