This report examines the local government role in emergency medical services (EMS) in New York State and particularly the growing role that counties are playing in EMS provision. Declining staffing levels, increasing costs and other challenges have put pressure on the State’s EMS agencies. In many cases, counties are stepping up to help. Their EMS expenditures are growing rapidly and increasingly they are participating directly in providing EMS to their residents, either as primary responders or as back-up providers to their local EMS agencies. The current circumstances call for more State involvement to support the efforts of counties and other local governments to turn fragmented and ad hoc responses into comprehensive solutions.