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Interview with Karl Yordy
Date:  September 4, 1991
Interviewer:  Storm Whaley
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Yordy:  The program you are about to see is one in a series of
interviews documenting the history of the Regional Medical
Programs.  Our guest today is Karl Yordy of the Institute of
Medicine, who was Deputy Director of the Division of Regional
Medical Programs when it was at NIH [National Institutes of
Health].  
     Karl, it's good to see you.  Were you involved in the
Regional Medical Program beginnings?  Were you there at the
creation?

Yordy:  Yes.  My beginning involvement was right after the
DeBakey Commission report, The Report of the President's
Commission on Heart Disease, Cancer and Stroke, was issued,
which, as you may recall, was right after the landslide election
of Lyndon Johnson in 1964.  As was true of Lyndon Johnson's style
and all the things that had to do with Great Society, things
happened very rapidly.  A decision was made very quickly that
there would be legislation introduced to implement the DeBakey
Commission report.  
     I was the head of the Office of Legislation in the Office of
the Director at NIH at the time, and since it was assumed that
NIH would probably have some involvement in the program, Dr.
Stewart Sessems [phonetic], who was the Deputy Director of NIH,
and myself were assigned by Dr. [James] Shannon, the Director of
NIH, to sort of follow the development of this legislation.  So
we sat in on all of the sessions when the nature of the
legislation was discussed, looked at the drafts and reviewed the
drafts, and then stayed with that all through the process of the
hearings in the Senate and in the House and the final passage of
the legislation.  

Whaley:  Karl, wasn't there some variation between the DeBakey
report and the legislation?

Yordy:  Yes.  I think that some of that variation was inevitable. 
I think it took some particular paths.  The DeBakey Commission
report contained thirty-five recommendations.  The thirty-five
recommendations were quite disparate, and I once actually asked
Dr. DeBakey, "How can you make a logical continuum out of all
these recommendations?  They don't seem to fit together."
     He said, "We had a number of subgroups on the commission,
and the subgroups all went and developed their own
recommendations, and in the end we put them all together and put
them in the package."
     So each, in and of itself, made logical sense.  Taken as a
group, it was clear that they didn't quite fit together, so some
kind of transformation was necessary.  It is key, I think, that
the transformation was actually done under the guidance of Dr.
Dempsey, who had been a member of the commission, chairman of one
of the panels on the commission, and Dr. Dempsey, meanwhile, had
become the Special Assistant the Secretary of HEW for Health and
Medical Affairs.  So Dr. Dempsey was the person who, in a sense,
stayed behind to actually supervise the writing of the
legislation.  So the actual legislation that emerged from the
administration, the bills introduced in the House and the Senate,
bore fairly heavy imprint of Dr. Dempsey's view of what he
thought was most important out of the DeBakey Commission report.

Whaley:  Do I remember correctly that there was a kind of neck-
and-neck race with Comprehensive Health Planning at about that
time?  

Yordy:  No.  That actually emerged a little later and is an
interesting story in and of itself.  The legislation had actually
passed, or was about to pass, in October of '65, when the then
surgeon general, who had just been appointed surgeon general, Dr.
William Stewart, sent forward through the departmental channels
and to the Bureau of the Budget a recommendation for new
legislation which was eventually what became Comprehensive Health
Planning.  That came, therefore, right after RMP.  RMP was in
place as a piece of legislation, as a final enacted law, when the
first ideas for CHP were actually put forward in a formal way.
     The other interesting thing is that Dr. Stewart, prior to
becoming surgeon general in October of 1965, had, prior to that,
been slated to be the Director of Regional Medical Programs.  At
that time he was Director of the Heart Institute.  But right
before that, he had been Dr. Dempsey's assistant down in the
office of the secretary.  So he had participated in the drafting
of the RMP legislation.  So the development of CHP under Dr.
Stewart's leadership actually was being done by an individual who
had been very much involved in the development of RMP.  
     I got a call from a good friend of mine at the Bureau of the
Budget right after that legislation was submitted by the
department, and he called and said, "Karl, can you explain to me
the relationship between this new legislation that's being
proposed and legislation that just passed--Regional Medical
Program?"  
     My answer, which was the honest answer, was, no, I could
not.  Because I don't think at that point there was, in fact, an
articulated view of what the relationship was between the two.

