Reports the findings of a survey of state EMS directors regarding access to rural EMS; programs and initiatives by state EMS agencies that target rural and volunteer EMS providers; integration initiatives by rural EMS providers; issues in medical direction for rural EMS; and anticipated effects of the new Medicare fee schedule on rural EMS providers. Findings include: there is substantial state-by-state variation in the approach to EMS issues; EMS system development has not been a priority in state efforts; state EMS agencies address rural EMS provider needs in a limited manner; medical direction in rural EMS is a major issue in most states, but few states place a high priority on it; and EMS integration is sometimes seen as a panacea, but is not easily accomplished. Concludes that the time is right for a new national initiative to address EMS issues and to stimulate the development of EMS as a system, beyond its current fragmented state.