Is the Future of EMS County-Based?
EMS is undergoing a period of transition. Long-standing structural challenges such as reimbursement, rising costs, workforce sustainability, increasing service expectations, and governance fragmentation have exposed the limits of traditional local EMS models.
In response, policymakers and system leaders are examining how EMS is organized, funded, and overseen. Two recent articles, one examining New York’s legislatively directed move toward county EMS planning1 and another from Wisconsin2 outlining the case for county leadership in EMS, highlight a converging conclusion: while EMS remains a locally delivered service, its future increasingly depends on county-level coordination, planning, and leadership.
Historically, EMS systems evolved at the municipal or volunteer level, reflecting community-based traditions and modest service demands with some fluctuation. Over time, EMS has become more complex, regulated, and intertwined with public health and human services. Data from the Wisconsin Office of Rural Health’s 2023 EMS Reliability Report show that many local systems struggle with ambulance availability and staffing reliability, particularly in rural and volunteer-based agencies.3
These challenges are not only operational; they're structural. Many municipalities lack the administrative capacity, overall knowledge of EMS, fiscal flexibility, and staffing infrastructure necessary to manage modern EMS systems effectively, leaving communities dependent on a few individuals and vulnerable to service disruptions. As EMS responsibilities expand to include community paramedicine, behavioral health response, and even some level of public health interventions, local models face increasing strain.²
County governments are well positioned to provide the scale and coordination modern-day EMS requires. Counties already oversee public health, emergency
management, and human services—systems that intersect daily with EMS operations. They typically possess greater administrative depth, financial management, and experience coordinating services across multiple jurisdictions ensuring a standard of care over a large geographic area or region.
Examples from Wisconsin demonstrate the advantages of county leadership. Countywide and county-supported EMS models in Door, Waushara, and Oneida Counties show how counties can stabilize funding and professionalize staffing while preserving local presence and accountability.
This county-anchored approach isn't unique to Wisconsin or emerging policy discussions; it’s already well established in other states. In Maryland, EMS operates within a highly coordinated statewide system that sets clinical standards and medical oversight; counties serve as the primary operational entities delivering fire-based and standalone EMS services. This model reflects a balance between strong statewide coordination and robust county-level delivery, allowing counties to tailor services to local needs within a unified system framework.
Maryland concluded that counties represent the most viable level of government for organizing, sustaining, and coordinating modern EMS systems beyond municipal boundaries. Their experiences demonstrate that EMS can remain community-rooted while being county-anchored, balancing local responsiveness with regional stability.
New York’s recent requirement that counties develop comprehensive EMS plans reflects a growing recognition that EMS challenges operate on a regional scale. The mandate positions counties as the logical locus for assessing service gaps, examining workforce needs, and coordinating care across municipal boundaries. County-led planning has the potential to promote data-driven system design and collaboration among municipalities, hospitals, and emergency response partners.
Both initiatives also reflect an emerging consensus that EMS must be regarded as essential public infrastructure. EMS providers are often the first point of contact for individuals experiencing acute medical, behavioral health, or social crises. Counties, which oversee public health and human services, are uniquely positioned to integrate EMS into broader prevention, care coordination, and population health strategies.
Counties also play a central role in emergency management and disaster preparedness. Integrating EMS into county-level planning, training, and incident command structures enhances resilience during pandemics, natural disasters, and large-scale emergencies.
So, is the future of EMS county-based? The evidence suggests it’s increasingly county-led, with counties acting as a de-facto “safety net” even as services remain locally delivered. Municipal agencies continue to provide vital community trust and responsiveness, but counties offer the coordination, scale, and capacity needed to ensure system reliability and equity. As more states elevate the county role in EMS policy, the future of EMS appears increasingly community-rooted and county-anchored.
About the Author
Raphael M. Barishansky, DrPH, has served as Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health and Director of the Office of Emergency Medical Services at the Connecticut Department of Public Health. He is a member of the EMS World Editorial Advisory Board.
References
1. FingerLakes1.com. “Hochul Vetoes Two EMS Bills, Signs Planning Measure as Rural Service Gaps Persist.” December 29, 2025.
2. Wisconsin Counties Association. “A System on the Brink: Why County Leadership Is Needed for Emergency Medical Services.” Wisconsin Counties Magazine, January 2026.
3. Wisconsin Office of Rural Health. 2023 EMS Reliability Report. University of Wisconsin–Madison School of Medicine and Public Health.
