The prospect that American Medical Response can hang on to the virtual monopoly it has enjoyed as the dominant provider of ambulance service in geographically expansive San Bernardino County over the last two decades has narrowed significantly over the last several months. Indeed, it appears that the company may be on verge of being driven out of business in this neck of the woods entirely.
The powers that be in the regional, county and municipal governmental structure were once so enamored with American Medical Response that they conferred favored status upon the company, which is known by the acronym AMR. Those fickle politicians, however, have now taken up with a consortium of governmental agencies and its selected corporate partner to create a quasi-public, quasi-private emergency medical transportation program that is being touted as the wave of the future.
More than a year-and-a-half ago, the San Bernardino County Board of Supervisors moved vigorously and determinedly to end AMR’s ambulance service franchise. In doing so, American Medical Response’s corporate officers felt the county had done so a little to spiritedly and with some purpose that might have indicated it was not acting with collective purity of heart. AMR sued San Bernardino County, doing so on two fronts, in both state and federal court.
Rulings made this year with regard to the case brought in federal court and what appears to be the reaction to those rulings by the judge hearing the matter in state court do not appear to bode well for American Medical Response, as those in the know now appear to be preparing for AMR’s near-monopoly to be supplanted by the consortium.
A panel of three judges with the U.S. Ninth Circuit Court of Appeals – consisting of Justices Consuelo Callahan, Roopali Desai and Ana De Alba – earlier this year upheld Judge Kenly Kato’s ruling that the anti-trust principle cited by the law firm representing American Medical Response in the federal suit is inapplicable. As a result, the legal challenge to San Bernardino County’s December 2023 decision to confer a franchise for emergency medical response throughout most of the county’s desert region on CONFIRE – otherwise known as Consolidated Fire Agencies – resides now in San Bernardino Superior Court, in this case under the scrutiny of Superior Court Judge Jay Robinson.
The matter, one of substance for a multitude of practical reasons, is fraught with substantial political considerations. It extends even beyond the huge geographical confines of San Bernardino County to cover the entirety of both Inyo and Mono counties and represents a huge impact on the bottom line of two out-of-state corporations, one based in Colorado and another in Arizona.
At the heart of the contretemps is a creature of San Bernardino County governance, ICEMA, a joint powers agency formed in 1975 by San Bernardino, Inyo and Mono counties to coordinate emergency medical response by planning, implementing and evaluating an effective emergency medical services (EMS) system including fire departments, public ambulances, prehospital providers, hospitals, and specialty hospitals, such as trauma, stroke and cardiac care providers.
In an act evincing an uncommon degree of trust as well as a concession to the logistical difficulty of effectuating bureaucratic management across a 33,467-square mile area, officials in both Inyo and Mono counties designated the San Bernardino County Board of Supervisors would serve as the governing board for the agency.
The Inland Counties Emergency Management Agency oversees issues pertaining to emergency medical response within the expanse of 20,105-square mile San Bernardino County, 10,227-square mile Inyo County and 3,132-square mile Mono County, a combined area that is larger than 12 different states, including Maine, South Carolina, West Virginia, Maryland, Vermont, New Hampshire, Massachusetts, New Jersey, Hawaii, Connecticut, Delaware and Rhode Island separately and larger than Vermont, New Hampshire, Massachusetts and New Jersey combined.
There are extensive expanses within all three of those counties which are only sparsely populated but which still need, from time to time, emergency medical response. Thus, there are swathes of territory in each where one ambulance company has not only primacy but a virtual monopoly in that it, and only it, is authorized and licensed to function there under normal circumstances. The ostensible rationale for granting these monopolies is that operating ambulances is an expensive proposition, not to mention one that is crucial to public health and safety. Competition between ambulance companies has the potential, so the reasoning goes, of driving down the prices those companies charge to the point that their operations will not be profitable enough for them to remain in business. Upon these ambulance companies going out of business, the public would be put into a position where there would be insufficient emergency medical transportation service available to ensure public safety. In this way, those arrangements – the exclusive operating zones – have been established.
