Ambulance Roll-Ups, Consolidation, Private Equity and the Role of Antitrust

By J.R. Howell

On April 11, 2026, Matt Stoller published “Emergency Prices: How Private Equity Captured the Ambulance Market” (available at https://www.thebignewsletter.com/p/code-red-why-your-city-cant-affordor) (last visited April 13, 2026). This article takes a dive into the research and examines private equity consolidation in the emergency vehicles market, particularly ambulances, from an antitrust litigation perspective. 

For municipal buyers, the cost of emergency vehicles is rising. Consider the instance of the City of Evanston, which in 2023, approved $237,001 for a Braun Chief XL Type III ambulance. In 2025, the City of Coalinga reported that a new ambulance and equipment was expected to reach about $445,000, while a remount would cost about $240,000 and return to service materially faster. While neither of these facts proves an antitrust violation, they are anecdotes that invite legal scrutiny.[1][2]  

The public record also supports a broader structural story. Over roughly two decades, ambulance manufacturing brands that once operated as separate firms were gathered into two large umbrellas: the REV lineage associated with American Industrial Partners (“AIP”) and the Demers-Braun-Crestline-Medix lineage later acquired by J.B. Poindexter, with REV itself then sold to Terex in 2026. That consolidation is significant, as are dealer territories, repeat-fleet standardization, remount restrictions, and procurement systems that often narrow competition before bidding even begins. But legal analysis has to stay disciplined. High prices are not unlawful by themselves. Backlogs are not unlawful by themselves. Private-equity ownership is not unlawful by itself. The real question is narrower and sharper: whether serial acquisitions, lifecycle controls, and channel structure created a competition problem that current law can recognize and remedy.[3][4]  

1. Can antitrust law unwind an ambulance roll-up?

The governing federal tools are familiar but differently suited to the job. Section 7 of the Clayton Act targets acquisitions whose effect may be substantially to lessen competition or tend to create a monopoly. Section 2 of the Sherman Act targets monopolization and attempted monopolization, which means a plaintiff must prove monopoly power in a relevant market and exclusionary conduct, not just size or success. Section 5 of the FTC Act, especially after the FTC’s 2022 policy statement, is the most obviously adaptable instrument for serial-acquisition theories because it is designed to reach unfair methods of competition, including conduct that may be incipient or not neatly captured by older doctrinal boxes.[5][6][7]

On the facts presently visible, a serious roll-up theory is beginning to develop. The AIP side of the story is well documented: AIP acquired Halcore, which held Horton, American Emergency Vehicles, and Leader; formed Allied Specialty Vehicles with ambulance brands including Horton, Wheeled Coach, AEV, and Leader; and soon after added Road Rescue. On the other side, Demers, Braun, Crestline, and Medix were assembled into a combined platform that later moved to J.B. Poindexter. REV’s own 2024 Form 10-K describes the company as the largest manufacturer by unit volume of fire and ambulance vehicles in the United States, while J.B. Poindexter describes DBCM as one of North America’s largest ambulance manufacturers. Those are meaningful admissions of scale, but what remains is a litigated market-definition analysis and an examination of the exact relevant present market shares.[3][4][11] 

A party trying to turn that structure into a Section 7 or Section 2 case would need more than a family tree of acquisitions. It would need an evidence-based product market and geographic market. That inquiry could turn out to be narrower than “all ambulances,” perhaps modular ambulances or specific types used by public-safety fleets, or it could prove broader once substitution and entry are tested. It would also need proof that the cumulative effect of these acquisitions reduced competitive options in a legally meaningful sense, for example by increasing prices above competitive levels, worsening service or lead times relative to what a competitive market would have produced, or reducing meaningful output or innovation. That is where contemporary agency thinking on roll-ups is relevant. The FTC’s U.S. Anesthesia Partners case and the agency’s 2024 request for information on serial acquisitions reflect a willingness to view a sequence of sub-threshold deals as a single competitive strategy.[8][10][30]  

The ambulance-market record gives plaintiffs some tantalizing evidence, though not yet a complete liability package. REV’s recent investor materials described a $4.2 billion backlog exiting fiscal 2024 and a $4.4 billion backlog exiting fiscal 2025 in the fire and emergency groups, while also highlighting increased shipments and pricing of fire apparatus and ambulances, improved price realization, and productivity actions within the ambulance group. While those materials are not confessions of illegality, they are the sort of documents antitrust lawyers notice because they tend to indicate, or disprove, constrained supply, stronger pricing, and deliberate operating choices in a concentrated setting.[12]  

