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Interview with Mr. Paul G. Rogers 
Date:  August 14, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Donald A.B. Lindberg, M.D.
Transcriber:  Techni-type Transcriptions/DDR


Lindberg:  I'm Donald Lindberg, Director of the National Library
of Medicine.  It's my privilege today to interview Mr. Paul
Rogers in connection with NLM studies of the history and
legislation of Regional Medical Programs in the United States.
     Paul, thank you so much for being with us.

Rogers:  I'm delighted to be here, Don.

Lindberg:  I know that you were, from 1955 to 1979, just about,
"Mr. Health" in the United States Congress.  Many of those years
you chaired the Subcommittee on Public Health and the
Environment.  We're here to talk about Regional Medical Program,
but many, many pieces of legislation passed under your gavel on
that committee.  The authorizing legislation and then,
ultimately, the oversight hearings are two areas that I hope
you'll permit us to talk about.

Rogers:  Surely.

Lindberg:  I'm particularly anxious to know about your view of
the ideas behind Regional Medical Programs and the reasons that
your committee and the rest of Congress created the legislation
that authorized those programs to begin.

Rogers:  You know, I suppose it really started with President
Johnson's speech to the Congress, his address, where he said he
thought we should devote more attention in this nation to heart
disease, cancer, and stroke, which at that time, I think, from
the study that was done showed about 71 percent of the deaths in
the nation were attributed to those diseases or related diseases. 
So he stated that he would appoint a commission to look into this
and make a report as to what should be done, and he did that
after making those remarks to the Congress, and appointed Mike
[Michael] DeBakey, who was then at Baylor, I think I recall.

Lindberg:  Yes.

Rogers:  Mike, of course, did a good job.  He had some really
outstanding citizens on this committee, or commission.  They did
a very rapid study and reported back to the president, who then,
of course, sent the report on up to the Congress with suggested
legislation.  Oren Harris was then Chairman of the Committee of
Interstate and Foreign Commerce.  That committee has now been
changed, as you know, to Energy and Commerce and chaired by John
Dingell.  But Oren picked up on this and, of course, it was
Lister Hill in the Senate that handled the two pieces of
legislation, one from the Senate, one from the House.  The
recommendations were put into legislative form and then the
Congress worked its will.

Lindberg:  The Congress indeed did.  In looking over the DeBakey
report, The Report of the President's Commission on Heart
Disease, Cancer, and Stroke, and its deliberations, then
comparing that with the legislation which the Congress ultimately
passed, there were a few differences.  Do you want to comment on
any of those?

Rogers:  There were some significant differences.  The DeBakey
report called for national programs in these diseases and that
facilities should be built for research, for clinical
demonstrations, and so forth.  Patients, even patient care, had
been mentioned in the report.  The idea, I think, was to take the
latest knowledge from research centers, to spread it out through
the nation, through the hospitals, through our delivery system,
and get the best knowledge out so that people could be treated
accordingly.  That was the concept of that thing.  
     Well, the AMA got very disturbed about that, quite
exercised, when they thought about centers being built, even. 
They envisioned big hospital centers, maybe, where there would be
a center of excellence for cancer, maybe one would be built for
heart diseases, one for stroke, or maybe a couple of them
together, but in region locations throughout the country.  They
thought--and it had been talked about, even--that patients then
would be directed to these centers of excellence to cure their
diseases or at least treat them.  Well, this really disturbed AMA
because they thought it was kind of the beginning of a national
health program, which they were not supportive of, of course. 
And also they could see that if a person in a community were sent
out of that community, that person's doctor had lost control.

Lindberg:  Yes.  Might never come back.

Rogers:  Might never come back.  Their whole way of operating
would have been changed.  So they very vigorously fought those
types of provisions effectively.  As I recall, AAMC was not
pleased with some of the provisions as proposed.  That's the
American Association of Medical Colleges.  So there was some
opposition there and there was opposition from others, too, but I
think the main opposition was AMA.  
     So the Congress reacted and they cut out any approval for
the building of facilities to calm down the concerns that people
were going to be sent away.  They made the program a cooperative
program, where it was not something that someone can come in and
direct.  You had to get cooperation from people in all of the
communities, the medical center, whatever.  The only patient care
that could be done was in research, in demonstration, but you
really couldn't deliver care; it had to be paid for in a
traditional way.  You could not change that.  So that first
legislation acceded, really, to the concerns of AMA in those
points.  

