The EMS Compact: Real-World Impacts on Providers and Agencies
An ambulance service in Bristol, Tennessee, looks through the empty file of new applicants when contemplating the addition of adding a power-shift; a wildfire coordination center unit looks through their list of licensed EMS providers for the latest deployment. Properly licensed personnel continue to be rare commodities. Enter the available personnel from the “Compact states.”
The Emergency Medical Services (EMS) Compact is not just another regulatory framework—it’s a game-changer for EMS professionals, agencies, and disaster response efforts across the United States. As the Compact continues to evolve, it's transforming how EMS providers work, breaking down decades-old bureaucratic barriers, and fundamentally altering the landscape of interstate emergency medical care. With an increasing number of states adopting the Compact and the growing frequency of natural disasters demanding rapid response, the urgency and relevance of this initiative have never been greater. The question is no longer whether the EMS Compact is beneficial—it’s how far-reaching its impact will be.1
Enhancing EMS Mobility
EMS professionals have long faced an uphill battle when attempting to work across state lines. Outdated, fragmented licensure requirements forced providers to endure excessive delays, redundant credentialing, and bureaucratic red tape. The EMS Compact, modeled after the Driver’s License Compact, provides a much-needed solution by allowing providers to operate in any participating state without undergoing a lengthy licensure process—so long as they are employed by a duly authorized agency. This newfound mobility has given EMS personnel greater career flexibility, enhanced disaster response coordination, and improved access to care for patients in need.2
According to Donnie Woodyard, executive director of the EMS Compact, the system grants each state autonomy over its licensees while enabling seamless cross-border practice.3 However, this increased mobility doesn’t override state regulations. Agencies must ensure compliance with state-specific protocols, and providers must adapt to differences in scope-of-practice regulations, equipment, and medical control policies.
Woodyard emphasizes that the Compact is not a universal work permit but a framework for streamlined licensure. “This is not a blanket license to work anywhere,” he explains. “EMS professionals must still be employed by an authorized entity within a Compact state and adhere to its regulations.”
The Compact’s Increasing Impact
The numbers tell a powerful story. Twenty-four states have officially joined the EMS Compact, with Oklahoma being the most recent addition and legislation is pending in several others.3 According to NAEMT, EMS workforce shortages have reached crisis levels, with vacancy rates for paramedics and EMTs hovering between 15% and 30% in some regions.1 The Compact is rapidly proving itself as an essential tool to alleviate this staffing crunch, providing a way for qualified professionals to move where they are needed most.
AEMT Johnny Smithson, who just relocated from another state to Virginia, credits the EMS Compact with saving him months of paperwork. “Without the Compact, I would have been stuck waiting for a new license, instead of being able to start a new job in Tennessee,” he said. Beyond addressing workforce shortages, the Compact plays an equally vital role in ensuring rapid deployment of EMS professionals during disasters, where time-sensitive response is crucial.
EMS Compact and Disaster Response
Disasters underscore just how critical this kind of mobility is. The past year alone has seen a devastating series of hurricanes, wildfires, and extreme weather events that have pushed EMS agencies to their breaking points. Previously, EMS professionals hoping to assist in out-of-state disaster response had to navigate weeks of credentialing delays, such as formal federal or state disaster declarations, before they could step in to help. Under the EMS Compact, they can now deploy rapidly—sometimes within hours—to support emergency efforts.4
Yet not all disasters are treated equally under existing mutual aid agreements. Woodyard points out that EMS personnel responding to wildfires, for example, are not always covered under the Emergency Management Assistance Compact (EMAC) because many wildfires are not included under the Stafford Act, which governs most federal disaster relief efforts. That means many EMS providers deployed to wildfire incidents must, in most cases, obtain a state EMS license for every state they potentially are dispatched into. The EMS Compact provides a viable alternative, enabling licensed EMS professionals to step in without additional red tape, ensuring that responders reach affected communities faster than ever before.4
Beyond natural disasters, the EMS Compact also has significant implications for the daily operations of EMS agencies. Many regions, particularly those along state borders, rely on EMS personnel who may live in one state but work in another. Before the Compact, these individuals often faced unnecessary regulatory challenges, forcing agencies to either hire only in-state personnel or pay the costs of securing separate licensure for out-of-state employees. Now, Compact-participating states can hire from a larger pool of professionals without dealing with additional regulatory burdens. This has not only improved staffing levels but has also allowed rural and underserved areas to recruit more effectively, ensuring better coverage and response times.
Challenges in State Adoption
While the EMS Compact offers numerous advantages, its adoption hasn't been universal due to a complex interplay of factors, including concerns about state sovereignty, financial implications, and administrative hurdles. California's distinct decentralized EMS structure exemplifies these challenges. California paramedic licensure is handled at the state level by the Emergency Medical Services Authority (EMSA), while EMT certification is managed at the county level by local EMS agencies (LEMSAs).