In years past, prior to the founding of ICEMA, such exclusive operating zones had not been demarked in San Bernardino County and there was widespread, indeed cutthroat competition between ambulance operators. In what was then the most heavily populated area of San Bernardino County – the east and west valleys extending from Redlands and Mentone in the east to Chino and Montclair in the west in the late 1960s and into the 1970s, four relatively young men in their late 20s and early 30s – Terry Russ, Homer Aerts, Don Reed and Steve Dickmeyer – owned and operated their own ambulance companies. Each had been granted access to the emergency dispatch center’s radio transmissions and when a call for an ambulance went out, depending on where their vehicles happened to be at the time, they or the other drivers they employed would rush to the scene, trying to be the first to arrive and get the privilege – and the money – for transporting the injured party to the hospital. Over the years, all four experienced hundreds of incidents where one would be traveling full tilt in one direction to get to an accident or medical emergency and would pass another going in the opposite direction to get to another mishap or yet living victim in need of assistance. In the late 1970s, the four got together, smoked a peace pipe and resolved to stop their blind competition and instead coordinate their responses by apportioning the shared geography they were serving into operating zones. The next step was to merge their separate companies into one – which was called Mercy Ambulance.
Together, as the four heads of Mercy Ambulance, Russ, Aerts, Reed and Dickmeyer had a strength that exceeded that of the sum of the four parts. Pooling their profits, they had money to make political donations to members of the board of supervisors, the various city council members in the communities where Mercy was entrenched and the county sheriff. Within two to three years, Mercy Ambulance was a major political donor and player, rivaling developers and other holders of the county’s various service franchises. Using that influence, they began to squeeze smaller ambulance companies out of the San Bernardino County picture entirely, buying them out, forcing them into bankruptcy, closure altogether or into departing for some other geographical area. With or without being granted exclusive operating areas, Mercy claimed a virtual monopoly in San Bernardino County, such that its only competitors were the ones willing to run just one or two ambulances in remote locations where profitability for Mercy was marginal or nonexistent.
Mercy’s advantage and profitability had become so overwhelming that it was able to create an air division, consisting of helicopter ambulances which could fly to remote areas of the desert and mountains to retrieve and transport the injured in a fraction of the time it would take to reach them by traditional ground-based ambulance. This put Mercy Ambulance on the cutting edge of the ambulance industry, which over the course of a decade-and-a-half made Russ, Aerts, Reed and Dickmeyer fabulously wealthy. By the late 1990s, the four were in their late 50s and 60s, longer in the tooth and weary of the bustle and intensity of providing a service with life-or-death implications 24 hours a day and 365 days per year. They sold Mercy Air Ambulance to a Japanese company and headed into a comfortable retirement.
That left a vacuum, which a few companies, including some start-ups whose owners saw an opportunity and a few with existing operations just outside the county’s periphery, sought to fill. Gradually at first and then with greater alacrity, boldness and ruthlessness as it succeeded, Greenwood Village, Colorado-based American Medical Response, Inc. – AMR for short – took over from Mercy as the county’s preeminent emergency medical transport provider. The company took a leaf out of Mercy’s playbook and began making substantial political contributions, primarily to incumbent politicians in an effort to ingratiate the company with the powers that be, in essence solidifying its hold on the exclusive operating zones that had by that point become an intrinsic part of the ambulance industry in California and in San Bernardino County. The smaller ambulance companies competing for a piece of the San Bernardino County pie, like those that two and three decades previously had tried to stay in place while Mercy was taking over, could not afford to make political donations in the same amounts or to the sheer number of politicians that AMR was backing. Soon, those companies dried up and blew away, at least in San Bernardino County.
For two decades AMR was, within San Bernardino County, the primary corporate beneficiary of the move toward exclusive operating zones in San Bernardino County. Of note, and of at least some credit to San Bernardino County’s supervisors over the years, those supervisors, giving AMR the inside track in San Bernardino County, did not use their authority as the Inland Counties Emergency Management Authority board members to impose AMR as the sole ambulance service provider in Inyo and Mono counties.

