Wendover's Air Ambulance Investigation Gets the Economics Right—and the Medical Evidence Wrong
Wendover Productions makes a serious case against America's air ambulance industry. Its strongest evidence concerns private-equity ownership, extraordinary charges, weak price competition and patients who cannot choose their emergency provider. But its most emotionally powerful conclusion rests on a much less secure foundation: the suggestion that 96 out of every 100 air ambulance flights leave patients financially worse off without saving their lives.
That is not what the underlying medical research establishes. And the distinction matters. An industry can exploit a broken payment system without every flight being unnecessary, every patient being harmed, or every helicopter operator behaving alike.
The four-lives statistic does not prove that 96 patients are harmed
The video says the best research estimates that four lives are saved for every 100 air ambulance flights. It then converts the remaining 96 into patients who lose a year of income, delay retirement, abandon plans for their children's education, or lose the ability to buy a home.
The research does not establish that conclusion.
The closest identifiable source for the four-per-100 figure is a 2009 review by Akkie Ringburg and colleagues, Lives Saved by Helicopter Emergency Medical Services. It examined 16 studies published through April 2007. Although its overall mean estimate was four additional survivors per 100 uses, its four studies considered reliable produced a lower estimate of 2.7. The review itself called for more consistent research methods.
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There is a second problem: an additional survivor is not the same thing as a patient receiving no benefit. A flight can provide specialist medical care, reduce disability, accelerate access to surgery, or transport someone who cannot safely travel by road. A mortality estimate does not measure all these outcomes.
A 2012 study published in JAMA examined 223,475 adults with major trauma. After propensity-score matching, helicopter transport was associated with absolute survival improvements of 1.5 percentage points at Level I trauma centers and 1.4 points at Level II centers. This was observational evidence, not proof that helicopters benefit every patient, but it directly contradicts any suggestion that their medical contribution is negligible.
JAMA Network
More recent evidence also deserves attention. A 2025 systematic review examined 63 studies comparing helicopter and ground transport. Although 92% of the underlying data were retrospective and unadjusted results were broadly similar, adjusted analyses generally favored air transport. The researchers concluded that further work was needed to establish the true effects.
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The defensible conclusion is that helicopter transport can improve survival for selected patients, but its benefit varies with injury severity, medical staffing, geography, and the alternative transport available. There is no credible basis for treating every flight that does not produce an additional death prevented as a medical failure.
And there is certainly no evidence in these studies that the other 96 patients each lose a year of income. That is an emotionally effective illustration masquerading as a measured consequence.
The overtriage statistics do not establish helicopter overuse
Wendover cites a 2013 JAMA Surgery study reporting that 24% of transferred adults and 49% of transferred children met the definition of secondary overtriage at Dartmouth-Hitchcock Medical Center in rural New Hampshire.
The finding is real. Its application to air ambulances is the problem.
The study examined one trauma center's transfers between 2007 and 2011. It classified patients as overtriaged if they had an Injury Severity Score below 15, required no operation, and left within 48 hours. It did not establish that the same patients could safely have remained at their original hospitals.
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There is a particularly revealing detail the video does not discuss: 91% of the patients classified as overtriaged arrived by ground, compared with 76% of transfers not classified as overtriaged. Only 8% of the overtriaged group arrived by air, compared with 24% of the other group.
JAMA Network
That is a serious distinction. The study demonstrates unnecessary transfers are a problem in trauma systems. It does not demonstrate that helicopter transfers are responsible for a comparable proportion of unnecessary journeys.
Nor were all these patients trivial cases. Almost one-third of the overtriaged group had injuries classified as serious under the Abbreviated Injury Scale, and some required specialist assessment.
JAMA Network
Wendover has taken a legitimate criticism of hospital-transfer practices and placed it inside an indictment of air ambulance companies without establishing the connection. That is not a small statistical omission. It changes who the evidence actually implicates.
A price–cost gap is not a profit calculation
Wendover compares an average flight price of $27,900 with operating costs of $6,000–$13,000 and presents the difference as evidence of extraordinary profitability.
There are two problems with this calculation.
First, the $27,900 figure comes from the Health Care Cost Institute's 2017 analysis. It represents an average allowed amount among commercially insured patients under 65 with employer-sponsored coverage, not the average amount billed to every American patient or the amount collected by every operator. The underlying dataset contained more than 100,000 trips.
Health Care Cost Institute
Second, the $6,000–$13,000 cost estimate came from interviews with representatives of just eight providers in 2016. It was not an independently audited industry-wide cost calculation. The GAO explicitly warned that no comprehensive national database of air ambulance operating costs existed.
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The missing context is important. According to the GAO, maintaining one helicopter around the clock required approximately 13 employees: four pilots, four nurses, four paramedics and a mechanic. Aircraft ownership, staffing and readiness costs continue whether a helicopter flies or sits at its base.
The GAO also found that providers carrying fewer patients had to recover their fixed costs across fewer transports. This is particularly relevant to rural operations, where a helicopter may cover a large geographical area but receive relatively few calls.
GAO
There is another economic consideration Wendover leaves out: payer mix.
