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Air medical services in the United States struggled financially for a number of decades; the industry as a whole experienced only modest growth until 2000. However, by 2005, an estimated 700 air ambulances were in operation, more than double the number from a decade before. Unfortunately, that same growth was associated with a more than 200% increase in helicopter crashes. From 2000 to 2005, 60 people died in 84 crashes, and an estimated 10% of air ambulances in the United States had experienced crashes [72]. At the same time, the number of flights paid for by Medicare was up 58% from 2001, and during the same period Medicare payments for air ambulance transports doubled to $103 million [73]. This has led to a belief that the improved reimbursement for air medical services that came with the implementation of the national fee schedule in 2002 was a factor that contributed to this increase in the use of helicopters.

Efforts by states to regulate air ambulance services have been hampered by legal challenges from the industry related to the Airline Deregulation Act of 1978. The act preempts states from regulating Federal Aviation Authority (FAA)‐licensed air transport services in ways that affect their rates, routes, or services. Although the FAA recognizes the role of states in regulating the medical aspects of air ambulance services, questions frequently arise as to what is medical and what is related to rates, routes, or services [74].