Journal / Essay · Health

The Math of the Ambulance Bill

Congress passed a law fixing the surprise medical bill. It fixed almost every version of it — except the one that shows up first, before anyone's had a chance to check which hospital is in-network.

And Then You're Dead · August 2026 · 3 min read

The No Surprises Act took effect in 2022, and it did what it was supposed to for most emergency care: if you're treated at an in-network hospital, you can't be balance-billed just because the ER doctor who happened to see you was personally out-of-network. One major category of emergency transport was left out entirely.

What Actually Got Fixed

Before the law, both emergency-room visits and elective surgeries carried real surprise-billing risk — the kind where the facility is covered but a specific provider inside it isn't.

The Act closed that gap for hospital-based emergency care, air ambulances, and out-of-network providers working inside in-network facilities. That's real, measurable progress — and it's also not the whole picture.

The Carve-Out Nobody Chooses

Lawmakers left one category out of the bill specifically: ground ambulances — the ordinary, drive-to-the-hospital kind, used in the overwhelming majority of actual emergencies.

Ground ambulances are used in 98% of emergency transportation — and up to half of those rides carry a surprise out-of-network charge.

About 51% of emergency ground ambulance rides and 39% of non-emergency rides include an out-of-network charge that can leave a privately insured patient exposed. Roughly 28% of privately insured ambulance rides overall could result in an actual surprise bill. Unlike almost every other piece of a hospital visit, you generally can't choose or verify network status for the ambulance that shows up — dispatch sends whichever unit is available, and by definition, nobody's checking insurance cards mid-emergency.

What Happens After the Ride

The gap in the law isn't hypothetical. Providers report using it.

In a Texas survey, 77% of ground ambulance providers said they "always" or "sometimes" balance-bill patients when a commercial health plan doesn't cover the full charge — 45% said they always do it. That's not an edge case slipping through; it's a routine, acknowledged billing practice, operating in the specific gap Congress left when it wrote the No Surprises Act.

Why the Gap Exists

This wasn't an oversight so much as a deliberate deferral. Federal lawmakers left ground ambulances out of the 2022 law citing the wide variety of ground ambulance services, a patchwork of existing state and local regulation, and — tellingly — a lack of reliable cost data to even set a fair benchmark. A handful of states have since passed their own ground-ambulance billing protections, but coverage is inconsistent, and no federal fix has followed.

And Then You're Dead

The math of the No Surprises Act is that it protects you at almost every point in an emergency except the very first one — the ride there. Congress fixed the bill from the hospital. It left the bill from getting to the hospital exactly as unpredictable as it always was, for the one part of the emergency nobody gets to shop around for.

That's it. That's the whole thing.

Read about medical debt · or see every essay