Behind this pricing model was a competitive industry, comprised of family-owned and privately held companies serving specific regions. Major companies included Wheeled Coach (founded in Florida in 1975), American Emergency Vehicles (AEV) (founded in North Carolina in 1982), Horton Ambulance (founded in Ohio in 1968), Leader Ambulance (founded in California in 1975), Road Rescue (founded in Minnesota in 1976), Braun Ambulance (founded in Ohio in 1961), Mccoy Miller Emergency Vehicles (founded in Indiana in 1974), and Marque Ambulance (founded in Indiana in 1990).

The story of how a once vibrant industry turned brittle begins in the mid-2000s, when a private equity firm named American Industrial Partners (AIP) decided to enter the business and consolidate the makers of modular ambulances. AIP specializes in “middle market” industrial businesses; it is already being investigated by the Senate and Federal antitrust enforcers for its roll-up of fire trucks and fire apparatuses, which caused price hikes and shortages in that sector. And its work in ambulances seems to mirror its fire apparatus approach.