 Still, the defense case is substantial. The first and strongest answer is that the same years featured extraordinary supply shocks, labor shortages, inflation, and chassis scarcity. Antitrust law does not punish firms for surviving a storm or for charging prices that the market will bear absent exclusionary conduct. The second answer is remedial. Even if an agency or court concluded that the industry rolled uphill into a competition problem, retrospective breakups of deeply integrated manufacturing assets are difficult and disruptive. Divestiture remains theoretically available under Section 16 and Section 7, but the practical burden of unscrambling operations years after integration is heavy, especially in emergency-response manufacturing where buyers already face long queues.[10][13]

That practical point shapes the likely remedy menu. The most realistic outcomes are narrow tools: prior-approval or prior-notice obligations for future acquisitions, injunctions against specific contracting or channel practices, targeted document demands, and state-level investigations that force a clearer record about pricing, distribution, and aftermarket restrictions. Put differently, antitrust law may help stop a problem before it starts.[7][10][13] 

 2. The law of the aftermarket: repairs, remounts, and useful life

Beyond initial vehicle-pricing questions, there are the issues of remounts. This opens an inquiry into the question of leverage. The City of Coalinga’s 2025 staff report (linked in the endnotes) is unusually candid: a remount would cut cost sharply relative to a new build and shorten delivery from as much as two years to roughly six to eight months. In a market of long queues and capital strain, remount issues are substantial.[2]  

For that reason, the Supreme Court’s decision in Eastman Kodak is the natural doctrinal starting point. Kodak teaches that a firm can possess market power in a derivative aftermarket, even without monopoly power in the foremarket, when customers are locked in by switching costs, information costs, or both. In this setting, the relevant aftermarket may not be just repair. It may be some combination of remount services, structural warranty preservation, authorized service, access to technical specifications, or approved parts and repair pathways over the useful life of the patient module.[14]

Here the public record is concrete enough to raise a real question. Excellance states that its twenty-five-year structural warranty is renewed in the event of a chassis remount only if the re-chassis work is completed by Excellance. Osage states that its aluminum box warranty transfers onto a new chassis only if the remount is performed by Osage, and that warranty repairs must be performed by Osage or an authorized repair center. These amount to lifecycle controls that can influence whether a fleet buyer truly has a practical option to use an independent remounter when the original chassis degrades with time.[15][16]  

A careful legal analysis, however, also has to confront the manufacturers’ best response, and it is a serious one. Ambulance remounts sit inside a dense compliance environment. Federal staged-manufacturing rules allocate certification duties among incomplete-vehicle manufacturers, final-stage manufacturers, and alterers. The eCFR provisions governing Parts 567 and 568 make clear that the final-stage manufacturer or alterer bears legal responsibility for continued conformity with applicable federal motor vehicle safety standards. CAAS’s Ground Vehicle Standard likewise imposes specific remount compliance obligations and directs remounters to follow OEM body-builder guides, incomplete vehicle documents, and relevant chassis-program guidance. That regulatory architecture gives manufacturers a facially legitimate reason to say: if someone else moves the box, rewires systems, or alters mounting and safety geometry, we are not going to warrant the structure as if nothing happened.[18][19]  

That is why the aftermarket theory is plausible but not automatic. A plaintiff would need to show more than the existence of restrictions. It would need evidence that buyers were materially locked in, that lifecycle costs were not reasonably knowable at the time of original purchase, that the restrictions functionally foreclosed qualified independents rather than merely preserving compliance, and that the OEM’s qualification standard was pretextual or unnecessarily exclusionary. Sophisticated public buyers cut both ways on this question. They are less sympathetic than individual consumers, but they also buy expensive, long-lived equipment where post-sale restrictions can have substantial fiscal effects.

One doctrine that is less useful here than it first appears is Magnuson-Moss. That statute speaks to consumer products normally used for personal, family, or household purposes, which makes it a poor fit for municipal ambulance purchases. The stronger legal lanes are antitrust, contract, warranty, and state unfair-practices theories, not consumer-warranty law imported from the kitchen-appliance aisle into the apparatus bay.[17]

The practical answer is therefore contractual and structural. Where possible, public buyers should negotiate remount rights at the front end. The contract should define the conditions under which a third-party remounter can preserve structural warranty coverage, require objective qualification criteria rather than brand loyalty, and secure access to drawings, interfaces, parts, and service information necessary for compliant remount work. In this section of the market, the lock is often installed at the moment of first sale.[2][15][16][19]  