Whaley:  What was the ostensible purpose of Regional Medical
Programs?

Yordy:  Regional Medical Programs, I think was primarily based on
the concept of a natural extension of the successful development
by medical enterprise in this country, as epitomized by NIH and
the very rapid growth of NIH in the previous ten to fifteen
years.  The notion, I think, of some of the people that thought
up the President's Commission on Heart Disease, Cancer and
Stroke, people like Mary Lasker and Michael DeBakey, Sidney
Farber, and people like that, was that they needed to be
concerned about how the benefits of this great growth of medical
knowledge would, in fact, get out to the people of the country. 
Mary Lasker, as you know, has an advertising background, and she
was always very, very perceptive about what the nation as a whole
would respond to.  I think she perceived that if the research
enterprise was seen as too elitist, as too separated from the
benefits to the people, that would be a limiting factor on the
growth of medical research.  So I think that was the primary
push, that we needed some kind of effort that would, as the
phrase was used at the time, take the benefits of research out to
the bedside.  
     The other theme that came in, in the commission from some of
the people involved in the commission, people like Bill Kissick
[phonetic] on the staff, was the notion that you needed to have
more organization to the arrangements for medical care in the
United States.  They drew on the history of regionalization as a
concept in medical care, going back to the Dawson Report in
England in 1920 and the original underpinnings of the Hill-Burton
legislation in this country in 1946.  So there was this notion of
how you bring the benefits of research and the advances in
medicine out to the country and then the accompanying sense of
how you achieve a better organization of medical care in
accomplishing that.  

Whaley:  There has been a good deal of discussion about assisting
medical schools in that period.  Did this precede the overt
support of medical schools, or did it follow?

Yordy:  It came right after.  The log jam on support of federal
involvement in support of medical education had occurred a couple
of years before, the breaking of that log jam.  This was, by
almost all dimensions, an expansionist period of public policy in
matters relating to medicine and medical care.  You had the
development of biomedical research at NIH; you had then the
intent to expand the supply of physicians; overt federal actions
taken to support medical education and expand the supply of
physicians; you had, of course, the Hill-Burton Program, which
had been around for a somewhat longer time, expanding the supply
of hospitals; you had programs like Regional Medical Programs
expanding the transmission of knowledge into better practice; you
had the expansion of programs for the poor; expansion of federal
financing for medical care in general.  After all, Medicare and
Medicaid had passed in the same year as Regional Medical
Programs.  A very expansionist period.  
     There was a lot of expansion in medical education, some of
it stimulated at the grass roots level.  Lubbock, Texas, wanted a
new medical school, and so forth and so on.  Some of it is simply
a response of the medical education enterprise in the country,
very explicit public policy incentives and pressures to expand. 
So Regional Medical Programs came into being in this very
expansionist setting.

Whaley:  Did the RMP have the cooperation of organized medicine?

Yordy:  The history of organized medicine's relationship with RMP
is a very complex one.  I think that because of its move so
quickly following the release of the DeBakey Commission report,
which organized medicine did not like--by the way, a tactical
thing that was done by the DeBakey Commission was to send a copy
of the report to every practicing physician in the United States. 
They mailed a copy of the report to every practicing physician in
the U.S.  So every practicing physician sitting out there,
practicing, got a copy of this report in the mail.  He mostly
looked at it, and from the reactions that we heard from some of
them, the reasons were, "My God!  Dr. DeBakey is going to set up
some kind of specialized capabilities around the country that is
going to divert patients away from us."  One person used the
phrase, "It's going to be like a VA Medical Center at every
street corner."  
     So there was a lot of inherent anxiety about the notions of
a federally supported program which was going to do something
about the organization of medical care and would be linked to
academic medical centers and to the great centers of medical
excellence like Sloan-Kettering and so forth, and that wasn't a
very friendly thought to the average practicing physician.
     Secondly, this came along at precisely the same time as the
passage of Medicare and Medicaid, which, as you know, organized
medicine had strongly opposed, and they viewed that as a great
defeat.  Right after Medicare and Medicaid passed, the leadership
of AMA came to the secretary and said, "We may have a rebellion
on our hands on the part of the physicians of the country if you
strike us with this second blow after Medicare and Medicaid.  So
could you please do something to put off this other blow?"  
     Secretary Gardner said, "Of course, I could not do that if I
wanted to, which I don't, but I'll refer you on to the
president."  
     There was then a meeting with Lyndon Johnson.  As I
understand, Lyndon Johnson used some fairly firm words in what he
thought of the tactics of organized medicine at that point.  So
what was worked out was sort of a face-saving compromise, which
was that there were some changes in the legislation as it went
its way through Congress, some of which probably would have
happened anyway, but which the AMA then could claim credit for,
like the addition of the requirement of practicing physician and
the regional advisory committees, so that the AMA could go back
to its membership and say, "We still don't much like this, but
it's been improved through our efforts."  