Symons Ambulance was a primary provider of ambulance service in Inyo County from 1989 until 2023, but discontinued doing so because it was sustaining financial losses in doing so. Since that time, the fire departments and the hospital districts of the county’s various communities have provided ambulance service in Inyo County. The main ambulance service provider in Mono County is the county’s own Mono County EMS, a government-operated service that provides both pre-hospital care and inter-facility ambulance transport.
Some have long disputed that the exclusive operating zones are necessary, and they assert the zone system is rather a ploy by which county politicians have further inculcated a pay-to-play ethos into the county’s governmental function, with the exclusive operating permits being granted to the companies or company proving to be the most generous in handing out political donations to incumbent politicians. Among those critics of exclusive operating zones are some who maintain the monopolistic system has long endangered public safety. One of those was San Bernardino County’s firefighters’ union, known as Local 935, which in 2014 suggested the exclusive operating approach has on occasion created critical shortages in the High Desert’s ambulance transport system.
For years, the county’s decision-makers ignored those warnings, and the AMR contract was “rolled over” in what the county referred to as “a grandfathered process.” In late 2022 county officials began to look toward what action would be taken with regard to the expiration or continuation of the AMR contract. On December 20, 2022, the county released a request for proposals – a solicitation of bids – inviting prospective providers to provide ground ambulance service in 11 of the county’s 26 exclusive operating areas.
Responding to the request were AMR and Consolidated Fire Agencies. Known by its acronym CONFIRE, Consolidated Fire Agencies is a joint powers authority which provides communications, dispatch, computer information systems support and geographic location information to its nine founding member agencies – the Apple Valley Fire Protection District, Chino Valley Independent Fire District, the Colton Fire Department, the Loma Linda Fire Department, the Rancho Cucamonga Fire Department, the Redlands Fire Department, the Rialto Fire Department, the San Bernardino County Fire District and the Victorville Fire Department – and four later-joining contract agencies – the Big Bear Fire Department, the Montclair Fire Department, the Running Springs Fire District and the San Manuel Fire Department.
In its response, AMR stated it could commit 12,889 weekly unit hours to respond to calls, had 111 ambulances available during peak system demand and stationed throughout the service area backed with 39 additional available ambulances available to meet surges. It emphasized that it was the current provider of the services with vehicle infrastructure in place and 10 managers and 18 field supervisors and a medical director familiar with the comprehensive needs of the service area. The company offered rates of $3,958 for both basic life support and advanced life support, $2,834 to carry out an interfacility transport, and $4,392 for critical care transport.
In its response, CONFIRE said it would subcontract with Priority Ambulance, which also serves Maricopa County in Arizona and therefore could devote 10,371 weekly unit hours to respond to calls, had 93 ambulances available at peak demand, with 45 additional ambulances available to meet surges throughout the service area, that it will establish ambulance staging locations, put on-board personnel in place and acquire vehicles upon receiving the contract. It offered an assurance that it has leadership and management to meet the demands of providing the service, including nine managers and 18 operations supervisors as well as a medical director and that it controls the regional emergency services communication system. Its proposed rates for its advance life support service were $3,547 for non-emergency and interfacility transfer, $4,053 for emergency transport, $2,533 for non-emergency basic life transport and $3,167 for emergency basic life transport and CCT $5,067 for critical care transport.
What the county referred to as an “independent review panel,” made up of four evaluators, individually scored each proposal on 14 key areas – system requirements, response time standards, clinical performance, deployment plans, vehicles, medical supplies and equipment, personnel, hospital and community requirements, disaster preparedness/response, quality management, electronic patient care reports, centralized emergency medical dispatching, financial and administrative requirements qualifications, and future system enhancements – for the purpose of making a recommendation to the county for final negotiation of contract terms. The total cumulative scores, against a standard with 1,720 points maximum, favored AMR, which registered 1,519 total points against 1,515 points for CONFIRE.
