EMS Access Disparities: Lessons from Underserved Communities and Historical Inequities

When a cardiac arrest occurs, survival depends on seconds. Yet across the United States in 2025, the likelihood of an ambulance arriving quickly still depends heavily on where a person lives. In historically underinvested urban neighborhoods, response times may stretch beyond national benchmarks. In rural America, patients may live more than 25 minutes from the nearest ambulance station. These inequities are not new; they are the product of decades of policies, geographic realities, and financial limitations that have left some communities with inadequate emergency coverage.

Although disparities often align with racial and ethnic demographics, the drivers are essentially social determinants of health (SDOH) — poverty, housing, infrastructure, and geography — which influence how EMS is organized and delivered.¹ By examining these root causes, EMS leaders can better understand how to close gaps and build systems that serve all communities equitably.

The Lasting Shadow of Redlining

“Redlining” was a federal mortgage-lending practice introduced in the 1930s through the Home Owners’ Loan Corporation (HOLC).² Neighborhoods with higher proportions of Black residents or immigrants were outlined in red on maps and deemed “hazardous” for mortgage investment. This denied residents access to home loans, devalued property, and slowed economic development for decades.

A 2025 cross-sectional analysis published in JAMA Network Open examined EMS access in 236 U.S. cities.³ Investigators found that more than 2.2 million residents lacked “rapid EMS access” — defined as being within a 5-minute modeled drive of an ambulance station. People in historically “Grade D” redlined areas had 1.67 times greater odds of living outside rapid coverage compared to those in “Grade A” areas. In the Great Lakes region, this disparity was closer to threefold.³

It is important to clarify: the disparity is not caused by race itself. Instead, the economic and infrastructure deficits created by discriminatory housing policies persist in the form of fewer EMS stations, lower tax revenue, and weaker healthcare infrastructure. Race intersects with these factors because minority populations were disproportionately affected by redlining, but today’s inequities are more accurately tied to SDOH.

Survival Gaps in Out-of-Hospital Cardiac Arrest

The downstream effects of these access gaps are stark in out-of-hospital cardiac arrest (OHCA). National survival to hospital discharge for EMS-treated adult OHCA is approximately 10.2%.⁴ But studies show that survival is significantly lower in minority-majority neighborhoods. In Chicago, for example, Black and Hispanic patients had 30% lower odds of favorable neurologic survival compared with White patients, even after controlling for income and neighborhood factors.⁵

Similarly, an analysis of EMS agencies serving minority-majority populations found risk-standardized OHCA survival rates nearly two percentage points lower compared to agencies serving predominantly White communities.⁶ This is not attributable to race as a biological factor. Still, to later recognition of cardiac arrest, lower rates of bystander CPR, delayed EMS arrival, and limited access to advanced post-resuscitation care — all SDOH-mediated.

Disparities in Behavioral Health Emergencies

Inequities extend beyond cardiac arrest. A 2025 study of nearly 200,000 EMS encounters for behavioral health emergencies in Ohio found that Black patients had higher odds of restraint and/or sedation compared to White patients.⁷ The finding reflects broader systemic inequities in behavioral health care access, insurance coverage, and social support systems. Again, the key driver is not race alone, but structural inequities in care delivery and social services that intersect with race and place.

Rural “Ambulance Deserts”

In rural America, the disparities are geographic and economic. The Maine Rural Health Research Center defines “ambulance deserts” as areas where residents live more than 25 minutes from the nearest ambulance station.⁸ Approximately 4.5 million people across 41 states fall into this category.

Rural EMS faces unique challenges: low call volumes, long distances, small tax bases, and a reliance on volunteers. In Montana, median transport times for volunteer-staffed services exceed an hour, compared with less than 20 minutes for paid agencies.⁹ Without statutory designation of EMS as an essential service, many rural counties operate on unstable funding, leaving wide geographic gaps.

Some states are responding. Minnesota approved a $30 million package in 2024: $24 million in short-term emergency ambulance aid and $6 million for a “sprint medic” pilot program designed to bring advanced providers more quickly to rural scenes.¹⁰,¹¹ These initiatives highlight the importance of dedicated state-level investment but scaling them nationally will require federal recognition of EMS as essential.

Urban Overload and Hospital Bottlenecks

While rural agencies struggle with deserts, urban systems confront overload. A statewide study of 5.9 million ambulance arrivals in California (2019–2022) found a mean ambulance patient offload time (APOT) of 42.8 minutes, with many hospitals exceeding the 30-minute standard.¹² Emergency department visits surged 25% statewide between 2020 and 2023 (11.9 million to 14.9 million annually), exacerbating hospital crowding.¹³

These delays mean ambulances remain tied up at EDs rather than returning to service. California’s Assembly Bill 40 (2023) requires local EMS agencies and hospitals to set APOT standards and implement reduction strategies.¹⁴ But, for frontline medics, the lived reality remains waiting with patients in hallways, unable to respond to the next call.

