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Interview with Dr. Roger O. Egeberg
Date:  July 30, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Diane Rehm
Transcriber:  Techni-type Transcriptions/DDR



Rehm:  The interview you are about to see is one of a series
designed to record and document the history of Regional Medical
Programs.  With me is Dr. Roger Egeberg, Senior Scholar in
Residence at the Institute of Medicine of the National Academy of
Sciences.  Dr. Egeberg served as Assistant Secretary for Health
from 1969 to 1971 and then as Special Assistant to the Secretary
of HEW and Consultant to the President on Health Affairs until
1977.
     Dr. Egeberg, it is such a pleasure to have you here.

Egeberg:  Thank you.  It's a delight to be here with you.

Rehm:  Dr. Egeberg, please tell us first about the RMPs, what
they were designed to do and what the thinking behind them was.

Egeberg:  Part of this will have to be information I got two or
three years after I was involved, but I think I should start with
the atmosphere in the whole health program.  For one thing, those
in practice were worried about socialized medicine and afraid
that the government might try to do that to them.  The hospitals
were a little bit weary of the government interfering with their
business and with the medical schools, which many of them didn't
quite trust.  Medical schools may have looked down on some of the
hospitals, but I don't think so.  Certainly I didn't feel that in
our school.  But many of the people in practice already were
running down their own medical schools, the ones they'd graduated
from.  So there was a general feeling of distrust practically
going to the stage of paranoia in some instances.
     Let me give you an instance.  I became Chief of Medicine and
then head of the hospital, of the V.A. Hospital in Los Angeles, a
2,000-bed hospital.  I thought perhaps since we were next to the
biggest, I ought to get a license in California.  So after I'd
gone through the preliminaries, I had to interview somebody.  He
was very nice and he talked to me like this, and he was so glad I
was coming to town, and he welcomed me.  He said, "By the way,
where are you going to practice?"
     I said, "Well, I'm in the Veterans Administration."
     "Oh.  That horrible thing?  Thanks."  And that was the end
of the interview.  That was an expressed one, but you could feel
it all the time.
     So some of that must have reached Washington.  Also the cost
of health care in relation to the gross national product was
going up.  I think it was down around 4.5 percent then and it's
up around 12, 15, 17 [percent] now.  Under [Lyndon B.] Johnson,
they got enough worried so that President Johnson appointed a
commission to study the delivery of health care.  How could they
see that everybody was taken care of?  That problem was existing
already at that time.  How could they see that the people who
were practicing farthest away from medical teaching institutions
could be brought up to date?  How could they see that there was
more cooperation between the various facets of medicine?  
     So he appointed a commission and he made Dr. [Michael]
DeBakey the head of it.  Of course, it became the DeBakey
Commission.  They had about thirty-five recommendations.  One of
them was that they felt that medicine might be practiced
differently in different parts of this country, and they felt
that it might not be so good to have one system or one pattern of
paying, let's say, for the whole country.  Also they thought they
might get some good ideas if they could regionalize it.  So they
decided to have a problem--or they recommended that there be a
program, a regional program of raising the level of medicine and
doing those things that I just mentioned to you.
     Well, that came out and met with great distrust and
opposition by the whole medical profession, by hospitals,
everybody.  Then it hit Congress, and Congress wanted to do
something about it right away.  This was in 1965.  They pretty
much did what the spirit of the recommendations came across with,
but then they began to hear from people out in the sticks, and
they inserted some things which I think were very wise: "This is
not to disturb the present method of the practice of medicine and
it's not to disturb the present relationship between doctors and
hospitals." And they reassured those two pretty well organized
components.
     Again that background, in 1966 the program was started,
Public Law 239 ___, and one of the first people involved in it
was Dr. [Robert Q.] Marston, who later became the Director of the
National Institutes of Health, and Dr. Stewart, who later became
Surgeon General.  Marston went out to peddle what they had to
offer.  They didn't want to have too many regulations.  They
really wanted to leave it quite open to the regions to solve this
problem.  But with Congress' additional things that they imposed
in the law, they were helped very much.