Whaley:  Was LBJ very interested in RMP directly?

Yordy:  He was interested in the sense that he clearly saw this
as a piece of his rather grand strategy, is what is described as
the Great Society.  The extent to which he had any intimate
knowledge or interest, my sense is he didn't have a very strong
one.  He, of course, knew Dr. DeBakey and it didn't hurt that
there was a Texas connection there.  But he, I don't think, ever
paid a lot of detailed attention to this.  He was an expansionist
type of person, and to the extent that this was involved in that
general thrust, he was in favor of it.  Of course, it was his
great legislative powers which he had developed while he was
Majority Leader of the Senate, that made it so possible to get so
much legislation through the Congress in such a short time.

Whaley:  The RMP had a lot to do with medical schools.  They were
at the center of each of the regions.  Did it have an effect on
the medical schools in the long run?

Yordy:  I think it did, although I think some of that kind of
effect is still being played out all these many years later. 
Medical schools, like most other human institutions, are somewhat
opportunistic, and I think many of them looked at this new
program coming along and some of them had some anxieties about
it, but they said, "Well, there is going to be some money
provided and it's going to enable us to do some things.  We
certainly want to make sure we're involved."  So we succeeded, I
think, in getting essentially all the medical schools in the
country involved in one way or another in the program.  
     The naturalness to which they took to that involvement
varied a lot from school to school in ways that you might
anticipate.  Schools that had strong traditions of reaching out
to the community and really viewed themselves as playing a role
with the broader community found this new role rather comfortable
and found it, in fact, one that was able to facilitate a lot of
the things which they'd been thinking about anyway.  I'm thinking
here of schools like the University of Washington in Seattle, the
University of Missouri, universities that often were state
universities and had a tradition of reaching out.  The more
elite, private medical schools, I think, had a harder time sort
of figuring out how this fit into their own sense of their
mission and role. 
     I think in terms of permanent effect, medical schools are
very complex places and they have a lot of different perspectives
and people with all sorts of different ideas, and what RMP did, I
think, was become a facilitating device for those people and
forces within medical schools that wanted to think about how the
Academic Medical Center and its capabilities could, in fact,
relate more to the broader community.  I think many people got
involved in RMP who were people who, in a sense, have kept up
that sort of reform mission for medical schools and medical
education in this country.  It's not accidental, I think, that
some of the people who were very active in the early days of RMP
were people who were also very active in the effort to sort of
reform and rejuvenate the Association of American Medical
Colleges, the [unclear] report, which came out right before RMP. 
Bob [Robert Q.] Marston and John Hoagness [phonetic] and many
others were people who were involved in that movement, were
people who were also very involved in RMP.  

Whaley:  Many different projects were asked for in connection
with each of these big applications that were made, several
million dollars, some of them.  Do you remember any of them?