 3. The chassis bottleneck as a competition problem

The chassis issue is the portion of this story most likely to attract dramatic rhetoric and the least likely, on the current public record, to support a viable antitrust complaint. Ambulance builders operate in a staged-manufacturing system that depends on incomplete or base vehicles, body-builder guidance, certification allocation, and integration constraints. That is enough to make chassis supply a strategic bottleneck. It is not enough, by itself, to make it an antitrust violation.[18][19][20]  

A bottleneck becomes an antitrust problem when a firm with upstream leverage uses it to raise rivals’ costs, discriminate in access, or foreclose meaningful competition downstream. In ambulance manufacturing, that could mean coercing a chassis supplier to deny or delay supply to independent builders, tying access to exclusionary conditions, or using certification or allocation systems that favor insiders. These are proof-heavy theories. They require evidence of discriminatory allocation, coercive agreements, or deliberate exclusion.

The current record points more clearly to scarcity than to sabotage. For instance, the City of Coalinga reported that its supplier had no ambulances available for immediate purchase, that new-build lead times had increased to twenty-four months minimum, and that remounts were being used as a workaround. Prosper’s 2025 sales agreement warned of extended OEM chassis lead times, severe labor and supply shortages, supplier exits, and pass-through price increases from vendors. Those are classic seller-market documents. They may describe a market with too much power and too little resilience, but they do not, without more, establish that dominant ambulance manufacturers manipulated chassis access to exclude smaller rivals.[2][32]  

That does not mean the chassis story is legally irrelevant. It means the question is evidentiary. If future discovery turned up discriminatory allocation data, OEM communications about preferred builders, or certification practices used as exclusionary filters rather than safety controls, the theory would sharpen. Until then, the better legal description is that chassis dependence magnifies concentration, lengthens queues, and strengthens incumbent bargaining power, while the current public record remains too thin to separate ordinary scarcity from actionable foreclosure.

Where possible, buyers should require disclosure of chassis order placement, VIN assignment, expected delivery windows, and substitution or cancellation rights if the chassis milestone slips.[2][18][19][32][33]  

4. The dealer moat: exclusive territories meets public procurement

Exclusive dealer systems are ordinary vertical restraints, and under Sylvania and Leegin they are generally judged under the rule of reason, not treated as per se unlawful. That is relevant here because exclusive territory allegations are not standalone violations of federal antitrust law, even if they suggest a larger pattern of anti-competitive conduct. [22]

At the same time, the public record shows that dealer structure is central to how ambulance competition actually works. REV’s 2024 Form 10-K says the company sells ambulances through internal direct sales personnel and a select group of independent dealers in North America, that independent dealers provide full coverage of the U.S. domestic market and both sales and service, that dealers hold strong positions in assigned territories, and that REV periodically assists dealers in composing bid packages for larger opportunities. Demers-Braun-Crestline announced in 2020 that Glick Fire Equipment would be its exclusive dealer in Pennsylvania. While those facts do not prove unlawful vertical restraints, they do show that territorial channel control is not incidental.[11][21]  

The realities of municipal procurement can change the way competition laws operate with respect to otherwise lawful distribution practices. Fleet standardization is rational. REV itself says fleet owners frequently standardize through repeat purchases of existing brands and product configurations. That logic can materialize into bid specifications that mirror an incumbent fleet’s dimensions, module layout, electrical architecture, or compatibility assumptions. Once that happens, an exclusive dealer system can turn seemingly formal competition into a constrained channel. Intrabrand competition disappears by design, and interbrand competition may disappear because the specification itself limited the buyer’s options.[11][23]  

Cooperative purchasing contracts can intensify that effect. HGACBuy openly promotes the fact that its contracts allow local governments to buy without duplicating the competitive-bidding process, and its ambulance procurement documents contemplate dealer networks and contract assignments to dealers. None of that is improper on its face. Cooperative contracts save time and administrative cost. But they can also reinforce incumbent brands if local buyers stop asking whether the convenience of the vehicle is slowly becoming the convenience of the vendor.[23][24]  

Exclusive territories may in some circumstances be lawful. Municipal buyers may be trapped by their own specifications, compatibility preferences, and procurement shortcuts.[11][21][23][24]  

5. Do municipal buyers have standing to sue over ambulance prices?

Illinois Brick generally limits federal antitrust damages actions to direct purchasers. If a city buys from an exclusive dealer rather than directly from the manufacturer, the city is usually the indirect purchaser for federal-damages purposes, even if everyone in the chain knows perfectly well which OEM set the broad commercial terms. That is the pass-on problem in municipal clothing: the city may feel the overcharge most acutely, but federal law may still see it as one step too far down the chain.[25]