Rehm:  Let me ask you, if I may, were the regions equally divided
around the country?  How were those regions shaped and formed? 
Did that have to do with population?  Was it an arbitrary
decision?  How were those decisions made?

Egeberg:  At the time I thought it was a natural one, because we
grew until we had enough in California so we made it the
California region.  But there were some smaller states where they
didn't really want to specify.  They thought maybe the regions
would sort of take care of themselves.  In a sense I think they
had a good feeling there.  You asked them, "Well, how are you
going to do it?"  They would say, "Well, that's up to you."  I
think some of the regions had to be helped where two or three
states had to be brought together, because California, even at
that time, had somewhere around 11, 12 million people.

Rehm:  In California, then, and with your own involvement, how
did it work?

Egeberg:  I was invited--I don't know how many others--to hear
Dr. Marston speak about this new program.  Washington could have
been in Siberia, as far as my thinking was concerned.  I'm sorry
to sound that ignorant, but I was paying no attention to
Washington.

Rehm:  Focused completely and entirely on California.

Egeberg:  On my job and the local scene.  As a matter of fact, I
had just become a dean, and I was a dean from across the tracks,
because I had not come up the academic ladder.  I'd come up more
of another ladder and put in.  
     Well, I came back feeling that this sounded like a good
idea, particularly since our school, which was right near the
Mexican part of Los Angeles, felt closely related to its
community.  We thought this could help.  The idea, as far as they
went, was that medical schools, or centers of learning, which
might be a cluster of hospitals, should reach out and associate
with other areas where they could help see to it that the level
of the practice of medicine was up to what it was near the
medical school, and that they should also see that the doctors in
that area, whether connected with a hospital or not, were also,
as you couldn't help thinking, brought up.  Because at that time
there were still quite a few doctors practicing who had graduated
in medical schools which had long since become extinct because
they didn't rate.  So there was a worry about the level of health
care.  
     But I thought this was a good idea.  The university was
conservative about it, this faculty was, but the executive
committee, after I explained it to them, came along.  So we were
the first people in California to join.  There still was
hostility, but Congress had done something terribly important:
they had included the medical profession and the hospitals right
in the law.  So some of the first money to come didn't come to a
medical school; it went to the California Medical Association. 
Wasn't that bright?  And next to the California Hospital.  And
they became part of the program.  They saw that we didn't have
horns or tails, and we started to work together pleasantly.
     Gradually--and I think this is the place to tell it--aside
from the medical and the hospital organizations, we had the
Schools of Public Health brought in, we had the Cancer Society,
that branch of the Cancer Society brought in, the Heart
Association, and one or two others.  Then we had nineteen members
and eight members who were considered consumer representatives
were put on.  So we had a pretty good mix.

Rehm:  What was your own function?  How did you work within this
group?

Egeberg:  I was interested in starting it, so I picked a hospital
that I knew was good and was pretty far away, and I thought,
"That's really reaching out."  We went to Bakersfield and talked
with the Kern [phonetic] County General Hospital, which was a
very good one, and after a few conversations they thought it was
a good idea and we said, "Let's try it."  So we began with them. 
We started first with the concept that had sort of been given to
us, which was bring the people in and give them some quick
postgraduate education, or continuing education, on some subject,
and then let them go back to their hospital and talk about it. 
Well, that was a lemon and it didn't take us long to see that.

Rehm:  Why didn't that work?

Egeberg:  Well, it wasn't theirs.  This guy gave a couple of
speeches and they weren't interested anymore.  

Rehm:  And somehow you were imposing that, but it was not
something that they were interested in taking back.

Egeberg:  So we thought--and I have a feeling I may have been the
one who thought about it--"Why don't we do it in their place?" 
So we decided to create teaching clinics in the hospitals which
we were going to work with, and if we could get a clinic going on
any subject--now, remember (I didn't bring it out), this was to
be cancer, heart disease, and stroke and allied things.  That's
what it really came out as.  That was the program.

