Matt Stoller delivers a startling diagnosis for a crisis that feels like natural inflation but is actually engineered scarcity: your city can't afford a new ambulance because private equity has turned emergency vehicles into a profit center rather than a public utility. This piece is notable not just for tracing the 337% price spike in a single city, but for exposing how two conglomerates now control nearly the entire North American market, creating artificial backlogs that investors celebrate as financial assets. In an era where every household feels the pinch of rising costs, Stoller provides the missing link between a paramedic's frustration and a Wall Street quarterly report.
The Anatomy of a Roll-Up
Stoller begins by dismantling the idea that price hikes are inevitable market forces. He writes, "Markets are a function of law. There are companies and dealers and financiers behind every industry, so we can actually try to understand why they are happening." This framing is crucial; it shifts the blame from abstract "cost of living" pressures to specific corporate strategies. The author details how Evanston, Illinois, watched the price of an ambulance jump from $148,000 in 2011 to half a million dollars in 2024, a surge far outpacing inflation.
The core of the argument rests on the consolidation of the industry. Stoller traces the history of private equity firm American Industrial Partners (AIP), which began acquiring family-owned manufacturers in the mid-2000s. He notes that AIP "bundled all of the companies it acquired in the specialty-vehicle sector into a conglomerate called REV Group," which now controls an estimated seventy percent of the market. This mirrors the firm's earlier work in fire apparatus, a connection that adds significant weight to the analysis. As Stoller points out, the industry once had stable costs, with cities like Winter Springs, Florida, paying $135,000 for an ambulance in 2000. The shift to a duopoly has shattered that stability.
The consolidation of ambulance production into the hands of two conglomerates is one part of the problem, but there have also been two other changes in the structure of this market.
Critics might argue that supply chain disruptions and microchip shortages are the primary drivers of these delays, a point the industry frequently raises. Stoller acknowledges these external factors but argues they are exacerbated, not caused, by market concentration. He writes, "The industry has blamed its inability to keep pace with rising demand on essential microchip shortages... But there's also been a change in the market structure." This distinction is vital because it suggests that even if supply chains normalize, the pricing power remains with the monopolists.
The Economics of Backlogs
Perhaps the most chilling insight Stoller offers is the revelation that delays are not a bug in the system, but a feature. He highlights how REV Group reports its massive backlog of unfulfilled orders as a "highlight" to investors. Stoller writes, "REV Group has touted its extreme backlog as a way to increase shareholder value because it 'enables strong visibility into future net sales.'" This inversion of logic—where scarcity creates value rather than urgency—is a hallmark of monopolistic behavior. The result is that a city ordering an ambulance today might not receive it until 2028.
The author also exposes the role of exclusive dealer networks in inflating costs. By forcing municipalities to buy through licensed regional dealers, the conglomerates eliminate price competition. A paramedic in Kentucky is quoted noting the impact: "you have to go through a dealer now," and "[w]ith the dealer mark-up, it raised the price significantly." Stoller uses this to illustrate how the entire purchasing experience has been weaponized against public budgets. The argument is bolstered by the fact that these companies spend only one percent of their revenue on capital investments, choosing instead to hoard profits and rely on existing, constrained capacity.
The Chassis Bottleneck
Stoller digs deeper into the supply chain, identifying a critical bottleneck: the chassis. An ambulance is essentially a specialized body built on a truck frame, and Ford controls seventy percent of this market. Stoller writes, "This total reliance continues despite REV Group telling its investors that chassis supply issues have lost the company up to $120 million in incremental revenue." He argues that this dependence is a choice, not a necessity. He points out that some of the very companies now owned by REV Group used to manufacture their own chassis, such as Spartan Motor Chassis, before being acquired and stripped of that capability.
The author suggests that the conglomerates could expand production but choose not to because it would lower their profit margins. Stoller notes, "REV Group and DBCM may be seeking to control the entire purchasing and aftermarket experience as well." This strategic decision to under-invest in capacity while charging premium prices is the engine of the crisis. The piece effectively connects the dots between a private equity firm's desire for "low capital intensity" and a city's inability to save a life in a timely manner.
Bottom Line
Matt Stoller's strongest move is reframing a public health crisis as a failure of antitrust enforcement, proving that the high cost of emergency care is a direct result of market consolidation rather than inevitable economic forces. While the argument relies heavily on public records and investor reports, it leaves little room for doubt that the current duopoly is prioritizing shareholder returns over public safety. The most urgent takeaway is that without regulatory intervention to break up these conglomerates or force capacity expansion, the backlog will only grow, leaving communities with no choice but to pay exorbitant prices for delayed care.