Based on what the county characterized as the negligible difference between the scores, it provided AMR and CONFIRE with notice to enter into contract negotiations with the county and that the final contract approval rested with the board of supervisors.
After those negotiations concluded, the county purchasing division on October 27, 2023, emailed AMR a notice of intent to recommend that it be awarded a contract extension from the time its then-current contract expired on March 31, 2024 from April 1, 2024 through September 30, 2024 to allow CONFIRE to get prepared to take on the contract for an initial term from October 1, 2024 through September 30, 2029.
AMR lodged a protest, alleging the county had failed to follow the selection procedures, did not adhere to requirements specified in the request for proposal, had awarded the contract to the entity which had lost in the competition and that it had otherwise violated state and/or federal law. The county’s purchasing agent, Ariel Gill, after reviewing and considering the protest, notified AMR of its decision to deny it.
At the December 5, 2023 board of supervisors meeting, a motion by Supervisor Jesse Armendarez seconded by Supervisor Curt Hagman to deny the protest from American Medical Response and schedule a vote to consider awarding the contract to Consolidated Fire Agencies and its private subcontractor Priority Ambulance passed by a unanimous vote. During the December 5, 2023 meeting, AMR was represented by a spokesman who neglected to identify himself and Mike Rice, the company’s vice president of operations, who made no comments. The unidentified spokesperson said AMR offered “stability, performance and clinical excellence. AMR is in the best position to take this into the future. We’re fully integrated with the fire departments, public health, behavioral health, the communities we serve.” He emphasized that AMR had a “depth of resources, history of performance, experience and expertise, disaster response capability and represented a lower risk of liability to the cities and county than having public agencies provide ambulance service. He said that “AMR meets or exceeds all response [time] standards” and featured as part of its vehicle fleet “all-wheel-drive units in key areas that need that… and a disaster command vehicle.” He said the company had helicopter ambulances and was “financially strong” with an established sustainable model.”
CONFIRE was represented by Rancho Cucamonga City Councilwoman Lynn Kennedy, the chairwoman of the CONFIRE Board of Directors, as well as Rancho Cucamonga Fire Chief Mike McCliman and CONFIRE Chief Nathan Cook. Lynne Kennedy said what CONFIRE offered was something that “will result in increased resources, decreased response times and a delivery model that includes private/public partnership, a private partnership with Priority Ambulance that has the capacity to serve our county and the public partnership that crosses the continuum of care, making sure that every single resident receives the right care at the right time on time every time without exception.”
CONFIRE, Kennedy said, “is going to improve our service delivery, establish an efficient system and invest both financial and human resources back into the system.”
County officials reasoned that both CONFIRE and AMR performed, for all intents and purposes, equally well in the evaluation of their proposed offerings of service. The deciding factors that tipped the decision in CONFIRE’s favor, according to the county, was a state law which encourages local agencies to develop emergency medical transportation capability dovetailed with San Bernardino County Policy 1104, which calls for making a determination of “best value” when entering into such contracts. Assembly Bill 1705, passed in 2019, allows an ambulance service provider operated by the state, a county, a city, a county and city or cities, fire protection district, special district, community services district, health care district, or a federally recognized Indian tribe – in short a governmental entity – to receive a supplemental Medi-Cal reimbursement when the patient being transported is a Medi-Cal recipient, in addition to the rate of payment the provider would otherwise receive for those services. By applying the advantage inherent in Assembly Bill 1705, which was put in place to facilitate local agencies developing in-house ambulance/emergency medical transportation capability, the county would be able to capture those supplemental Medi-Cal payments, while AMR, as a private sector provider, would not be eligible for such reimbursements. Thus, the added “value” of the arrangement involving CONFIRE dictated the county contract with it, according to county officials.
“Of the two proposers that we heard today, CONFIRE JPA [joint powers authority] may be eligible for this funding, but only CONFIRE JPA,” Chairwoman of the Board of Supervisors Dawn Rowe at the December 5, 2023 meeting said the board’s decision in favor of CONFIRE hinged on the additional funding the county received by having governmental entities provide the ambulance service.
