State Actions to Address EMS Workforce Shortages

By Kelsie George and Shannon Sweeney | July 2022


Emergency medical services clinicians provide urgent medical care for individuals experiencing serious illness and injury across the United States. To respond quickly and efficiently, 911 call centers, known as public safety access points, gather information, triage and prioritize emergency calls for help, then notify and dispatch appropriate EMS clinicians to respond. Rural communities often have fewer EMS clinicians covering large geographic areas, requiring rural agencies to prioritize limited resources when responding to emergency calls. The ability of state EMS systems to respond to the emergency health care needs of residents relies on the strength and sustainability of the EMS workforce.

The tasks EMS clinicians may perform within their license to practice vary by state, but generally include administering cardiopulmonary resuscitation and certain medications, treating wounds and transporting patients to health care facilities. EMS professionals play a critical role in battling the opioid crisis by responding to overdose calls, sharing data with public health officials and linking patients to addiction treatment programs.

The EMS workforce includes: emergency medical responders, emergency medical technicians, advanced emergency medical technicians, paramedics and other EMS clinicians, including nurses and physicians.


General Duties

Emergency Medical Responder (EMR)

Initiates immediate lifesaving care to critical patients while awaiting additional EMS response and to assist higher-level personnel at the scene and during transport.

Emergency Medical Technician (EMT)

Provides basic emergency medical care and transportation for critical and emergent patients. 

Advanced Emergency Medical Technician (AEMT)

Provides basic and limited advanced emergency medical care and transportation for critical and emergent patients.


Provides advanced emergency medical care and transportation for critical and emergent patients.

Local communities often design their own EMS systems and may organize them in a variety of ways. EMS agencies may be volunteer, career or a combination; operated by government, health care systems or private entities; and function as stand-alone, fire-based or law-enforcement-based services. EMS is usually provided by a municipal government through a fire department or as a stand-alone service alongside fire and police services, or is a contracted service with a private for-profit or nonprofit entity.

State Action

To address EMS workforce shortages, state legislatures are considering various policy options, including adjusting licensure and certification requirements, expanding recruitment and retention efforts, and addressing burnout and safety concerns.

Licensure and Certification: Several states have altered licensure requirements to expand the number of EMS clinicians who can practice within the state, particularly in high-needs areas. The National Registry of Emergency Medical Technicians (NREMT) is the largest certifying body for EMS professionals with 46 states using its standards as the basis for licensure.

Most states require via statute or administrative rules that licensed EMTs be at least 18 years of age, but at least six states have taken legislative or administrative actions to lower the age at which individuals can apply for licensure. New Jersey allows minors ages 16-17 to enroll in EMT-Basic training with signed parental consent. Minors who pass the NREMT assessment are also issued a provisional EMT-Basic license. Individuals on a provisional license require direct supervision and do not meet minimum personnel requirements.

Twenty-one states participate in the EMS Compact, which facilitates the movement of licensed EMS clinicians across state boundaries to increase access to patient care, reduce states’ administrative burden and enhance EMS systems across state lines. Participating states agree to standardized licensure requirements, including FBI background checks, NREMT certification and collaborative investigations involving EMS personnel. Pennsylvania became the most recent state to join the compact after enacting legislation in July 2022.

Recruitment and Retention: States are exploring ways—particularly through financial incentives like increased compensation and tax incentives—to ensure EMS clinicians enter and remain in the workforce.

The two primary reasons cited for leaving the EMS field are a desire for a career change and dissatisfaction with pay and benefits. Research suggests that increasing career and promotion opportunities and pay rates may improve retention among EMS clinicians. Maine, where 25% of EMS professionals are paid full time, enacted legislation in 2022 to create a pilot program to explore current and alternative models for providing EMS.

States also provide tax credits to improve the retention and recruitment of EMS clinicians. Since 2017, Nebraska has offered a $250 refundable income tax credit to qualified active emergency responders, rescue squad members or volunteer firefighters (including first-aid, rescue, ambulance or emergency services professionals).

Burnout and Safety: EMS clinicians tend to experience high levels of acute and chronic stress, high rates of depression and substance abuse, and higher risk of suicide than the general public. Research shows that burnout levels increase with the years of EMS experience and tend to be higher among clinicians who work shifts lasting 12-24 hours. To meet the mental and behavioral health needs of EMS clinicians, several states provide access to mental health resources. Utah established a grant program to provide mental health resources to EMTs, AEMTs, paramedics and other first responders in 2022.

The COVID-19 pandemic further exacerbated burnout, fatigue and physical illness among EMS clinicians. During the public health emergency, Indiana added COVID-19 to the list of diseases considered an exposure risk for emergency and public safety professionals, making EMS clinicians eligible for certain benefits if there is a presumption of disability or death incurred in the line of duty.

Federal Action

Federal agencies have created models and standards for EMS clinicians. Most states use the models and standards below as a foundation for state regulation of the EMS workforce.

Scope of Practice Model: The National EMS Scope of Practice Model, developed in 2007 and most recently revised in 2019, provides a national standard for EMR, EMT, AEMT and paramedic education, certification, licensure and credentialing. All 50 states and the territories have adopted the model as their foundation for state regulatory requirements for EMS clinicians.

Data Collection: Standard EMS data collection provides valuable information on areas of need related to EMS care, as well as information for EMS training and continuing education curricula. The National EMS Information System supports state efforts to collect, store and share EMS data. All 50 states, the District of Columbia, Guam, the Mariana Islands, the Virgin Islands, and some tribal nations submit data to the system, which collaborates with other federal agencies to leverage the rich EMS data for public health, emergency management and other collaborations.