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In 1974, the Robert Wood Johnson Foundation allocated $15 million for EMS‐related activities, the largest single contribution for the development of health systems ever made in the United States by a non‐profit foundation. Forty‐four areas of the country received grants of up to $400,000 to develop EMS systems [32]. This money was intended to encourage communities to build regional EMS systems, emphasizing the overall goal of improving access to general medical care, in addition to the original focus on trauma. The money was provided over a 2‐year period to establish new demonstration projects and develop regional emergency medical communications systems [33].

In early 1974, a newly reorganized DHEW Division of Emergency Medical Services began implementing the legislative mandate. Adopted from earlier experiences, the basic principles were that an effective and comprehensive system must have resources sufficient in quality and quantity to meet a wide variety of demands, with the recognition that the discrete geographic regions established must have sufficient populations and resources to enable them to become self‐sufficient eventually.

Each state was also to designate a coordinating agency for statewide EMS efforts. Ultimately, 304 EMS regions were established nationwide. By 1979, 17 regions were fully functional and independent of federal money. However, of the 304 geographic areas, 22 had no activity and 96 were still in the planning phase [34].

In the regulations, David Boyd strictly interpreted the congressional legislative intent of the EMS Systems Act to mandate that all regions adopt all 15 essential components of the legislation. Regions were limited to five grants, and with each year of funding, progress toward more sophisticated operational levels was expected. By the end of the third year of funding, regions were expected to have basic life support (BLS) capabilities, which required no physician involvement. ALS capability, which was expected to perform traditional physician activities and have physician oversight, was expected at the end of the fifth year. The use of BLS and ALS terminology in the regulations spread widely. However, the original definitions that corresponded directly to the funded emergency medical technician‐ambulance (EMT‐A) and paramedic levels of training quickly became elusive as states created variations in the EMT‐A and paramedic levels. Nationally, the EMT‐A level required no medical involvement, but some states such as Kentucky did extend medical oversight to BLS because of insurance laws – laws making medical care and transportation across a county line virtually impossible without a physician’s approval over the radio.

Developing the geographic regions required to secure federal funding through the EMS Systems Act usually necessitated new EMS legislation at the state level. The state laws that developed throughout the 1970s varied markedly regarding the issues of medical oversight, overall operational authority, and financing. In some states, physician involvement was required. In others, medical oversight was not even mentioned in law or regulation. Often, responsibility for coordinating activities was assigned to a regional EMS council of physicians, prehospital personnel, insurance companies, and consumers who often had specific interests to protect. The level of physician input was inconsistent across the nation.