Lindberg:  Yes.  I recall that the DeBakey report kind of
complained that the NIH could only spend 50 percent matching
funds on facilities, and he wanted to go up to 75 percent.  Of
course, as we both know, we have zero authority right at the
moment.

Rogers:  That's right.  It was completely locked out at the
beginning.  

Lindberg:  The legislation on the RMP program did, however, keep
faith with one critical element of the heart, cancer, stroke
plan, and that was the planning on a community level, the idea
that the determination would be made on a local basis of what the
priorities were and how they would be carried through.  

Rogers:  And your advisory groups.

Lindberg:  Advisory groups, yes.  Huge numbers of advisory groups
and a whole lot of lay participation.

Rogers:  There was a tremendous amount of participation from lay
people.  Once it got going, and interestingly, I thought, those
from the medical profession who participated in the program once
it got going became its champions.  They saw the value of getting
this knowledge out and spreading it out and some of the programs
that eventually developed from the basic three diseases that were
talked about--heart, stroke, cancer--then other programs
developed.  The exercise of getting people to work together was
exceptional.

Lindberg:  Yes.  Others, both [Merlin] Duval and [Vernon E.]
Wilson, have emphasized that people met around tables together
that otherwise never, never pooled their interest in health
affairs, and this participatory function of RMP was critical.

Rogers:  I think it was.  You take the Emergency Medical Services
Program.  Regional Medical Programs got that organized in many
areas of the nation.  

Lindberg:  Kidney also.

Rogers:  Kidney.  Of course, at the last, I think it moved even
into preventive services and so forth.  But it was an effective
program and the Congress was highly supportive of it.

Lindberg:  One of the things, Paul, that people have commented on
is the question, did RMP not understand what it was supposed to
do?  Did it not have a clean focus?  Did it waffle and change
direction and so forth?  I don't know that there were any changes
in legislation exactly.  I want to ask about that.  But it did
appear that there had always been a kind of dynamic between
categorical heart, cancer, and stroke versus the general
facilitation of health care delivery and health services
research.  Did the Congress play a role in that?  Which side were
they on?

Rogers:  I think they were for broadening, as I recall.  They
thought it should be broadened, as long as we had the facilities,
and that network of people working together, we thought it should
be applied to increase health care generally, although, as we've
talked about, the first emphasis was categorical on those three
diseases.  But that began to change because they could do other
things.  Now, that became a criticism from those who did not like
the program, who said, "Oh, you've lost the purpose."  Well, we
really didn't because we were improving health care for people.

Lindberg:  Seventy percent of deaths is so close to everything
that it wouldn't take too great an extension to cover illness in
general, would it?

Rogers:  That's right.  

Lindberg:  But I think it was criticized in that respect.  I
don't want to hurry you past this point at all, but ultimately in
1973 there were a set of oversight hearings.  By then the
hearings of RMP had gathered their forces, and I guess perhaps
the new administration had taken a different view of the program. 
In any case, your committee held oversight hearings.  I wonder if
you'd tell a little bit about how that went.

Rogers:  There was a change of administration, as you may recall,
and President Nixon had come in.  We'd had [Robert H.] Finch as
secretary and then Cap [Caspar] Weinberger.  They had begun the
cutting of programs, and even the impounding of funds.  We went
through a big battle in impoundment of funds, some of which were
the Regional Medical Program that they had impounded.  So the
administration was looking for programs that they could reduce or
eliminate, and someone over there settled on Regional Medical
Program, saying that other programs had taken over sufficiently,
or the authorities were there, so that you didn't need the
Regional Medical Programs to continue.  
     I remember in the testimony, they sent John Zapp [phonetic],
who was then, as I recall, the legislative deputy assistant
secretary, the secretary for Health would not come, nor would the
secretary.  They let the messenger, who had to give the bad news
that they were cutting this program, come before the Congress,
and our committee gave him really a pretty rough time, on both
sides of the aisle.