Yordy:  Yes.  Of course, there were some themes in that, some of
which had disturbed some people.  One of the themes was
continuing medical education activities.  Obviously continuing
medical education fell rather naturally into the kind of mission
that was seen for RMP.  So many--in fact, most, I think--
applications had some elements that expanded continuing medical
education.  
     One of the things that occurred through RMP, to talk about
lasting effects, was that it did focus some additional attention
on the question of just how effective is continuing medical
education and how can it be made more effective.  We actually
organized some activities that got some of the best people in the
country who were interested in evaluating effects of educational
activities involved through RMP in thinking how that could be
made more effective.  That's a continuing issue, of course, in
all educational programs.  But that was clearly one theme.  There
were many ideas and many activities that were supported by RMP.
     Another was, of course, the question of the introduction of
new technology, especially the introduction of new technology
that was in some way or other reaching out to the community.  We
facilitated some things that were starting to happen anyway.  I
think the move toward intensive care units for cardiovascular
care was facilitated many places by RMP.  You could get arguments
about whether that was a good thing and cost effective in the
long run, but it was certainly something that has now become a
permanent part of the capacity--sort of an expected capacity--of
medical care.  But then some things were more creative beyond
that.  
     There was an effort, for instance, out of the Missouri RMP,
one of the first operational RMPs, that set up a communication
link between a group of physicians, cardiologists, in
Springfield, Missouri, and the medical center in Columbia, that
would permit the remote reading of EKGs, a capacity that's now
routine in medical care.  So there were those kinds of
facilitations.  
     There were also things that were done which are a little
more peripheral in some sense, but I think were really quite
basic.  In recent years in medical care policy, there's been a
lot of attention given to small area variations in medical care. 
Interestingly enough, the original work that led to all of that
was done by Dr. Jack Windberg [phonetic] in the Vermont RMP.  The
whole development of that form of analysis, of better
understanding the patterns of medical care, was done actually
through RMP.  
     So there's quite a variety of kinds of things that were
stimulated by it.

Whaley:  RMP then was in a position to respond to an application
for a project, say, for a care unit?

Yordy:  What we did in the early days--and this, I think, was Dr.
Marston's (the original director) vision of RMP--was to think of
it as a learning model.  That is, rather than specify with great
detail exactly how an RMP was going to function and what it would
look like and what its activities would be, we were looking to
the creativity of the country out there to develop its ideas,
with the notion that you then, over time, would see what worked
and what was more effective.  There would be an exchange of
information among RMPs, and the characteristics of RMPs, in a
sense, emerged from the grass roots.  So it was a kind of
learning model.  
     I think one of the somewhat naive ideas we had at that point
was that we really thought we had the time for such a learning
model.  We actually said it in a speech once that we thought that
the full evolution of this would take twenty-five years.  But we
were very open to all sorts of ideas, as long as they went
through a review process which looked at these ideas and saw that
they were consistent with not only the specifics of the basic
framework set up in the legislation, but with the general intent
of the program.  

Whaley:  The RMP moved in '68 from the NIH.  What were the
circumstances that led to that?  

Yordy:  There were several.  One is that Dr. Shannon, in his
remarkable leadership of NIH, had, in fact, been taking a number
of steps over the years to see to it that NIH did have its
primary focus on the research mission.  That meant that service
programs, which in various ways had sprung up in the NIH context,
in some other examples had moved out of NIH to other parts of the
Public Health Service.  Therefore, it was always seen, from the
very beginning, that it might be logical for RMP to move out of
NIH into a service-oriented environment after the program was
started.  The interest in making sure that it started at NIH,
which was pretty strong at NIH, was that it wanted to make sure
that, in a sense, it got off on the right foot.  It also wanted
to make sure that the relationships with the medical schools were
well established.  The main channels in the Public Health Service
at that time were bureaus that dealt primarily through the states
on public health activities.  NIH was dealing primarily with the
medical schools.  Since this was seen as primarily dealing with
the medical schools as the sort of center or key component of the
organization, it was seen that NIH was a more logical setting. 
     But it was a service program, so after having gotten started
up the right path, there really was not a strong opposition
within NIH to the move.  In fact, it really was acquiesced as a
thing that might be appropriate at some point.  
     The second thing, there was a kind of a deal, in a sense, in
that reorganization, which NIH was fairly influential in, and
that was that the health manpower programs were located elsewhere
in another bureau of the Public Health Service.  Consistent with
this notion that NIH was the main path of relationship to the
medical schools, there was, in that organization of '68, the move
of that health manpower bureau under the umbrella of NIH.  So
there was a kind of swap.  This service-oriented program would go
with the rest of the service-oriented activities of the Public
Health Service, and the health manpower programs would come
within NIH.