That distinction becomes outcome-determinative in the ambulance setting because the public record indicates that much of the market runs through dealers. REV says it sells ambulances through a select group of independent dealers as well as internal personnel, and independent dealers provide full domestic coverage. So the standing analysis can change markedly based on channel. A direct OEM purchase by a multi-state key account looks different from a county buying through its regional dealer. The former has a better path to federal damages. The latter usually does not.[11][25]  

Federal law is not a total dead end. Clayton Act Section 16 authorizes private injunctive relief, and Illinois Brick does not erase that remedy. More importantly, state law may be substantially friendlier. California’s Cartwright Act expressly allows suit regardless of whether the plaintiff dealt directly or indirectly with the defendant, treats the state and its political subdivisions and public agencies as persons under the section, and authorizes the Attorney General to sue on behalf of those public entities. Illinois law likewise treats the state, counties, municipalities, and other political subdivisions as persons with standing, authorizes the Attorney General to bring actions on their behalf, and expressly preserves indirect-purchaser damages claims under state law, though it limits indirect-purchaser class actions to the Attorney General. In those states, the dealer in the middle is still a litigation complication.[26][27][28]  

The strategic implication is straightforward. The weakest plaintiffs are small municipalities trying to bring federal damages cases through a dealer chain. The stronger institutional plaintiffs are state attorneys general, and in repealer states, large counties, cities, or other public agencies with the resources to build a state-law record. Purchasing cooperatives may also be useful fact-gatherers, even when they are not themselves the headline plaintiffs, because they can compare terms across jurisdictions and identify recurring channel or lifecycle restrictions. In this corner of the law, who sues is nearly as important as what they say.[11][26][27][28]  

6. Why merger review misses private-equity roll-ups

For 2025, the FTC stated that the size-of-transaction threshold for HSR reportability was $126.4 million. For 2026, the FTC announced that the threshold would rise to $133.9 million. Serial-acquisition strategies thrive below those lines, especially where the targets are middle-market companies, privately held family businesses, or add-on deals whose value is meaningful for competition but modest for filing purposes.[29]  

That is why platform-and-add-on strategies can calcify a market without ever producing the dramatic moment of a headline merger challenge. The ambulance-industry acquisition trail fits the pattern at a high level: foundational platform deals followed by a sequence of brand or capability additions that, viewed one by one, can look operationally logical and legally ordinary. By the time the market starts to feel stiff and brittle to public buyers, the structure may be the cumulative residue of many smaller decisions rather than one deal big enough to trigger the antitrust concerns.[3][4][29] 

The agencies know this. In 2024, the FTC and DOJ launched a public inquiry into serial acquisitions and roll-up strategies, expressly noting that many such deals need not be reported and may allow firms to amass significant control without early scrutiny. And the 2024 final revisions to the HSR rules now require additional prior-acquisition information, including reporting by sellers of prior acquisitions in the same or related lines of business, precisely because that information helps the agencies identify roll-up strategies that would otherwise appear only as isolated incidents.[30][31] 

While those developments are relevant, they are mostly prospective. They make future roll-ups easier to spot. They do not automatically solve the remedial problem posed by already integrated industries. That is why further reform remains a legislative and policy question. Congress could lower relevant thresholds, create aggregation rules for serial acquisitions by the same sponsor or platform within a sector, or require broader notice for platform add-ons even below standard thresholds. Agencies can also continue to use Section 5 and post-consummation Section 7 challenges, but those are harder, slower, and more resource-intensive than catching a problem before it starts.[7][9][29][30][31]  

7. Contracting in a highly concentrated market: what public buyers should demand now

Consider again the instance of Caroline County, whose agreement allowed automatic price adjustment for manufacturer modifications and compliance modifications, including FMVSS and EPA-related changes, and made such change orders binding on the customer even without customer joinder. Prosper’s 2025 sales agreement required payment upon delivery or before release from the factory and warned that price increases from certain suppliers would be passed through to the buyer. HGACBuy, by contrast, requires written approval for price changes and substantive documentation supporting them. That spread of terms shows the negotiation terrain clearly: some public buyers are accepting broad, seller-friendly pass-through language while cooperative frameworks at least attempt to force documentation and approval discipline.[24][32][33] 

The first demand should therefore be price architecture, not just price. Contracts should cap escalation where possible and, at minimum, require open-book substantiation tied to specific supplier invoices or documented manufacturer notices. Vague “market conditions” language is too loose given the price and service issues that buyers are facing. A city buying a high-cost apparatus with long lead times should know what cost categories are adjustable, what evidence triggers adjustment, who approves it, and when the buyer may refuse. HGACBuy’s requirement that price changes be supported with substantive documentation and approved in writing is not a perfect solution, but it is a step in the right direction—where buyers have any bargaining power at all.[24][32][33]  

The second demand is milestone visibility. In a chassis-dependent market, buyers should require dates for chassis order placement, VIN or equivalent allocation notice, expected factory receipt, body-production milestones, testing, and delivery. The buyer should also have termination, rebid, or renegotiation rights if key milestones are missed without documented force majeure.