Lindberg:  You certainly questioned him carefully.

Rogers:  Very carefully.  Both sides of the aisle.  It was not
just from one side.  So the thrust of the testimony, as I recall,
that they gave was that, for instance, comprehensive health
planning, they said, "Oh, well, this will take up some of the
slack on what's going on in planning and so forth."  I don't
think that was a legitimate position, but that was one that they
took.  There were other explanations.  But basically it got down
to the fact that they were just going to cut programs and the
budget had nothing in it, and they wanted to end the program in
1973, just phase it out.  
     Now, as I recall, we kept the program at least going another
year, but the pressures to cut the program, to cut funding, was
very heavy from the Office of Management and Budget and from the
department itself.  

Lindberg:  It is easy to understand that, and every year one
looks for money to do the business of the government.  If that
were the case, though, what role does evaluation play in this? 
We heard a lot of talk about how RMP might have been more
carefully evaluated or such programs in the future might have
evaluation built in them.  How much good would this do, actually,
once such a circumstance arises?

Rogers:  I believe we asked for their evaluation that the
department had done, and most of them were highly rated, most of
the programs.  There may have been about fourteen out of the
fifty-some that were not highly rated, but they were not too bad.

Lindberg:  Yes.

Rogers:  So that didn't have any direct relationship to the
position the department took in phasing out the program, because
they'd just rated it a few months before and said they were doing
fine.  

Lindberg:  Yes.  I think I remember an interchange in which you
were asked that question.

Rogers:  It was a political judgment that they wanted to cut the
program and, too, there had been continued pressure from some of
the people who had been against it.  When the presidency changed,
they were able to be more effective with the administration and
putting pressure on Management and Budget and the department.

Lindberg:  After RMP got going, did AMA like it, or did they
still want to see it--

Rogers:  Well, they never supported it highly.  Some of the
individuals, doctors who were actually involved in the program,
liked it and defended it before the committee, but still the
official position of AMA, I think, was always that it was not
what they wanted.  

Lindberg:  Did they actually campaign to see it ended?

Rogers:  I think there was some direct negotiations with the
department and with the administration.  So that was done, I'm
sure.

Lindberg:  One of the problems of that evaluation, as the program
had broadened to include all health care and health care delivery
and so forth, it would seem that it would inevitably take a
longer period of time before a dramatic change might occur and be
evaluated.  Isn't that so?

Rogers:  Yes, it should have been.  They impounded the funds in
order to cut the spending, you see, in 1973, and a lawsuit had to
be brought, which was brought.  The judge's decision was against
the government, saying they had no right to impound funds.  So
those funds had to be released.  So the program did continue for
another year, but here again they came back cutting no proposal
in the budget at all.

Lindberg:  Strange world.

Rogers:  Yes, it was.  

Lindberg:  I know that you, in the Congress, were looking at
these matters of public policy, not out in the sticks running
programs the way I was, but I wondered, in your visits back to
Florida, for example, or elsewhere in the country, did you see
any direct evidence yourself of Regional Medical Program
activities, or was it brought to your attention?

Rogers:  Yes, and we made some visits around, the committee.  I
was very much impressed with what they were doing.  Phil Hampton
in Florida was running a very good program, and, of course, they
were also working on computerization, getting information out,
getting statistics, all sorts of things that were helpful in
delivering care to people.  

Lindberg:  I thought so, too.

Rogers:  No question about it.

Lindberg:  In the current times there is consideration, once
again, of broad programs to improve health for the nation and so
forth, rethinking health care delivery schemes.  Is there
anything that we could learn from this RMP experience and, in
fact, the experience of the whole era in which you largely ran
health care, authorizing legislation in the Congress?  There was
quite a bit of it, a lot of it very wise, all of it well
intended, certainly, but now we're twenty-five years later.  What
have we learned from that?

Rogers:  I'm sure I haven't tried to analyze all the lessons, but
I'm sure there are a lot.  For instance, getting the DeBakey
Commission, the president getting a number of experts to come in
to propose nationally an approach in health care, I think that's
a good concept.  This was also done, as you know, in cancer.

