Private companies own and operate most ambulances in California, and provide about 75 percent of all emergency ambulance rides. In the other 25 percent of cases, the local fire department has its own ambulances and drives patients to the hospital. More than two-thirds of ambulance trips are for patients with government insurance (such as Medicare or Medi-Cal), about 20 percent are for patients with commercial health insurance, and the remainder have no insurance. On average, commercial insurers pay $1,800 per ambulance ride—more than double the $750 cost of an ambulance trip in California. Medicare pays about $450 per trip, while Medi-Cal pays about $100 per trip.
Counties typically choose the ambulance company through a competitive bidding process, and the ambulance company pays the county for the right to provide ambulance trips in that area. The ambulance company generates revenue by collecting payments from patients' insurers. There are 17,000 emergency medical technicians (EMTs) and paramedics in California and about 3,600 ambulances.
Meal and Rest Breaks Taken by EMTs and Paramedics. In practice, EMTs and paramedics are “on call” for their entire work shift in case they receive an emergency call. This means that their breaks are sometimes interrupted by 911 calls. They can also be interrupted by a request to reposition to a new posting location. As a result, EMTs and paramedics are often unable to plan their meal and rest breaks. At the same time, most ambulance shifts include down time between emergency calls. (Urban areas tend to have less down time than rural areas do.) As a result, crews often have enough down time in their shift to take uninterrupted meal and rest breaks even though they are technically on call.
In 2016, the California Supreme Court ruled that on-call breaks violate state labor law, in a ruling called the Augustus decision. Instead, employers must provide breaks that are off-duty and not interruptible, even if an emergency occurs. To follow state law under this decision, ambulance crews would have to go off-duty during their meal and rest breaks. This would increase costs to ambulances companies—potentially by more than $100 million each year statewide. To address higher costs and still remain profitable, companies would need to raise revenue and/or reduce costs. It is likely that much of these higher costs would be borne by counties.
Proposition 11 Proposal
This measure makes changes to state laws that affect private-sector EMTs and paramedics. The measure would not apply to EMTs and paramedics who work for public agencies, such as fire departments.
Requires On-Call Meal and Rest Breaks for EMTs and Paramedics. The measure requires EMTs and paramedics to stay on call during their whole shift. In effect, the measure continues the industry practice of requiring EMTs and paramedics to remain on call during breaks. At the same time, however, the measure requires that meal breaks (1) not be during the first or last hour of a shift, and (2) be spaced at least two hours apart. The measure requires ambulance companies to operate enough ambulances to meet these meal break schedules.
Seeks to Limit Costs for Past Practice of On-Call Meal and Rest Breaks. The Augustus decision suggests that the practice of requiring EMTs and paramedics to stay on call during breaks is against the law. Private ambulance companies may now owe penalties for these past violations. Several groups of EMTs and paramedics have sued ambulance companies alleging these violations. These lawsuits are still active. In addition to requiring on-call meal and rest breaks going forward, this measure states that the past industry practice of on-call meal and rest breaks was allowable. This could eliminate costs that ambulance companies may face related to these lawsuits.
Requires Employer-Paid Training and Mental Health Services. The measure requires ambulance companies to offer EMTs and paramedics (1) annual natural disaster, active shooter, and violence prevention training; (2) mental health and wellness education; (3) mental health counseling sessions; and (4) access to long-term mental health services.
Source: LAO Analysis of Proposition 11