In the GAO's 2016 provider sample, approximately 35% of transports were Medicare, 21% Medicaid and 9% self-pay. Private insurance accounted for only 32%. Seven of the eight providers interviewed said privately insured patients generated the majority of their transport revenue, despite representing a minority of journeys.
Six providers said they adjusted private insurance prices to compensate for lower payments from government programmes.
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None of this makes excessive charges acceptable. But it means the difference between a provider's reported operating cost and an allowed payment cannot simply be labelled profit.
Wendover knows that the companies do not publish sufficient financial information to establish their actual profitability. It nevertheless concludes that they are pocketing thousands of dollars per patient.
That is an accusation beyond the evidence.
The private-equity evidence is real, but the profit claim remains unproven
There is considerably stronger evidence against the industry's ownership structure than the video's speculative calculation.
A 2020 Brookings analysis examined Medicare billing data and identified two private-equity firms controlling approximately 64% of the national helicopter air ambulance Medicare market in 2017.
Their carriers had a standardized average charge of $48,250 per helicopter transport, compared with $28,800 for carriers outside private-equity ownership and publicly traded ownership categories.
Private-equity carriers also increased their helicopter charges by 79% between 2012 and 2017, compared with 36% among other carriers, after adjusting for inflation.
Brookings
A subsequent USC-Brookings analysis examined commercial insurance claims from Aetna, Humana and UnitedHealthcare covering 2014–2017.
It found:
- Standardized allowed amounts of $32,051 for private-equity or publicly traded carriers, compared with $20,146 for other providers.
- Approximately 89% of transports by the combined private-equity and publicly traded group were out-of-network, compared with 59% for hospital, nonprofit and independent providers in 2017.
- Potential surprise bills averaged $26,507 for the combined private-equity and publicly traded group in 2017, compared with $15,671 for other providers.
Brookings
These are substantial differences. They provide a much stronger basis for investigating ownership, pricing power and the incentives created by out-of-network billing.
But there is an important distinction: the second study groups private-equity-owned and publicly traded carriers together. Its results cannot all be attributed exclusively to private equity.
The research also measures charges, allowed payments and potential balance bills, not audited net profits.
The studies disclose support from Arnold Ventures through the USC-Brookings research initiative. That funding deserves transparency, but it is not evidence that the findings were manipulated.
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The better indictment is therefore straightforward: private-equity ownership was associated with substantially higher charges and greater exposure to potential surprise bills. The evidence does not establish exactly how much profit investors extracted from each flight.
There is no need to invent that figure. The documented pricing differences are serious enough.
The 77% surprise-billing figure needs a closer look
Wendover presents the finding that 77% of air ambulance flights were out-of-network as though it means patients were routinely responsible for the entire bill.
The underlying research is more complicated.
The 2020 Milbank Quarterly study examined 36,312 claims from 2014–2017. Thirty-six percent of claims had missing network-status information, which the researchers classified as out-of-network based on their analysis of the providers involved.
The resulting 77% figure was therefore an estimate, not a direct count of claims with confirmed out-of-network status.
Wiley Online Library
More importantly, the study found that approximately 40% of helicopter transports had the potential to generate a surprise balance bill, averaging $19,851.
The word potential matters.
Insurers paid the full provider charge in approximately 48% of out-of-network helicopter claims, leaving no additional balance to bill the patient beyond ordinary cost-sharing. The researchers also acknowledged that their dataset did not establish how many actual bills were sent or ultimately paid.
Wiley Online Library
The financial problem was substantial. But 77% out-of-network does not mean 77% of patients paid the entire $30,000–$50,000 charge.
That distinction matters when a documentary moves from measuring financial exposure to describing actual household losses.
The No Surprises Act changed the situation after the video
Wendover was right to identify the No Surprises Act as a potential solution in its original discussion. At the time, implementation was still ahead.
But the law took effect on January 1, 2022, and its consequences are now measurable.
For covered air ambulance services under most private group and individual health insurance plans, an out-of-network provider cannot bill the patient beyond the applicable in-network cost-sharing amount. The provider and insurer must resolve their payment disagreement through negotiation or the federal independent dispute resolution process.
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This did not repeal the Airline Deregulation Act or impose a universal price ceiling.
It changed who can be made responsible for the bill.
There are also limitations. The No Surprises Act does not force an insurance plan to cover every possible air ambulance service. For example, if a plan covers only emergency air ambulance services, it does not have to cover a non-emergency interfacility transfer simply because the patient was flown.
U.S. Department of Labor
The most useful recent evidence comes from a February 2026 Government Accountability Office report.
Examining approximately 69,000 professional air ambulance claims from 2019–2023, the GAO found the following in-network proportions:
Year In-network claims 2019 89.3% 2020 91.3% 2021 89.8% 2022 96.2% 2023 93.9%These figures come from a different claims dataset than the older 77% study, so the two should not be treated as directly comparable. The GAO also cautioned that it could not attribute the changes specifically to the No Surprises Act.