Third, public buyers should rebalance acceptance and post-sale leverage. Caroline County’s agreement deemed the vehicle accepted absent timely notice of substantial nonconformance. Prosper’s agreement stressed disclaimer language and accelerated payment timing. Buyers should instead preserve inspection windows, acceptance testing rights, retainage or delayed final payment until training and documentation are complete, and explicit remedies for unexcused delay. Liquidated damages can be used, but only if they are calibrated. Overreaching penalty language may simply produce fewer bids in a thin market. A well-drafted clause distinguishes genuine force majeure from mere backlog and places the burden of documentation on the seller.[32][33]  

Fourth, the contract should reach beyond delivery into the vehicle’s second life. That means warranty transferability, remount rights, access to parts and service information, and clear rules for when an independent but qualified remounter may preserve structural coverage. It also means source transparency and change-of-control provisions. When a market is concentrated and still consolidating, buyers should know whether the company they are contracting with, or the service network they are relying on, changes hands before the last warranty claim is filed.

Finally, procurement counsel should treat specifications as competition instruments, not just technical appendices. Performance-based specs, nonproprietary language unless justified, written disclosure of vendor assistance in drafting technical requirements, and routine benchmarking against cooperative or neighboring-jurisdiction purchases all help reopen lanes that dealer structure and fleet standardization tend to narrow. In a market this tight, the contract cannot do everything. But it can stop the buyer from signing away leverage with the purchase order.[11][15][16][21][23][24][32][33] 

The legal bottom line is uneven but not bleak. Current law can plausibly do something about future consolidation and perhaps about specific channel or aftermarket practices, especially through Section 5, state antitrust law, and aggressive investigative work. The strongest present claims are the ones grounded in structure plus concrete control points: serial-acquisition scrutiny, dealer-and-procurement interaction, and remount or warranty restrictions that may distort lifecycle competition. The weakest present claims are federal damages suits by municipalities buying through dealers and any broad accusation that chassis scarcity alone proves exclusionary conduct. The biggest reforms would require legislation or rule change: better roll-up reporting, stronger aggregation rules for serial acquisitions, and a friendlier federal regime for public buyers harmed through layered distribution chains.[7][9][25][26][27][28][29][30][31]  

For municipal buyers and procurement counsel, the immediate assignment is clear. Treat every ambulance purchase as both an apparatus acquisition and a lifecycle competition negotiation. Ask who controls the channel, who controls the warranty, who controls the remount, who controls the chassis milestone, and who gets to rewrite the price after you sign. In this market, the most expensive clause is often the one that looked harmless when it was still perceived as boilerplate.  

