The Front Door Problem

For most of my career, the EMS workforce conversation has really been a retention conversation. How do we keep the people we have? Wellness programs, recognition, career ladders, tuition reimbursement. All of it is worth doing. But a new statewide report out of Florida suggests that, when it comes to the paramedic shortage, we may have been working on the wrong end of the problem.

The report is Amplifying Florida EMS Voices: Results of the 2026 Annual EMS Agency Survey, prepared by the Florida Center for Emergency Medical Services at USF Health for the Florida Department of Health's Bureau of Emergency Medical Oversight. Lead author Dr. Michael Lozano and his colleagues surveyed agencies between February and May of this year and heard from 230 of them, a 69.5 percent response rate among the state's licensed ground services. Just as important, the agencies that answered looked like the ones that did not: no meaningful difference by call volume, rural status, or region. Most of the workforce numbers we quote nationally come from voluntary samples of whoever chose to respond. This one covers most of a large state's system.

The shortage is a paramedic shortage

Six in ten Florida agencies, 60.3 percent, report an active staffing shortage. Look closer and it is almost entirely a paramedic problem. A paramedic shortage was reported by 58.5 percent of agencies. An EMT shortage was reported by 21.4 percent, and only four agencies in the entire state said they were short of EMTs but not paramedics.

Responding agencies reported 1,799 open paramedic positions against 18,384 budgeted, and 68.5 percent of agencies that provide advanced life support had at least one paramedic vacancy. The shortage also does not care how big an agency is or where it sits. The share of agencies reporting a shortage holds at roughly 60 percent across all five size groups and all five regions of the state. Rural agencies ran somewhat higher, 71.4 percent against 56.8 percent, but the difference did not reach statistical significance. This is a system-wide condition, not a pocket of trouble.

Pay at the door, not at the top

The most useful finding in the report is about what does and does not line up with vacancies.

Agencies that offer higher entry-level pay carry meaningfully fewer vacancies, for paramedics and EMTs alike, and that relationship holds after accounting for agency size and whether the agency is a fire department. Top-out pay, what an employee earns at the end of the salary ladder, shows no such relationship. Agencies with and without paramedic vacancies report the same median top-out pay band.

Retention programs tell a similar story. The number of retention strategies an agency runs has no significant relationship to its vacancy rate in either direction. Agencies with open positions and agencies without them both report a median of five such strategies. Agencies that track more human resources benchmarks actually report higher vacancy rates, which the authors reasonably read as agencies measuring more because they are already under pressure, not as measurement causing the problem.

The authors are careful to note that a single-year survey cannot prove cause and effect, and salary was reported in bands rather than exact figures. But the direction is hard to miss. Their conclusion is that Florida's workforce problem is primarily a recruitment problem rather than a retention problem.

Low turnover, same shortage

Turnover is where Florida looks different from much of the country. Nearly seven in ten responding agencies, 69.7 percent, report annual turnover of 10 percent or less. That figure is mostly a statement about who delivers EMS in Florida. About two in three responding agencies are fire departments, and 81.7 percent of fire-based agencies report turnover at or below 10 percent, compared with 45.1 percent of non-fire agencies. Among private non-hospital services, 38.5 percent report turnover above 20 percent. Once fire status is accounted for, size, region, and rural designation add nothing to the turnover picture.

Put those findings side by side. Here is a state where most agencies hold on to their people, and six in ten of them still cannot fill their paramedic positions. You cannot retain your way out of a shortage of people you never hired.

The pipeline is upstream of every agency

The report places Florida's findings in the national literature, and the national numbers point to the same place. It cites research finding that roughly 21 percent of paramedic students do not complete their programs and another 11 percent do not go on to certify. Every one of those losses happens before an agency ever posts a job.

That is not a new tension. The paramedic has been an expensive clinician to produce since the first programs of the late 1960s and early 1970s, and the profession has spent the decades since assuming the supply would keep up with the demand. The paramedic programs dashboard on this site maps where the nation's accredited programs actually are, and it is a useful companion to reports like this one. An agency can raise its starting pay. It cannot, on its own, build the educational pipeline that fills its applicant pool.

What Florida got right

The Florida report covers far more than workforce: medical direction, mental health support, community paramedicine, data systems, dispatch, disaster readiness, pediatric care, and trauma. It is worth reading in full. The full 128-question survey instrument is included as an appendix, which makes it a practical template for any state that wants to do the same. For readers who want the short version, the Center also published an eleven-page policy brief, and its first recommendation is the one this post is about: strengthen the paramedic pipeline.

What I value most is that Florida is asking at all, and asking every year. The 2026 survey follows a 2025 edition, and the state redesigned it this year to make it easier for agencies to complete. That is how a state finds out whether anything it tries actually works. Most states cannot tell you, with any confidence, how many paramedic positions are open today, let alone whether a pay increase or a retention program changed that number.

If the Florida findings hold up in other states, the lesson for EMS leaders is uncomfortable but clear. Keep investing in the people you have, because they deserve it. But the vacancy is decided at the front door.