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There is an additional finding worth noting: two insurers experienced increases of 24 and 34 percentage points in their in-network air ambulance claims between 2021 and 2022. One insurer explained that it had contracted with two of the three largest air ambulance providers.
That is evidence of changing commercial relationships, not simply a change in legislation.
GAO Files
The same GAO report found that average in-network helicopter transport payments fell in 2021 and 2022, then increased in 2023 to slightly above their 2019 level. These figures exclude mileage charges, so they do not represent the entire flight bill.
GAO Files
The result is neither a complete victory nor proof that the law failed. Patients with covered private insurance now have meaningful protection against surprise balance bills, while providers and insurers continue to negotiate substantial payments.
The industry still needs scrutiny, but the legal situation is no longer the one Wendover described.
The verdict: a strong investigation weakened by careless conclusions
Wendover identifies a genuine failure in American healthcare.
Patients cannot shop around during emergencies. Air ambulance providers have unusual pricing power. Private-equity ownership is associated with higher charges and greater exposure to surprise bills. State governments face restrictions on regulating airline prices.
Those findings deserve serious attention.
But three conclusions should never have been presented as established facts:
- That the 96 flights not credited with saving an additional life necessarily harmed patients.
- That secondary overtriage statistics demonstrate comparable unnecessary use of helicopters.
- That the difference between reported operating costs and provider charges establishes thousands of dollars in profit per patient.
The subsequent No Surprises Act also changed the financial relationship between patients, insurers and providers.
My objection is not that Wendover criticized a powerful industry. It is that the video occasionally substitutes moral certainty for the very statistical discipline its argument requires.
A helicopter can save a life and still be overpriced. An unnecessary transfer can burden a patient without proving that the entire air ambulance system is unnecessary. A private-equity company can charge substantially more than its competitors without the available evidence establishing its exact profit per flight.
These distinctions make the investigation more difficult, not less important.
The air ambulance industry deserves an investigation into its actual prices, costs, ownership and medical outcomes. But an investigation that turns estimated lives saved into 96 stories of financial ruin is not yet that investigation.
References
1. How Air Ambulances (Don't) Work — Wendover Productions. Original video. The original argument, statistics and conclusions examined in this critique.
2. Lives Saved by Helicopter Emergency Medical Services: An Overview of Literature — Ringburg et al., Air Medical Journal, 2009. PubMed. Establishes the range of estimated survival benefits and the more conservative 2.7-per-100 estimate from four reliable studies.
3. Lives Saved by Helicopter Emergency Medical Services — University of York, Database of Abstracts of Reviews of Effects, 2010. NCBI Bookshelf. Reports the overall mean estimate of four lives per 100 uses and identifies methodological limitations in the underlying research.
4. Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma — Galvagno et al., JAMA, 2012. JAMA. Provides adjusted survival comparisons involving more than 223,000 seriously injured patients.
5. Factors Influencing Outcomes of Trauma Patients Transferred in Trauma Systems by Air or Ground Ambulance — Alharbi et al., Prehospital Emergency Care, 2025. PubMed. Reviews 63 studies and identifies the difference between adjusted and unadjusted survival findings.
6. Secondary Overtriage: The Burden of Unnecessary Interfacility Transfers in a Rural Trauma System — Sorensen et al., JAMA Surgery, 2013. JAMA Network. Supplies the adult and pediatric overtriage figures and the crucial distinction between ground and air transfers.
7. Air Ambulance: Data Collection and Transparency Needed to Enhance DOT Oversight — U.S. Government Accountability Office, July 2017. GAO-17-637. Documents provider-reported operating costs, staffing requirements, payer mix, price variation and the absence of comprehensive industry cost data.
8. Air Ambulances – 10 Year Trends in Costs and Use — Health Care Cost Institute, November 2019. HCCI. Establishes the scope and methodology behind the widely cited $27,894 average helicopter price.
9. Out-of-Network Air Ambulance Bills: Prevalence, Magnitude, and Policy Solutions — Fuse Brown et al., The Milbank Quarterly, June 2020. Full research paper. Provides the 77% network estimate, its missing-data qualification and the distinction between potential and actual patient bills.
10. High Air Ambulance Charges Concentrated in Private Equity-Owned Carriers — Adler, Hannick and Lee, Brookings, October 2020. Brookings. Compares provider charges by ownership structure and documents the concentration of the Medicare market.
11. Private Equity-Owned Air Ambulances Receive Higher Payments, Generate Larger and More Frequent Surprise Bills — Adler et al., USC-Brookings, November 2021. USC Schaeffer Center. Compares allowed amounts, network participation and potential patient liabilities across ownership categories; discloses Arnold Ventures support.
12. Surprise Billing and Protecting Consumers — Centers for Medicare & Medicaid Services, updated September 2024. CMS. Establishes the protections that took effect in January 2022, including air ambulance balance-billing restrictions.
13. Private Health Insurance: Provider Participation and Payments for Selected Services Before and After the No Surprises Act — U.S. Government Accountability Office, February 19, 2026. GAO-26-107169. Provides the latest examined air ambulance network-participation and payment figures, together with important limitations on causal interpretation.