Workforce Strain and Burnout

No discussion of EMS disparities is complete without acknowledging the workforce crisis. The 2025 EMS Trend Report found that 59% of agencies report inadequate staffing, while 76% of providers identify burnout as a critical issue.¹⁵ Surveys suggest a significant proportion of providers are considering leaving the field within five years, citing fatigue, low wages, and insufficient support.

These shortages exacerbate disparities. In underfunded urban and rural areas, limited staffing translates directly into longer response times, increased reliance on mutual aid, and fewer available ambulances for simultaneous calls. Burnout also undermines quality and safety, leading to higher turnover in the very communities most in need.

Climate Change as a Force Multiplier

Climate change is intensifying EMS demand. The World Health Organization projects 250,000 additional annual deaths between 2030 and 2050 from climate-sensitive conditions like heat stress, diarrhea, malaria, and malnutrition.¹⁶ In the U.S., the CDC reported elevated heat-related emergency department visits in 2023 during extreme heat events, with parallel increases in EMS calls.¹⁷

These impacts are not evenly distributed. Urban neighborhoods historically subjected to redlining often coincide with “heat islands,” where a lack of green space and tree cover raises ambient temperatures. Rural areas, meanwhile, may be cut off entirely during wildfires or floods, as seen in western states in recent years. Communities already at the margins of EMS coverage are disproportionately affected.

Solutions: Community Paramedicine and Policy Reform

Despite these challenges, promising solutions are emerging. Community paramedicine and mobile integrated healthcare (MIH) programs expand the paramedic role to preventive and follow-up care. In California, pilots, frequent-user programs reduced 9-1-1 call volumes by 19%–35% and hospice programs reduced emergency department transports from 80% to under 30% without adverse outcomes.¹⁸ Federal proposals such as H.R. 4011 (2025) seek to fund these expansions nationally.¹⁹

Policy reforms can also help. GIS mapping of station placement allows targeted redistribution of resources, improving coverage by up to 10% in modeled states with higher per-capita funding.³ Transparency through public performance dashboards and community advisory boards can build accountability. At the workforce level, investment in wellness, wages, and realistic staffing models is essential to sustain the system.

Conclusion

EMS disparities in 2025 are the product of history, geography, and economics. Redlining’s legacy persists in urban access gaps. Rural regions remain underfunded and geographically challenged. Climate change adds strain, and a fragile workforce struggles to keep pace. While racial disparities remain measurable, especially in OHCA and behavioral health emergencies, the deeper drivers are social determinants of health — the conditions in which people live, work, and age.

The path forward requires system-level reforms: funding EMS as an essential service, investing in community paramedicine, reducing hospital bottlenecks, and building climate resilience. By focusing on SDOH and addressing inequities at their root, EMS can move toward a future where access to life-saving care no longer depends on a person’s ZIP code.

References

1. Marmot M, Wilkinson R. Social Determinants of Health. 3rd ed. Oxford University Press; 2020.
2. Jackson KT. Crabgrass Frontier: The Suburbanization of the United States. Oxford University Press; 1985.
3. Berry C, et al. Rapid Access to Emergency Medical Services Within Historically Redlined Areas. JAMA Netw Open. 2025;8(8):e2525684.
4. American Heart Association. Heart Disease and Stroke Statistics—2025 Update: At-a-Glance. Dallas, TX: AHA; 2025.
5. Del Rios M, et al. Out-of-Hospital Cardiac Arrest Outcomes by Community Demographics in Chicago. Circulation. 2025;151(5):431-440.
6. Uzendu A, et al. Association of Minority Population Catchments With Out-of-Hospital Cardiac Arrest Outcomes. JAMA Intern Med. 2023;183(7):633-641.
7. Bongiorno JS, et al. Disparities in the Management of Behavioral Health Emergencies in Prehospital Care. Prehosp Emerg Care. 2025;29(2):145-153.
8. Zuckerman R, et al. Ambulance Deserts: Geographic Disparities in EMS Provision. Maine Rural Health Research Center; 2023.
9. Montana Department of Public Health and Human Services. EMS Annual Report 2023. Helena, MT: DPHHS; 2023.
10. Minnesota House of Representatives. $30 Million for Rural EMS in 2024-2025 Budget. St Paul, MN; May 2024.
11. Minnesota Department of Revenue. Emergency Ambulance Service Aid Program. Dec 2024.
12. Feldmeier M, et al. Patterns in California Ambulance Patient Offload Times. JAMA Netw Open. 2024;7(6):e2416756.
13. California Hospital Association. Emergency Departments’ Overcrowding Crisis. Sacramento, CA; 2025.
14. California Assembly. AB 40: EMS Offload Times. Sacramento, CA; 2023.
15. EMS1, Fitch & Associates. What Paramedics Want in 2025: EMS Trend Report. July 2025.
16. World Health Organization. Climate Change and Health Fact Sheet. Geneva: WHO; 2025.
17. Centers for Disease Control and Prevention. Heat-Related Emergency Department Visits—United States, 2023. MMWR. 2024;73(18):489-494.
18. California Health Care Foundation. Community Paramedicine Evaluation. Oakland, CA; 2023.
19. H.R. 4011, 118th Congress (2025). EMS Grant Program Pilot Act.