Add medical transport by ambulance to the list of health-care systems in New Hampshire that says they are being strained to the breaking point.

“At the end of the day, the crisis is all about money,” said Justin Van Etten, executive director of the New Hampshire Ambulance Association, the trade group for ambulance services and other medical-transport operations owned by communities, hospitals and private companies, both non-profit and for-profit.

The group recently released a report titled “The State of Emergency in New Hampshire,” which argues that low reimbursement rates for Medicaid patients and from private insurance companies has caused low pay that is contributing to a shortage of EMTs and paramedics who are willing to work in ambulances, which in turn contributes to crowded hospitals and long wait times for health care, particularly in rural areas.

“If we don’t find more money in the next 3 to 6 months, this situation is going to get extremely bad,” Van Etten said Tuesday. “I just had to tell one of the largest hospitals in the state that they’re not going to have paramedic-level coverage for the foreseeable future. There’s just nobody left to work them.”

Three ambulance companies have shut down in New Hampshire this year, including Best Care in Gilford.

Similar concern about reimbursement rates has been expressed by many parts of the health-care system, ranging from the Choices for Independence program for people who want to age at home to youth mental-health services.

Two bills being considered by the legislature — SB86 and HB2 — would increase reimbursement rates for Medicaid patients in some situations and for medical transport.

“We’re trying to fight it on every front,” said Sen. Sue Prentiss, D-Lebanon, who is a paramedic and was formerly head of Emergency Medical Services in the state. “Last year was the first year in 17 that we got any type of substantive increase just for ambulances. … It’s finally up to 50% of the Medicare rate.”

New Hampshire’s aging population contributes to the problem.

Van Etten said that the situation is not as dire for 911 service, which gets taxpayer support from communities, but this is little consolation for non-emergency transport such as when a patient with a cardiac condition needs to be taken to a specialty hospital.

“If you’re in Concord you’re fine, but if you go to a smaller rural hospital in New Hampshire … we’re seeing increased situations where people are waiting days to get to a bigger hospital,” he said.

Similarly, New Hampshire hospital executives have said that a shortage of available beds is caused by lack of transport to take patients who are recovering from the hospital to a long-term care facility.

Compounding the problem has been more competition for EMTs and paramedics, although the number of such trained personnel in the state has stayed roughly static — around 5,000 — for years, Van Etten said.

“At urgent care clinics now, they’re largely staffed by EMTs. All sorts of businesses now require EMTs on staff. … An EMT might be able to make more money working at Canobie Lake Park for the summer — that job didn’t used to exist,” Van Etten said.

Payment from private insurance is also a problem, he said: “One of the largest insurance services in the state has started paying less than they paid a decade ago. … I could transport two patients, the same services, same distance, could be paid by the same insurance. One time they’d (reimburse) $375, next time $4,200. There is no rhyme or reason to what insurance companies pay.”

Aside from more money, the report says a possible solution could be to “organize EMS (Emergency Medical Service) at the county or regional levels to create a safety net and economies of scale from shared services.”

Last month Cheshire County became the first New Hampshire county to start its own EMS service following the closure of private DiLuzio Ambulance in Keene, N.H.