It's hard to make out exactly what your point is but you're correct if you're trying to say that the price here is not simply about supply and demand. The costs of ambulances are subsidized in many ways (but they're never "free") and you're also dealing with people who generally don't have the ability to shop around. It's not a "market" item, really, on either side of the transaction.

Regarding rural areas and small towns: they often keep costs down by having crappy medical services in general, and slower response times specifically. It's not always that bad, though. If a town isn't sprawled out response times shouldn't suffer so much.

I don't want to push this next claim too far, as I only have "I have heard" to back it & no actual numbers or links, but...

I have heard on more than one occasion that the reason emergency services (ambulances, ER, etc) are so expensive is to recover the cost of all the uninsured users.

People can be refused at a clinic if they have no insurance, so they go to ER for everything, where in many places they cannot be turned away. Hospitals therefore have to bill YOUR insurance to recover these costs

That's why your ambulance ride is so expensive.

You are assuming too much: my ambulance ride isn't expensive. I live in a municipality which provides its own ambulances. In a geographically dense suburb it's efficient, logical and cheap (relatively) for EMS services to piggyback off of fire services. There aren't enough free riders around for the system to fall over from the "uninsured." If you're around here, you've probably helped pay for it.

> Hospitals therefore have to bill YOUR insurance to recover these costs

You know who takes an even bigger hit? Uninsured but solvent patients. Insurance companies have greater bargaining power.

None of that has anything to do with the ambulance business.