Rehm:  Dr. Egeberg, was it to be primarily a teaching tool, a
teaching vehicle, or was there supposed to be a certain element
of care, health care, involved in that whole program?

Egeberg:  It was supposed to involve health care to the extent
that we made the doctors, we thought, better able to give that
health care.

Rehm:  Through education.

Egeberg:  Yes, but it specifically said that we should not,
through this law, get any money for the care of patients.  That
was definitely in there.  So the idea was to raise the level of
practice of the physicians of that area.  We got one started at
Bakersfield and later in some other hospitals, and we said, "You
may not need us, but if you want some special information on a
subject, fine."  Well, later we got a little more money and we
put a man in the hospital who would know what they were
interested in and perhaps get three or four patients in a certain
diagnostic area, and then ask us out to discuss that.  
     Suddenly, that took, and attending men of the hospital began
to like it.  They were very suspicious at first.  But when they
liked it, then other hospitals wanted to come in.  From trying to
recruit hospitals, we quickly went to looking over the
credentials of a hospital which we might accept.  
     My involvement was that about two or three months after us,
I think it was, the University of California at Los Angeles went
in, and then the University of California up in San Francisco--
their medical school is there--came in.  
     Then it was decided--and I can't remember who decided that--
that we would have a state association, so it was called the
California Committee on Regional Medical Programs.  I became the
first head of that.  In fact, I was head of that until I came to
Washington.  
     Once we got talking together--and I remember all these
groups that I've mentioned (and I won't mention them again), but
there were so many facets of medicine who were suspicious of each
other, who didn't like to talk to each other, and here we had
them all meeting and settling things the way we hoped they might
settle things in the Middle East.

Rehm:  It also sounds as though your group was rather doing
pioneer work in trying to find the best way to reach the various
doctors and to reach out to them.

Egeberg:  We thought we were, but each of us really had the
opportunity.  According to the law, each of us had the
opportunity to do pioneer work, so one might come out with a
solution that was different from another one.

Rehm:  And which was more appropriate to your region than might
have been appropriate to another.

Egeberg:  That's right.  Yes.  That was one of the nice things
about it.  It was more fluid than many things that come from
Washington.  I've got to tell you one story about that.  I've
always hated initials.  I can get U.S.A. and C.C.C., R.M.P.

Rehm:  And a few others, perhaps.

Egeberg:  And what's the income tax one?

Rehm:  I.R.S.

Egeberg:  I.R.S.  But otherwise, initials get me.  Well, one day
at one of these meetings somebody said, "I think the C.C.R.M.P.
should do this."  And then somebody said, "No, they shouldn't be
doing that.  They should be doing this."  A little bit later,
another one said C.C.R.M.P., and I hit the table and I said,
"Goddamn it, why do you have to use initials?  What is
C.C.R.M.P?"  And Paul Ward, who was the executive director,
nudged me and he said, "Roger, that is the California Committee
on Regional Medical Programs, which you have been chairing for
the last two years."  Well, it took me a while to explain that
away.
     I was director for two years, and I was trying to figure out
what our problems were.  I couldn't think of them all, but they
were, first, communication, and not communication with the other
people in medicine, but communication with the people outside of
medicine, to let them know what this was, and then communication,
of course, with the whole gamut of the people in the health
professions.

Rehm:  Help me to understand how you carried out that
communication with people outside medicine.  

Egeberg:  For one thing, the California Medical Association
stepped right up and created a number of brochures telling what
we were.  Now, if they hadn't brought them in at the beginning,
do you think they would have done anything like that?  

Rehm:  How were they distributed?  

Egeberg:  In various doctors' offices and also as widely as they
could, and we helped them distribute them.  They were good
brochures explaining what we hoped to do and how.