Whaley:  That also involved a move of the Director of Regional
Medical Programs.

Yordy:  That's right.  I think that was, again, part of the
strategy of making sure that this was all compatible, that RMP
would not slip off in a different direction, because Dr. Marston,
who had been the original director at NIH, became the first
administrator of the Health Services and Mental Health
Administration.  I became the Associate Administrator for
Planning and Evaluation of that agency.  
     But as happens in human events, in July or August of that
year--the reorganization took place in April of '68--Dr. Marston
was asked by Wilbur Cohen, then Secretary of HEW, to become the
Director of NIH.  So he went back to NIH, and RMP was, in a
sense, left to fend for itself in a new organizational
environment that was not all entirely friendly to RMP.

Whaley:  Was that the beginning of the end?

Yordy:  It was a piece of the end.  I think there were many
factors that contributed to the eventual elimination of the
Regional Medical Programs legislation.  They included the very
difficult budgetary climate of the period of time in which RMP
was getting started.  This was a period when the "guns and
butter" problem was arising with a vengeance.  RMP came into
being with fairly ambitious notions about what its funding level
was going to be.  The original legislation talked about $500
million a year.  Big dollars in those days--even now.  There were
budgetary people within the department, people like James Kelly,
who was then chief budget person for the department, who was
always very skeptical of RMP in the sense that he saw this big
budgetary increase in the future and he was always looking for
ways to constrain that.  
     Secondly, of course, just as the program was getting into
the operational phase, just when it was really taking off, Lyndon
Johnson decided he was not going to run again.  Richard Nixon
became the president of the United States, who, of course, had
nothing to do with the origins of RMP, and he came in with an
attitude that was fairly negative to all of the products of the
Great Society, including RMP.  So the presidential leadership
aspect, which had been very crucial to RMP, disappeared.  
     But then, in addition, the attention was going over to the
Medicare/Medicaid side in terms of health policy, and people
began to ask the questions of, "What are the real issues in
health services?"  RMP looked peripheral to some of the concerns
that were arising, like the concern, even in those days, of what
to do about the cost of medical care.  The assistant secretary,
actually, in the last days of the Johnson administration, sent
around a memo at one point asking all the programs in the
department to say what they were doing to try to constrain the
costs of medical care.  The Medicare/Medicaid budget was already
starting to take off on its rapid rise.  I wrote a memo back and
said, "We're probably going to increase the cost of medical
care."  [Laughter]  Tactically, probably not a wise thing to do,
but it was true.  
     So the expansionist era I was describing was coming into a
time when it was being questioned, both at the political level
and just in terms of the absolute dollar amounts in the budget. 
I think that was hostile.
     Secondly, there was a kind of--I won't say mindless, but
opportunistic Christmas-treeing of RMP.  People would sit around
and say, "We're going to do something about Emergency Medical
Services.  Where should we put it?  Oh, let's hook it onto RMP." 
I think what that did was sort of diffuse the sense of what RMP
might become.
     Finally, I think that some of its original sponsors became
somewhat disillusioned.  I think Mary Lasker and perhaps some of
Michael DeBakey's and some of Sidney Farber's and those kinds of
people's thoughts were that this really was intended to build up
the expert centers of specialized care.  To the extent that RMP
took a direction of trying to diffuse activities out in the
community, they weren't so sure that was exactly what they had in
mind.  

Whaley:  Karl, in our closing minute, can you tell us what we
learned from RMP?