Endnotes

1. City of Evanston, City Council Actions, July 24, 2023, available at https://doccenter.cityofevanston.org/WebLink/DocView.aspx?dbid=0&id=143933&repo=Other-City-Departments (last visited Apr. 12, 2026) (recording City Council approval of a purchase agreement for one 2023 Braun Chief XL Type III ambulance for $237,001.00).
2. City of Coalinga, Staff Report, Approve Purchase Order from Emergency Vehicle Group (EVG) to Remount Fire Department Ambulance, available at https://coalinga.novusagenda.com/AgendaPublic/CoverSheet.aspx?ItemID=5821&MeetingID=617 (last visited Apr. 12, 2026) (reporting that a new ambulance build had increased to a 24-month minimum lead time, was expected to cost about $445,000, and that a remount would cost about $240,000 and take approximately six to eight months).
3. American Industrial Partners, American Industrial Partners Purchases Halcore Group, Inc., available at https://americanindustrial.com/american-industrial-partners-purchases-halcore-group-inc/ (last visited Apr. 12, 2026) (announcing AIP’s acquisition of Horton Emergency Vehicles, American Emergency Vehicles, and Leader Emergency Vehicles through Halcore Group); American Industrial Partners, American Industrial Partners Announces the Formation of Allied Specialty Vehicles, Inc., a Leading Manufacturer of Specialty Vehicles in North America, available at https://americanindustrial.com/american-industrial-partners-announces-the-formation-of-allied-specialty-vehicles-inc-a-leading-manufacturer-of-specialty-vehicles-in-north-america/ (last visited Apr. 12, 2026) (describing ASV’s ambulance portfolio to include Horton, Wheeled Coach, American Emergency Vehicles, and Leader); American Industrial Partners, Allied Specialty Vehicles, Inc. Announces the Acquisition of Road Rescue, available at https://americanindustrial.com/allied-specialty-vehicles-inc-announces-the-acquisition-of-road-rescue/ (last visited Apr. 12, 2026) (announcing ASV’s purchase of Road Rescue from Spartan Motors).
4. Demers Braun Crestline, Demers Braun Crestline Acquires Medix Specialty Vehicles, available at https://www.demers-ambulances.com/ca-en/demers-braun-crestline-acquires-medix-specialty-vehicles/ (last visited Apr. 12, 2026) (announcing DBC’s acquisition of Medix and describing the deal as building on the 2018 Demers-Braun merger and Crestline acquisition); J.B. Poindexter & Co., J.B. Poindexter & Co., Inc. Acquires Ambulance Manufacturing Leader Demers Braun Crestline Medix, available at https://www.jbpoindexter.com/news/j-b-poindexter-co-inc-acquires-ambulance-manufacturing-leader-demers-braun-crestline-medix/ (last visited Apr. 12, 2026) (describing DBCM as one of North America’s largest ambulance manufacturers); Terex Corp., Terex and REV Group Complete Merger, Creating a Premier Specialty Equipment Manufacturer, available at https://investors.terex.com/news/news-details/2026/TEREX-AND-REV-GROUP-COMPLETE-MERGER-CREATING-A-PREMIER-SPECIALTY-EQUIPMENT-MANUFACTURER/default.aspx (last visited Apr. 12, 2026) (announcing the successful completion of the Terex-REV merger on Feb. 2, 2026).
5. Clayton Act, 15 U.S.C. § 18 (2024) (prohibiting acquisitions whose effect may be substantially to lessen competition or tend to create a monopoly).
6. Sherman Act, 15 U.S.C. § 2 (2024) (prohibiting monopolization and attempted monopolization); United States v. Grinnell Corp., 384 U.S. 563, 570-71 (1966) (explaining that monopolization requires monopoly power plus the willful acquisition or maintenance of that power, as distinguished from growth resulting from a superior product, business acumen, or historical accident).
7. Federal Trade Commission Act § 5, 15 U.S.C. § 45 (2024) (prohibiting unfair methods of competition); Fed. Trade Comm’n, Policy Statement Regarding the Scope of Unfair Methods of Competition Under Section 5 of the Federal Trade Commission Act, available at https://www.ftc.gov/legal-library/browse/policy-statement-regarding-scope-unfair-methods-competition-under-section-5-federal-trade-commission (last visited Apr. 12, 2026) (setting out the Commission’s view that Section 5 reaches conduct beyond the letter of the Sherman and Clayton Acts).
8. Fed. Trade Comm’n v. U.S. Anesthesia Partners, Inc., available at https://www.ftc.gov/legal-library/browse/cases-proceedings/2010031-us-anesthesia-partners-inc-ftc-v (last visited Apr. 12, 2026) (describing the FTC’s pending challenge to a roll-up strategy in anesthesiology); Fed. Trade Comm’n, FTC Approves Final Order with Welsh Carson, available at https://www.ftc.gov/news-events/news/press-releases/2025/05/ftc-approves-final-order-welsh-carson (last visited Apr. 12, 2026) (explaining that the FTC alleged anticompetitive acquisitions through U.S. Anesthesia Partners and imposed future notice obligations in the settlement with Welsh Carson).