Rehm:  How were individual medical users invited to make use of
your services?

Egeberg:  I don't know that they could, except they were told
what hospitals were part of the group.  There were some that we
left out.

Rehm:  Was it implied to those health care users that these RMPs,
or the hospitals engaging in the association, could somehow
improve care for these individuals?

Egeberg:  Yes, it was implied, or it was told quite nicely that
through this mechanism, the doctors in the far-off areas would be
kept up and kept abreast of the most recent advances in science,
and science was jumping ahead right then.  So the promise was
there that they'd be up to date, even if they were far away.

Rehm:  Dr. Egeberg, what do you believe were the most significant
accomplishments of the RMPs?

Egeberg:  I think the most significant accomplishments, aside
from the fact that I'm sure we improved the health care--though
you couldn't measure it by deaths and so forth; you'd have to go
a generation or two for that--were the fact that we had gotten
all of those organizations who were suspicious of each other to
sit down at the same table, talk over the same business, come to
compromises, make decisions, in a friendly fashion, because we
knew each other.  

Rehm:  The RMPs were in effect from 1966 until 1976 or
thereabouts, isn't that right?

Egeberg:  Thereabouts.  

Rehm:  Did that collegiality endure for that entire decade?

Egeberg:  It endured for some time after I left California, after
which I wasn't so sure what was going on.  I had other worries. 
But it's a very important thing for people to work together and
talk about it.  It happens internationally.

Rehm:  And to trust one another.  

Egeberg:  We were on the track of creating something that was
important to whatever next steps we wanted in the delivery of
health care.  

Rehm:  As you think back, then, the question of just why the RMPs
failed is one that comes to mind for me, and I'm sure you thought
about it a lot, too.  

Egeberg:  You use the word "failed."  I think they were
assassinated.  Now, you can kill people by ripping them open, you
can kill them by a bop on the head, or you can kill them by
choking.  Well, they first tried to kill them by choking.  This
was from way up above.  I think it began with Caspar Weinberger,
who had a feeling that Regional Medical Programs was just another
program that was going to drain money out of the Treasury and it
would be better to cancel them all and come out with a big
program, which I think medicine became worried about, might be
socialized medicine or health insurance for all.
     Well, I think that Caspar Weinberger sort of worked up a
particular antipathy to this because it was so hard to kill it. 
He tried to choke it by taking the funds and impounding the funds
in the middle of the year, saying, "You can't spend any more
money.  Save it till the next year," and then using that for the
next year instead of giving them any new money.  That's choking
them.  That's cutting down their funds.  You could hit them in
the head by a fiat, saying that they no longer exist.

Rehm:  Caspar Weinberger was then Secretary of HEW?

Egeberg:  Not quite.  No, he was head of OMB [Office of
Management and Budget], and OMB was where this came from.  OMB,
of course, was interested in the money end of it.  He looked at
it pretty much from that point of view.  He thought it was not
efficient, and I don't think he ever perhaps got exposed to the
good things that came out of it.

Rehm:  As Secretary of HEW, however, he did--

Egeberg:  Oh, yes, when he became secretary--

Rehm:  That was the end.

Egeberg:  That was the end.  

Rehm:  He wrote that, in fact, the RMPs had never clearly defined
themselves, that they had not found a clear role, that they had
tried to do too much, and that they had bitten off more than they
could chew and did not do it well.

Egeberg:  Yes.  Well, I don't like to be on the defensive, but we
were told that we each had the opportunity to try to solve the
problems that we saw.  Well, it was defined in the broad sense. 
He wanted to see it defined that we would see that everybody with
cancer got cured or killed or something in a certain amount of
time.
     Now, I am very fond of Caspar Weinberger, and I want to say
that.  I worked under him.  I liked him.  He's a modest person,
and I traveled through Russia and Poland with him, and he is
modest inside.  But his opinions sometimes aren't exactly like
mine.  This one, I think he had a sincere feeling that to get rid
of us was a good idea, and he tried many different ways.  