Yordy:  One of the things we learned is that a strategy like
this, which is based on a long-term perspective, is very
difficult to carry out in the American public policy and
political context.  That's one of the key lessons from RMP.
     I think we learned that you can, in fact, stimulate a lot of
interest and action in this country on a voluntary basis.  There
was nothing compulsory about RMP.  It did hold out certain
promises of money, but you had to respond with the ideas, and
those ideas sprang up.  We, after all, organized RMPs that
covered every part of the country on a voluntary basis.  You can
do a lot on a voluntary basis.  You need a longer period of time
to develop that strategy, and you can't do it in the face of
powerful forces that are working through the financing mechanisms
for medical care, which are carrying it in different directions. 
I think those are the main lessons.  

Whaley:  Thank you very much.  

[End of interview]
                           Addendum to Interview



Question:  Tell us the context of the DeBakey Commission report
and RMPs within the Lyndon Johnson Great Society.

Yordy:  The DeBakey Commission report was very consistent with
the basic thrust of the Great Society.  Lyndon Johnson was a man
that believed all things were possible, and sooner rather than
later.  Dr. DeBakey, I think, is of similar mind.  The Regional
Medical Programs was an ambitious effort to accelerate the
benefits of medical knowledge out to the benefit of the people.

Question:  Tell us about the transition from Johnson to Nixon and
what happened.

Yordy:  That was a very traumatic transition in many ways for
federal programs.  We had just been through the beginnings of the
Great Society and, in a sense, a person who had expressed great
hostility in the campaign to the Great Society had just gotten
elected president.  Lyndon Johnson stepped aside under very
difficult circumstances.  The Vietnam phenomenon was arising in
the country.  It was a very difficult time for public programs.
     Nixon, when he became president, really took off in some
rather interesting directions.  Part of that was that he
recognized he had to deal with a Democratic Congress, and that
is, of course, just a fact of life in a government based on
separation of powers.  So he couldn't simply do what you would in
a parliamentary system, which is do what he said he was going to
do in the campaign.  He had to deal with the Congress.  So that
was a limiting factor.
     Secondly, he had a kind of peculiar set of ambiguities about
which direction he wanted to take the country in the first term. 
Remember that his domestic policy advisor in his first years in
the White House was a man by the name of Daniel Patrick Moynihan. 
They were developing things like major welfare reform proposals
and things like that.  So Nixon, in the first years, was not sure
which direction he wanted to go, I think, in terms of his reform
of the American government.
     By the time he got around to the second term, he clearly had
in mind making more fundamental changes, and armed with the
overwhelming election of '72, I think he was determined to move
to start to shape the government in a more aggressive way in line
with his own beliefs, sort of "Congress be damned."  So I think
that was the climate that allowed him to move ahead.  
     RMP was a struggling entity long before that final demise. 
I think that the hope and the vision for the program really were
starting to disappear shortly after Nixon became president.  It
was sort of a holding action, sort of a fighting the frontiers at
that point.  

Question:  Can you talk a little bit about the events of January
1973?

Yordy:  This was right after Nixon's overwhelming election.  He
began a systematic effort to remove people from office, and he
removed Bob Marston as the head of NIH and moved Bob Ball as head
of the Social Security Administration, to take two examples of
people who have headed very strong agencies.  I think he saw this
as the time to finally put an end to Regional Medical Programs,
along with other things.  There were other Great Society vestiges
around.  The nature of American government allows for organized
protest against such efforts, and, again, the separation of
powers permits that.  The role of both the legislative branch and
the judicial branch, the president can't just do what he wants to
do.  So I think the events that were unfolding in '73 were that
kind of a struggle, where the people who were in favor of RMP
were using the other instruments of American government to try to
preserve this.  
     There were all sorts of other fights going on between Nixon
and the Congress at the same time.  There were impoundment
battles and all sorts of things that were really part of this
whole picture.  But Nixon was, obviously, emboldened in that
second term, and I think that's why he was able to succeed.  

Question:  On the 22nd of January, Dr. Marston went.  On the
29th, he released this, and then the reaction to that?  On the
first of February, the famous telegram.  

Yordy:  I am going to disappoint you.  I am not a good person to
tell you those specific events, because I, at that time, had left
the government and I was observing these things from afar.  So I
wasn't on the inside of those events.  The other kinds of things
I can talk about from having been there.  

Question:  That covers all the questions I have.