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By 1978, termination of federal funding in most regions was imminent, and the potential effect on operations and future development began to raise concerns. The 1976 and 1979 amendments to the EMS Systems Act reflected concerns about future funding and had consequently demanded evidence of financial self‐sufficiency as one basis for further support. DOT estimates of non‐federal monies spent annually between 1968 and 1980 ranged up to $800 million.

In 1979, DHEW officials estimated in testimony that 90% of regions with paramedic service had achieved financial self‐sufficiency by 1978 [44]. However, the Comptroller General, in a 1976 report entitled Progress in Developing Emergency Medical Services Systems, cited considerable inconsistency in the degree and duration of support provided by community resources [55]. A few years later, in 1979, the Comptroller General testified on the financial status of the EMS regions after analyzing grant applications under the 1976 amendments. By the 1980s, the discrepancy between DHEW’s and the Comptroller General’s estimates of financial self‐sufficiency of EMS systems suggested serious unrecognized difficulties in the continued underwriting of EMS systems.

The financial demands on an EMS system were considerable, related to four major elements: prehospital care, hospital care, communications, and management. The specific costs varied by community. The original 1966 NAS‐NRC report estimated that ambulance services accounted for about one‐fourth of total EMS system costs, with 75% of that amount for personnel. Communications costs varied from 7% of total cost when there was integration with existing public services, to 35% when completely new systems needed to be established. Although management costs were high during the development phases, they were originally expected to account for less than 2% of the total cost during the operational phase [52].

Health insurance reimbursement did not keep pace with EMS costs, which presented a real problem for EMS providers. Health care benefits were often limited to hospital care and had maximum fixed reimbursements. For example, 20% of Blue Cross patients were not covered for emergency transport, and, of those covered, one‐third were only covered after a motor vehicle crash. EMS reimbursement was focused on the transportation aspect of the service, a financial problem that has continued to plague EMS. By 1982, the NAS‐NRC wrote, “Availability of advanced emergency care throughout the nation is a worthy objective, but the cost of such services may prohibit communities from obtaining them” [52].