Rehm:  Was there an insufficient amount of political support,
then, for the RMPs so that when Caspar Weinberger wanted to see
them go, they went?

Egeberg:  Well, I'll tell you.  Several tricks were pulled, I
think.  Congress at one time, when they saw what was happening,
said, "No, no.  You follow what we said."  And finally they took
the matter to court and sued.  All the regional programs took--I
don't know who they would have taken to court, but maybe it was
Caspar Weinberger--anyhow, the department--and sued.  They won
the suit, and the judge made the department pay them.  I think it
was around $200 million that they'd been holding back. 

Rehm:  That money was then distributed to the RMPs.

Egeberg:  That was distributed, yes.  First they tried to stop
it, but I was in the executive committee for Eliot Richardson and
I brought in a man named Vern Wilson from Missouri, who was head
of HSMHA.  The RMPs came under HSMHA.  So he and I fought, he at
his level, because they came under him, I as best I could in the
executive committees of the HEW, tried to explain.  And I think I
sold Richardson on what we were gaining from this.

Rehm:  But apparently not sufficiently.

Egeberg:  Not sufficiently enough.  I think we postponed the
death by a couple of years.

Rehm:  What about the role of the AMA, Dr. Egeberg?  Could the
AMA have played a stronger supportive role in the RMPs?

Egeberg:  I suppose they could have, yes, but I think there were
many of them in our state that came along with us, as I told you. 
They really were working shoulder to shoulder with us.  There may
have been places where they didn't quite trust us or the people
who had the votes didn't.  I think the AMA expressed approval of
us, definitely, but I don't think they went to the floor and
considered it one of the things they'd fight for.

Rehm:  That was my question.  Since the AMA today would seem to
have so much political clout, one wonders, looking back then,
whether they could have exercised a greater amount of political
clout and seen to it that the RMPs continued.  

Egeberg:  I don't know.  That was out of my realm, and I don't
know whether they could have.  There were many people still in
favor in Congress.  What happened was this.  First they choked
them by postponing the use of the money.  Then they gutted them
by filling them full of a lot of other organizations, all these
little ones that Weinberger thought should be killed.  Then they
said, "We'll move all of these out," and they took heart disease,
cancer, and stroke.  Kidney disease they left in.  They removed
them from this and just let them die.  So they'd removed the
guts.

Rehm:  If the RMPs were re-established today, do you think that
they would have a valuable role to play in medicine, considering
the state in which we find medicine today?

Egeberg:  I've been thinking about that, and been thinking what
my feelings would be about the future.  I think that if they were
brought back, appropriately nurtured, and not given too much
money (I don't think it would be a very expensive program) that
they would help the basic problem we have now, and that is of
getting all these people--hospitals, practitioners, the societies
and so forth and their organizations--talking together.  It seems
to me that if you can get people talking together, you've made a
big step towards solving a problem.

Rehm:  So from your point of view, there would be some usefulness
for them even today.

Egeberg:  I think so, if the spirit that we felt was there could
be brought back.  I don't know why it couldn't.  

Rehm:  Is there anything else you'd like to add before we close?

Egeberg:  That was it.  

Rehm:  That was it?

Egeberg:  What would I suggest?  I thought I just suggested that
they bring them back.  

Rehm:  So you really feel that that was an idea that had true
value and that could be adapted for use today.

Egeberg:  Yes.  Maybe you could create something else that would
do it, but I felt that it was bringing together the people who
had been at loggerheads and making them work together and finding
they liked each other.  That's a terribly important thing.

Rehm:  Is there anything else you'd like to add before we close
this?

Egeberg:  No.  I'm just grateful for having had the opportunity
of expressing myself this way.

Rehm:  I'm delighted that you did.  Thank you so much for being
with us, Dr. Egeberg.

Egeberg:  Thank you very much.

Rehm:  I'm Diane Rehm from the National Library of Medicine.

[End of interview]