9. REV Group, Inc., Annual Report (Form 10-K) (for fiscal year ended Oct. 31, 2024), available at https://www.sec.gov/Archives/edgar/data/1687221/000095017024135208/revg-20241031.htm (last visited Apr. 12, 2026) (describing REV as the largest manufacturer by unit volume of fire and ambulance vehicles in the United States, discussing its installed base, and explaining its dealer-network strategy and bid-package assistance).
10. REV Group, Inc., REVG Fiscal Fourth Quarter 2024 Results, available at https://investors.revgroup.com//media/Files/R/Rev-IR/reports-and-presentations/revg-fiscal-fourth-quarter-2024-results.pdf (last visited Apr. 12, 2026) (reporting a $4.2 billion backlog and highlighting increased shipments and pricing of fire apparatus and ambulances and improved price realization); REV Group, Inc., REV Group Fourth Quarter 2025 Results, available at https://investors.revgroup.com//media/Files/R/Rev-IR/reports-and-presentations/4q25-earning-slides.pdf (last visited Apr. 12, 2026) (reporting a $4.4 billion backlog, increased pricing of fire apparatus and ambulances, and higher price realization).
11. REV Group, Inc., Annual Report (Form 10-K) (for fiscal year ended Oct. 31, 2024), available at https://www.sec.gov/Archives/edgar/data/1687221/000095017024135208/revg-20241031.htm (last visited Apr. 12, 2026) (stating that REV sells ambulances through internal direct sales personnel and a select group of independent dealers, that dealers provide full U.S. domestic coverage, and that fleet standardization and installed-base effects influence repeat purchases).
12. REV Group, Inc., REVG Fiscal Fourth Quarter 2024 Results, available at https://investors.revgroup.com//media/Files/R/Rev-IR/reports-and-presentations/revg-fiscal-fourth-quarter-2024-results.pdf (last visited Apr. 12, 2026) (describing 2024 fire-and-emergency backlog and price realization); REV Group, Inc., REV Group Fourth Quarter 2025 Results, available at https://investors.revgroup.com//media/Files/R/Rev-IR/reports-and-presentations/4q25-earning-slides.pdf (last visited Apr. 12, 2026) (describing 2025 fire-and-emergency backlog, increased ambulance pricing, and productivity actions within the ambulance group).
13. California v. Am. Stores Co., 495 U.S. 271, 295-96 (1990) (holding that divestiture is available in a proper private action for injunctive relief under Section 16 of the Clayton Act).
14. Eastman Kodak Co. v. Image Tech. Servs., Inc., 504 U.S. 451, 476-77 (1992) (holding that competition in the foremarket does not automatically defeat a claim of market power in a derivative aftermarket).
15. Excellance, Inc., Structural Warranty, available at https://excellance.com/structural-warranty/ (last visited Apr. 12, 2026) (providing that Excellance’s structural warranty is renewed after a chassis remount only if the re-chassis work is completed by Excellance and that warranty repairs are performed at Excellance or its designated facility).
16. Osage Industries, Inc., Limited Remount Warranty, available at https://osageambulances.com/wp-content/uploads/2025/06/Osage-Limited-Remount-Warranty.pdf (last visited Apr. 12, 2026) (stating that the Osage aluminum box warranty transfers onto a new chassis only if the remount is performed by Osage and that warranty repairs must be performed by Osage or an authorized repair center).
17. Magnuson-Moss Warranty Act, 15 U.S.C. § 2301(1) (2024) (defining “consumer product” as tangible personal property normally used for personal, family, or household purposes, which limits the statute’s fit for municipal ambulance purchases).
18. 49 C.F.R. pt. 567 (2026) (governing certification responsibilities, including final-stage manufacturers and alterers); 49 C.F.R. pt. 568 (2026) (governing incomplete, intermediate, and final-stage manufacturers of vehicles built in two or more stages).
19. Commission on Accreditation of Ambulance Services, Ground Vehicle Standard for Ambulances, available at https://www.groundvehiclestandard.org/wp-content/uploads/2019/06/CAAS_GVS_V2.0_Final_7.1.2019.pdf (last visited Apr. 12, 2026) (setting minimum requirements for ambulance remounts, requiring remounters to provide compliance documentation, and directing compliance with OEM chassis guidance, incomplete vehicle documents, and FMVSS).
20. Ford Pro, Ford Pro Upfitter Program for Commercial Vehicles, available at https://www.fordpro.com/en-us/upfit/pro-upfitter/ (last visited Apr. 12, 2026) (describing Ford’s upfitter accreditation program for commercial fleet businesses); Ford Pro, Commercial Upfits, available at https://www.fordpro.com/en-us/upfit/ (last visited Apr. 12, 2026) (describing ambulances as one of the vehicle configurations built on Ford upfit platforms).
21. Demers Ambulances, Demers-Braun-Crestline (DBC) Awards Exclusive Brand Representation in Pennsylvania State, available at https://www.demers-ambulances.com/us/press_release/demers-braun-crestline-dbc-awards-exclusive-brand-representation-in-pennsylvania-state/ (last visited Apr. 12, 2026) (announcing Glick Fire Equipment as the exclusive dealer in Pennsylvania for Demers, Braun, and Crestline).