Rice, who said noting during the December 5, 2023 meeting, tore into the board of supervisors after its vote, saying the decision “does not align with the best interests of the community and… puts 29 fewer ambulances a day on the road than what AMR proposed. The community and our hard-working employees will be negatively impacted.” He threatened legal action over the vote.

AMR made good on that threat, filing civil suits in both court and San Bernardino Superior Court.
In the federal suit, AMR’s legal team alleged the county’s action ran afoul of the Sherman Antitrust Act, passed by the U.S. Congress in 1890 to prohibit, trusts, monopolies and cartels, promote the economic fairness and competition, to regulate interstate commerce and “preserve free and unfettered competition as the rule of trade for the benefit of consumers.”
Judge Kenly Kiya Kato, overseeing the federal case, dismissed the case against the county, ruling the federal court did not have proper jurisdiction because the “county defendants are immune from liability” under the Sherman Antitrust Act. AMR appealed to the 9th Circuit Court of Appeals.
The 9th Circuit panel, consisting of judges Callahan, Desai and De Alba, wrote “In California, prehospital emergency medical services are governed by the Emergency Medical Services System and Prehospital Emergency Medical Care Personnel Act (“EMS Act”) [which] authorizes a county to grant emergency medical service providers the exclusive right to operate within certain geographic areas in the county so long as ‘a competitive process is utilized to select the provider’ pursuant to a State-approved ‘local plan.’ The California Legislature intended such authorization ‘to confer state action immunity from federal antitrust laws for actions taken by local government entities under the EMS Act.’ While the Sherman Act clearly forbids anticompetitive conduct by private market players, the Supreme Court in Parker v. Brown, 317 U.S. 341 (1943), held that the law ‘did not apply to anticompetitive restraints imposed by the States.’ The Supreme Court later explained that a local government is entitled to Parker immunity when its restriction on competition constitutes ‘an authorized implementation of state policy.’ Referred to as the ‘clear articulation test,’ the Supreme Court has held that ‘when a local governmental entity acts pursuant to a clearly articulated and affirmatively expressed state policy to displace competition, it is exempt from scrutiny under the federal antitrust laws.’ AMR does not dispute that the EMS Act ‘clearly articulated and affirmatively expressed’ the California Legislature’s policy to displace competition in the field of emergency medical services, but argues that the county defendants did not act ‘pursuant to’ this policy when awarding CONFIRE the exclusive contract. For example, AMR argues that the request for proposals required the county defendants to award the monopoly to the provider that received the ‘highest score,’ and that AMR received a higher score than CONFIRE. According to AMR, this shows that the county defendants awarded the monopoly to their ‘politically preferred provider in complete disregard of the state-mandated competitive process.’ We are unpersuaded.”
Ultimately, Callahan, Desai and De Alba denied AMR’s appeal and upheld Judge Kato.
The Sentinel’s efforts to reach Stephen Larson, the attorney representing AMR was unsuccessful. It is unknown whether Larson and the other attorney’s in his firm representing AMR, including Jonathan Phillips, Mehrunisa Ranjha and Benjamin Falstein, are contemplating appealing the 9th Circuit panel’s ruling to the U.S. Supreme Court.
U.S. Courts of Appeals routinely handle more than 50,000 cases each year. Generally, 7,000 to 8,000 or fewer of those decisions are appealed to the U.S. Supreme Court. On a yearly basis, the Supreme Court considers only about 100 of those cases. Historically, the Supreme Court tends to affirm the lower court’s decision in a majority of the cases it chooses to hear, with reversal rates typically in the range of 30 percent to 40 percent.
It thus appears that any hope that AMR has of preventing CONFIRE from taking over the lion’s share of ambulance service in the county comes down to the case being heard before Judge Robinson.
