Emergency Medical Services in California: Wages, Working Conditions, and Industry Profile

Ken Jacobs, Nereida Heller, Saba Waheedand Sam Appel

Press Coverage


Executive Summary

Emergency medical technicians (EMTs) and paramedics are the backbone of California’s emergency medical services (EMS) system. These professionals deliver vital care to California families and communities when life hangs in the balance. The principal services of this workforce are transporting patients between medical facilities in ambulances, and providing emergency treatment to patients in medical emergencies like sudden trauma and cardiac events (Narad, 1993). EMS is an essential public service provided on a local basis in every California municipality.

This report examines wages and working conditions for California’s EMTs and paramedics, and provides context on the industry and governance of the state’s EMS system. We have the following main findings:

The majority of workers in this growing sector are employed by private providers

  • In 2015, 16,720 EMTs and paramedics were employed in California.
  • Eighty percent of EMTs and paramedics worked for private EMS providers.
  • Between 2007 and 2013, EMS employment grew by 16 percent. Strong future growth is anticipated in the sector, largely due to the expected growth in California’s elderly

Wages for privates-sector EMS workers are low and stagnating

  • In 2014, the median hourly wage for private-sector EMTs and paramedics in California was $16.59. More than a third of California EMTs and paramedics were low-wage workers, defined as earning less than $13.63 an hour (which is two-thirds of the state median—a commonly used metric for low wages).
  • Private-sector EMTs and paramedics earned 39 percent less than their public-sector counterparts. Even when controlling for age, gender, geography, education, and race and ethnicity, public-sector wages were still much higher than private-sector wages.
  • The median wage for private-sector EMTs and paramedics fell 12 percent between 2007 and 2013, compared to a decline of 7 percent for public-sector EMTs and paramedics, and 5 percent for California workers overall.
  • Private-sector EMTs and paramedics were also more likely to be employed part time or part year.
  • One quarter of private-sector EMTs and paramedics in California were in households with incomes below 200 percent of the Federal Poverty Line, compared to 14 percent of those in the public sector.

EMS work can be dangerous, with high rates of mortality, injury, and mental and physical trauma

  • Previous research has found that EMTs and paramedics suffer  disproportionately from post-traumatic stress disorder (PTSD), depression, and suicidal ideation.
  • A common practice called posting (in which an EMT unit awaits calls while parked rather than at a comfort station) places significant hardships on EMTs and paramedics. Posting increases the likelihood of back pain and makes it difficult to take breaks. Temperature regulation is difficult in summer and winter, and posting locations may not be safe.
  • Current provision of training and continuing education is inadequate for both patient and worker safety.

Low wages and difficult working conditions exacerbate turnover among private-sector EMS workers.

  • National studies have found that recruitment and retention of workers is an ongoing problem for private EMS providers.
  • While we lack direct turnover data from private providers in California, key informants interviewed for this study reported that few workers stay with private providers for more than four years.
  • EMS workers in the state are younger on the whole than the overall California workforce, and the private-sector workforce is significantly younger than the public-sector workforce. In 2014, 57 percent of private industry EMTs and paramedics were between the ages of 20 and 29.

California industry context

  • Between 2013 and 2016, 78 percent of EMS service providers were in the public sector, but private firms operated 81 percent of ambulances.
  • The field of private-sector EMS providers is pyramidal: small local firms operate 15 percent of ambulances, medium-sized firms operate 37 percent, and two major firms operate 48 percent of ambulances.
  • Public health insurance providers furnish 58 percent of private-sector EMS revenue.
  • Large-scale private EMS provider firms make strong returns by lowering capital costs, maintaining low labor costs, and capitalizing on local monopolies granted by EMS agencies.

Regulatory context

  • California law requires each county to establish a local EMS program, and to create a local EMS agency (LEMSA) to oversee that program. California’s LEMSAs exercise the most direct authority over EMS workplaces through planning, enforcement, and granting of exclusive operating contracts with EMS provider firms. Provisions included—or left unspecified—in these contracts largely determine the working conditions of local EMTs and paramedics.
  • The California State EMS Authority (EMSA), California’s EMS agency, acts as a pass-through for federal funds, sets minimum workforce standards, and oversees county and multi- county EMS planning.

Policy recommendations

EMTs and paramedics provide a critical public service. State and county governments should take steps to improve wages and working conditions in this sector and thereby improve worker livelihoods and reduce workforce turnover. We recommend:

  • Minimum labor standards should be established for EMTs and paramedics that reflect their crucial role in emergency response, the risks they face on the job, and the training they are required to obtain. These standards should include higher wage requirements and health and wellness provisions.
  • Minimizing health risks to EMTs and paramedics should be prioritized: time limits should be placed on posting, workers should be provided access to adequate meal and rest breaks, and greater private- and public-sector resources should be directed towards mental healthcare.
  • To promote the creation of a long-term, well-trained EMS workforce, continuing education requirements should be revamped and protections for incumbent workers should be established for when contracts change.
  • Turnover rates should be reported by private companies and considered by LEMSAs in granting exclusive operating contracts.

EMS is both a critical healthcare and employment sector. State and local policies to improve working conditions will not only make EMT and paramedic careers sustainable for thousands of current workers, but will also improve emergency medical care throughout the state by addressing turnover, staffing shortages, and related issues at EMS providers. Policies to improve EMT and paramedic careers will also ensure that the projected growth in California’s elderly population translates into thousands of new, middle-class EMT and paramedic jobs in the coming decade.