22. Cont’l T.V., Inc. v. GTE Sylvania Inc., 433 U.S. 36, 57-59 (1977) (holding that nonprice vertical restrictions are analyzed under the rule of reason); Leegin Creative Leather Prods., Inc. v. PSKS, Inc., 551 U.S. 877, 890-92 (2007) (holding that vertical resale-price restraints are also analyzed under the rule of reason).
23. HGACBuy, Invitation No. AM10-18, Ambulances, EMS & Other Special Service Vehicles, available at https://www.hgacbuy.org/getmedia/6072d78a-4b2a-41ce-8522-132b9e601b76/AM10-18-Final.pdf (last visited Apr. 12, 2026) (stating that HGACBuy contracts allow local governments to avoid duplicating competitive bidding, contemplate use of dealer networks, and provide that most specific descriptive references are descriptive rather than restrictive unless otherwise noted).
24. HGACBuy, Invitation No. AM10-20, Ambulances, EMS & Other Special Service Vehicles, available at https://www.hgacbuy.org/getmedia/578bf47f-64c5-48e9-a2a3-a5bfbbb7a59b/AM10-20-Final.pdf (last visited Apr. 12, 2026) (requiring substantive documentation and written approval for price changes and treating temporary surcharges as price changes subject to review).
25. Illinois Brick Co. v. Illinois, 431 U.S. 720, 728-29, 746-47 (1977) (holding that indirect purchasers generally may not recover federal antitrust damages for passed-on overcharges).
26. Clayton Act § 16, 15 U.S.C. § 26 (2024) (authorizing private injunctive relief against threatened antitrust injury); California v. ARC Am. Corp., 490 U.S. 93, 101-02 (1989) (holding that federal antitrust law does not preempt state laws allowing indirect purchasers to seek damages).
27. Cal. Bus. & Prof. Code § 16750(a)-(c), available at https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=BPC&sectionNum=16750. (last visited Apr. 12, 2026) (authorizing suit regardless of whether the plaintiff dealt directly or indirectly with the defendant, deeming political subdivisions and public agencies persons under the section, and authorizing the Attorney General to sue on their behalf).
28. 740 Ill. Comp. Stat. 10/7(2), available at https://www.ilga.gov/documents/legislation/ilcs/documents/074000100K7.htm (last visited Apr. 12, 2026) (treating the state, counties, municipalities, and political subdivisions as persons with standing, authorizing the Attorney General to sue on their behalf, and preserving indirect-purchaser damages claims under Illinois law).
29. Fed. Trade Comm’n, New HSR Thresholds and Filing Fees for 2025, available at https://www.ftc.gov/enforcement/competition-matters/2025/02/new-hsr-thresholds-filing-fees-2025 (last visited Apr. 12, 2026) (stating that the 2025 size-of-transaction threshold is $126.4 million); Fed. Trade Comm’n, FTC Announces 2026 Update of Jurisdictional and Fee Thresholds for Premerger Notification Filings, available at https://www.ftc.gov/news-events/news/press-releases/2026/01/ftc-announces-2026-update-jurisdictional-fee-thresholds-premerger-notification-filings (last visited Apr. 12, 2026) (stating that the 2026 size-of-transaction threshold increases to $133.9 million).
30. Fed. Trade Comm’n, FTC and DOJ Seek Info on Serial Acquisitions, Roll-Up Strategies Across U.S. Economy, available at https://www.ftc.gov/news-events/news/press-releases/2024/05/ftc-doj-seek-info-serial-acquisitions-roll-strategies-across-us-economy (last visited Apr. 12, 2026) (announcing a public inquiry into serial acquisitions and roll-ups and noting that many such deals need not be reported before closing).
31. Premerger Notification; Reporting and Waiting Period Requirements, available at https://www.federalregister.gov/documents/2024/11/12/2024-25024/premerger-notification-reporting-and-waiting-period-requirements (last visited Apr. 12, 2026) (explaining that the final rule requires additional reporting of prior acquisitions in the same or related lines of business to assist the agencies in identifying roll-up or serial-acquisition strategies).
32. Town of Prosper Fire Department, Sales Agreement (Dec. 15, 2025), available at https://mccmeetingspublic.blob.core.usgovcloudapi.net/prospertx-meet-f4265447fe624dd591030704f28c1057/ITEM-Attachment-001-9bc69caa121e43f797bc45e9e3ef194b.pdf (last visited Apr. 12, 2026) (showing a Horton/Ford ambulance purchase price, payment-upon-delivery language, and a market-conditions advisory passing certain supplier price increases through to the buyer).
33. The County Commissioners of Caroline County, Maryland and Atlantic Emergency Solutions, Purchase Agreement, available at https://www.carolinemd.org/DocumentCenter/View/3416 (last visited Apr. 12, 2026) (showing automatic price-adjustment language for manufacturer and compliance modifications, seller-favorable cancellation terms, estimated rather than guaranteed delivery, an inspection-and-acceptance framework, and broad warranty disclaimers).