In the case Judge Robinson is hearing, Larson, Phillips, Ranjha and Falstein are seeking to establish that despite AMR being the “exclusive ‘grandfathered’ ambulance provider to the county,” the “county departed from this practice and for the first time published a state-approved request for proposals” to solicit entities interested in competing for the franchise. According to Larson, Phillips, Ranjha and Falstein, the “requirements set forth in the request for proposals were strict,” and the county was “required to award the exclusive contract to the bidder with the highest scoring proposal [in the competition]. Moreover, any provider whose proposal failed to meet the minimum qualifications specified in the request for proposals could not be considered at all.”
Despite what was supposed be a highly regulated and precisely controlled competition, according to Larson, Phillips, Ranjha and Falstein, the “county was willing to disregard this mandatory process in order to award the contract to its pre-ordained preferred provider – CONFIRE – regardless of whether it had submitted the best bid. In other words, the process actually employed by the county was not truly competitive at all.”
Larson, Phillips, Ranjha and Falstein maintain “The independent, non-biased review committee administering the request for proposals process gave AMR’s proposal a higher score than CONFIRE’s proposal based on scoring criteria set forth in the request for proposals.” Furthermore, according to Larson, Phillips, Ranjha and Falstein, [T]he board of supervisors voted to award the contract to the losing bidder, CONFIRE. By negotiating with and ultimately awarding the contract to an ambulance services provider with an inferior bid, the county and its board of supervisors acted contrary to the request for proposals and state law—and, consequently, outside the narrow confines of their antitrust immunity.”
According to Larson, Phillips, Ranjha and Falstein, “CONFIRE’s proposal should not have been considered to begin with, as it failed to fulfill basic minimum requirements mandated by the request for proposals.”
Among those minimum requirements, according to Larson, Phillips, Ranjha and Falstein was that Priority Ambulance meet specified previous experience criteria, including having continuously provided ambulance services for five of the last seven years while serving a population of 1 million.
Larson, Phillips, Ranjha and Falstein maintain that Priority’s contract with the City of Chandler, Arizona commenced in or about January 2022 and thus failed to satisfy the durational requirement in the request for proposals. Moreover, the lawyers argue, the two municipalities in Maricopa County Priority did serve for the requisite amount of time, the City of Glendale, Arizona, and the City of Goodyear, Arizona, have a population that amounts to 338,000 residents – far less than the service area population of 1,000,000 required under the request for proposals.
The 9th District Court declined to exercise supplemental jurisdiction over AMR’s two state-law claims. Judges Callahan, Desai and De Alba left a decision with regard to those issues to Judge Robinson, writing, “We note that the state court may be a more appropriate forum to litigate AMR’s challenges to the county defendants’ execution and administration of the request for proposals.
Nevertheless, at a September 5 hearing in San Bernardino County Superior Court, Judge Robinson said he was taking the 9th Circuit panel’s ruling under submission. There are passages within that ruling that do not presage well for AMR. At one point, the panel wrote, “Even if the county defendants erred in implementing the state-approved request for proposals and awarded the contract ‘in complete disregard of the State-mandated competitive process’ as AMR alleges, the county defendants are still entitled to Parker immunity. The Supreme Court held in Omni [another Sherman Antitrust Act case involving a governmental entity] that a local government was entitled to Parker immunity even when the nature of its regulation was allegedly substantively or procedurally defective. And this court has similarly held that a local government does not ‘forfeit’ Parker immunity merely because it imperfectly exercises its power under state law.”
According to Judges Callahan, Desai and De Alba, “While AMR received the highest total score, CONFIRE received the highest median score. The request for proposal does not define what the ‘highest score’ means, and also provides that the county defendants will award the contract to the ‘highest scoring proposer . . . whose proposal presents the greatest value’ and that ‘best meets the needs of the county.’ Accordingly, even if AMR had the ‘highest score,’ the plain language of the state-approved request for proposals gave the county defendants discretion to award the monopoly to the provider whose proposal presented ‘the greatest value’ to the county. Moreover, the county defendants articulated how CONFIRE presented the ‘greatest value’ to the county, namely, by being eligible for supplemental state funding, by improving public safety through closer integration or coordination of services, and by promising faster response times than AMR. The award of the monopoly to CONFIRE was thus the ‘foreseeable result’ of the state’s policy.”