This decentralized structure creates a particular challenge, as each county has its own requirements for EMTs, making state-level participation even more complex. While paramedics could theoretically align with Compact standards, EMTs would still face county-specific accreditation hurdles, meaning they would need to meet the varying requirements of each individual county, even if the state joined the Compact.
Additionally, some states have resisted joining due to concerns about both losing control of licensing and oversight and the financial implications of increased out-of-state competition.
Beyond the challenges of state adoption, addressing the remaining disparities in EMS practice will be crucial for the Compact's continued growth. While the Compact streamlines licensure, it does not yet standardize all aspects of EMS practice, meaning that EMS professionals working in different states may still need to familiarize themselves with variations in protocol, drug administration guidelines, and equipment usage.
Expanding the EMS Compact Beyond the U.S.
The Compact’s impact isn’t just being recognized domestically. Interest in the model has extended beyond U.S. borders, with officials from Canada and Mexico expressing curiosity about how they might participate. However, because the Compact operates under federal law and a provision rooted in the U.S. Constitution, all interstate compact agreements are limited to the United States. International expansion would necessitate a formal treaty, a process that is both complex and time-consuming. Nevertheless, the fact that other countries are looking to the EMS Compact as a model underscores its significance as a pioneering effort in healthcare mobility.5
The Compact is also uniquely positioned to assist transitory EMS providers, particularly those who frequently relocate for employment opportunities. The regulatory landscape in the United States is often compared to a patchwork of independent nations operating under a shared federal system, with each state maintaining its own EMS governance and licensure standards. This fragmented system has long been a source of frustration for EMS professionals, but the Compact serves as a bridge between these regulatory environments. It brings a level of standardization that has long been absent in the industry, enabling a more dynamic, adaptable, and efficient EMS workforce.
Future Implications
Looking ahead, the future of the EMS Compact is brimming with possibilities. As more states consider joining, efforts to streamline EMS protocols and improve interagency coordination will enhance its effectiveness. Data tracking remains a key challenge, as the Compact does not currently monitor provider movement across state lines.6 If states integrate the National EMS ID number into ePCR data fields, and workforce data collection into existing systems such as the National EMS Information System (NEMSIS), agencies and policymakers could gain an unprecedented level of insight into how EMS personnel are deployed and utilized.
The EMS Compact, and its predecessor the Nurse License Compact, are considered the gold-standard for professional licensing and these compacts served as models for other health professions. Healthcare mobility is a growing priority across multiple disciplines. At least 17 occupational and health professions use interstate compacts, including nurses, physicians, occupational therapy, physician assistants, and respiratory therapists. Many of these compacts were inspired by the EMS and nursing compacts.
The EMS Compact represents more than just a regulatory change—it’s a fundamental shift in how emergency medical services operate in the United States. By eliminating unnecessary barriers, enhancing disaster response capabilities, and improving workforce mobility, the Compact is setting a new standard for EMS in the modern era. While challenges remain, its impact is already profound, and its potential is limitless. As more states embrace this model, the EMS Compact could well become the gold standard for interstate EMS collaboration, redefining how emergency medical care is delivered for years to come. With continued expansion and refinement, it has the potential to transform not just EMS, but the entire emergency response landscape.
With continued expansion and refinement, the Compact is not only redefining EMS mobility but also setting a precedent for future healthcare licensing frameworks. The next decade may see the Compact expand its reach, integrate more robust data tracking systems, and provide an even greater level of interoperability across states. The EMS Compact not only addresses today’s challenges but is paving the way for more adaptable, efficient, and responsive EMS systems for the future.
References
1. National Association of Emergency Medical Technicians (NAEMT). (2023). EMS Economic and Operational Models Survey 2023. Retrieved February 13, 2025, from https://naemt.org
2. Virginia Department of Health. (n.d.). EMS Interstate Compact (REPLICA). Retrieved February 13, 2025, from https://www.vdh.virginia.gov
3. Emergency Medical Services Compact. (n.d.-a). EMS Compact Member States. Retrieved February 13, 2025, from https://www.emscompact.gov
4. Emergency Medical Services Compact. (n.d.-b). The Role of EMS Compact in Disaster Response. Retrieved February 13, 2025, from https://www.emscompact.gov
5. Emergency Medical Services Compact. (n.d.-c). International Interest in the EMS Compact. Retrieved February 13, 2025, from https://www.emscompact.gov
6. Emergency Medical Services Compact. (n.d.-d). Tracking EMS Personnel Movement Through NEMSIS. Retrieved February 13, 2025, from https://www.emscompact.gov