Lindberg:  Yes.

Rogers:  Although it was appointed by the Senate.  That approach
still was used to focus attention on the public on it.  The
actual support, once this report is made, then the support has to
be built.  It's well if you can get providers involved in the
process.  In fact, that would have helped in the Regional Medical
Program if more of an effort, I think, had been used to bring in
the provider community more.  As we start talking about changes
now in health, I think that will be one of the key issues.  I
think you'll find now we have changes from those days, the
Regional Medical Program, when people are probably more
knowledgeable about what's happening because of the communication
improvement.  So that on TV we know, right off, what is
happening.  
     But you take the exchange of medical knowledge from the
research center to the hospitals, that need still exists.

Lindberg:  It certainly does.

Rogers:  Still exists.  Of course, the Library [National Library
of Medicine] performs a great function there.  But that needs to
be built more, and we need a persistent effort there.  
     Then to get treatment to people, access, that problem has
now been accentuated, where we have 37, 40 million people that
really don't have adequate access to the system.  That and the
cost factor, where costs have run up so much, of course, is going
to trigger real attention, not just from providers, as such, or
consumers, as such, but those intermediate bodies of industry, of
labor unions, and of organized consumer groups.

Lindberg:  Were labor or the corporations involved at all in the
RMP days?  I think they were not.

Rogers:  They really were not.  Now they are.

Lindberg:  Might that have saved the program?

Rogers:  It could have.  For instance, jumping to another
example, one reason why I think your cost containment program for
Medicare passed was because of industry.

Lindberg:  Oh, sure.

Rogers:  Getting so concerned that costs were getting out of
hand, and labor.  So once they got behind that move, it was
passed, as you recall.  Now you're finding today that those
groups are now interested enough again to speak out on access to
cost.  I think we will see new health programs adopted in the
nation.  It may take a little while, but it's not going to take
too much longer now, maybe after a presidential election.  

Lindberg:  I'm impressed that the priorities seem to be very
similar to RMP days, access to good care, wanting your health
care provider to be up to date in information.  There's a
disadvantaged population which are minorities and rural, same as
they were back in 1964.

Rogers:  I think the principles are there in that we have spent
federal dollars for research to find answers.  Everyone in the
RMP program, people felt that should be applied.  We paid for it,
we've got the knowledge; it ought to be used.  People still feel
that, and I think we helped educate people on that through the
RMP programs, so they know that this knowledge where we've been
spending money to find answers ought to be used and ought to be
applied, and people ought to have access.  
     The additional steps that are changing now are that they are
now willing to consider the government even providing a mechanism
to actually give that to people, where they weren't willing to do
that in the RMP program, other than on a little demonstration
basis.  So there was resistance then, and maybe that's one reason
they were able to destroy the program, in effect, because the
constituency of consumers had not been built as it will be in
these new programs.

Lindberg:  I remember some years back one candidate for the
presidency asked the country, "Are things better now or are they
worse?"  In the case of health care and health care availability,
they're better in that we know so much more and can do so much
more than we could in 1964, but what would you say about are they
better in terms of access?

Rogers:  Because of tremendous increase in cost, that affects
access, of course.  That's the big problem we're having to deal
with, and that's the most difficult problem to solve right now,
is how do we pay for it.  That is the problem that hangs up
everybody right now in proposing solutions for access, quality,
and general care.  

Lindberg:  What do you think the people want?  It's the skill of
the successful and professional and skilled politicians, such as
yourself, to know what the people want.  What do they want now?

Rogers:  I think there is building--and very significantly--a
demand for some cost controls in the health care system because
it's just grown so dramatically.  Cost controls.  I think people
generally are supportive of doing something on access and I think
they generally demand, and will continue to demand, quality.  So
I think that the whole effort to make changes in our health care
system is being supported more and more.  I think it's growing
very rapidly, and I think you will see significant changes in the
delivery of health care service in this country probably after
the next presidential election.

Lindberg:  Paul, you've been very kind in the past, and we
appreciate you taking the time to do this interview.  I must say
I'm proud that you were in the Congress.  Thank you so much.  

Rogers:  Thank you.  I've enjoyed working with you.

[End of interview]