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Interview with Irving J. Lewis
Date:  September 6, 1991
Location:  National Library of Medicine
           Bethesda, Maryland
Interviewer:  Storm Whaley
Transcriber:  Techni-type Transcriptions/DDR


Whaley: With me today in the studio is Irving J. Lewis, who was
the Chief of the Division of Health and Welfare in the Bureau of
the Budget (BoB) at the time the Regional Medical Programs (RMP)
were conceived and started, and then later was Deputy
Administrator of the Health Services and Mental Health
Administration (HSMHA) when RMP was at HSMHA.  
     Mr. Lewis, what are you doing these days?

Lewis:  I'm now retired.  I left the government in 1970 and went
to Albert Einstein Medical College and was on the faculty as a
professor of social medicine and public policy until 1986, and
then continued on in certain minor assignments.  Recently I've
returned to the Washington area, so I'm spending my retired years
here in the Washington area.  

Whaley:  I think for most people it works the other way around,
doesn't it?

Lewis:  That's right.  

Whaley:  When did you first hear of Regional Medical Programs?

Lewis:  I guess it would have been back in 1965, when I was
appointed Chief of the Health and Welfare Division in the old
Budget Bureau.  The Mike [Michael] DeBakey report on heart,
cancer, stroke was a major document in public policy circles at
that time.  That was a precedent to the piece of legislation
which eventually was called the Regional Medical Programs.  So
I'd say it was along about the summer or early fall of 1965 that
I became aware of Regional Medical Programs.  

Whaley:  Did the concept that finally emerged represent a kind of
compromise?

Lewis:  I'd say it represented a rather ninety-degree turn to the
right, maybe even a watering-down of the regional proposal,
because the original proposal of Mike DeBakey's commission was
for the creation of regional medical centers which would actually
deliver medical care to persons who had heart disease, cancer,
and stroke.  The idea of the DeBakey Commission was to move the
results of research from NIH [National Institutes of Health] and
the other laboratories to the actual arena of medical care, and
that was to be accomplished by the creation of regional medical
complexes which were a combination of both in-patient care and
ambulatory care and diagnostic and treatment centers.  So it was
a service program.  That was the original concept.  

Whaley:  Did that frighten the medical community?

Lewis:  Well, I don't know that it frightened the community, but
I recall very clearly a conversation I had once with Ed Dempsey,
who was the Special Assistant to Secretary of HEW back then in
'65, and he said the AMA [American Medical Association] had
concentrated on the passage of Medicare or Medicaid, whatever
that was going to be, which were financing provisions in health
care, and they had just not paid any attention to this one, and
they discovered at a very late date.  So the AMA, insofar as it
represented organized medicine, played a major role, in my
recollection, in having the whole concept change from a program
of direct medical care to a program of cooperative arrangements,
which is the heart of Regional Medical Programs.  

Whaley:  Was there much thought that it would have something to
do with medical education?

Lewis:  Yes, and from the beginning, the Regional Medical
Programs focused on the role of medical schools.  My own
background is one of politics and economics, so I think in
political terms quite often, and the power base for Regional
Medical Programs was to be the medical schools.  The focus of the
program was to be on health manpower, and on education,
continuing education and on training programs.

Whaley:  Do you think the RMPs changed medical schools?

Lewis:  No, I don't think RMPs changed medical schools, so far as
my contacts.  In New York, where, for example, I was quite aware
of the Regional Medical Programs, I don't think the medical
schools were changed by RMP at all.  

Whaley:  What about the business of getting the schools sort of
outside their own walls?  In some cases, I think, it was the
first time that some schools emerged from rather tight-knit
faculties not having much to do with the community.  Would you
say that would be in effect?

Lewis:  Oh, yes.  But the big question is whether the people who
were representing the medical schools in our RMP were the key
individuals in the medical schools.  My experience in some
fifteen years or more in medical schools in the New York area and
in some investigations outside of New York, is that the dominant
interest still remain the research people.  Research interests
and research manpower remain the dominant factors in the American
medical school.  

Whaley:  I wasn't at NIH at the time, but I understand that
President Johnson became very interested in the idea of getting
the results of research out, and he came to NIH, made a special
visit, as I recall, and gave people a pep talk or even more than
that, I might say, about doing that.  Was that the sense inside
BoB?

Lewis:  Oh, yes.  The president had, in the person of Douglas
Kator, who was his Special Assistant on Health Matters, a real
lightning rod to get the people in the research world to pay
attention to the president's interest.  President Johnson also
had a special briefing once in the Cabinet Room over at the White
House, which I attended, where all the principal directors of the
institutes at NIH briefed the president on what their work was
and what they were doing.  I particular remember Ted Cooper, who
was at that time head of the Heart Institute, coming and speaking
to the president.  

Whaley:  Do you think Johnson had the feeling that there was
reluctance on the part of researchers to get out with what they
were doing?

Lewis:  That's the feeling, but I think that there was a feeling
that there was a lot of information which was locked up in the
laboratories which hadn't yet made its way out into the world of
medical care, and that's what the president was trying to
achieve.  But we never really developed programs anywhere along
the line in the federal government which were designed to do
that, bring the results of research definitely out into the open. 
In order to do it, one would have had to have a different
combination and a different set of relationships between the
world of finance in health care and the world of organization and
delivery.  One would have had to have a different mind set in the
American medical school, where medical care and service to the
community would be the dominant considerations as opposed to the
research world.  

Whaley:  This was in the period when the NIH budget, I think, was
just touching a billion dollars.  So it was not that big an item,
I assume, in the BoB, that it later became.  

Lewis:  When I became Chief of the Health and Welfare Division,
the focus was on NIH, and the government was only just beginning
to move into the world of organization, delivery of care, and the
world of financing of care.  Until 1965 and the passage of the
Medicare/Medicaid legislation, government policy had focused on
the expansion of the NIH world of biomedical research and on the
expansion of facilities through the Hill-Burton Program.  So the
creation of hospitals and the creation of knowledge were the
government's focus until 1965, when we launched the programs of
financing of health care.  

Whaley:  The Division of Regional Programs was located in NIH. 
Was there any special reason for that location?

Lewis:  Jim Shannon was a particularly strong reason for being
located in NIH, and RMP was not regarded as a program of medical
care or a program of medical financing.  It was regarded
initially as a program where the government, by focusing on
medical schools and their relationships, would improve the
dissemination of information from the research laboratories.  
     I might also say that one of the emphases in RMP early on
was in health manpower, and health manpower was under the
direction of Jim Shannon back in 1965.  

Whaley:  So there was a combination of interests there then in
the medical schools, particularly.

Lewis:  Regardless of what it was in legislation, the focus and
the test of RMP's worth had to be in terms of service eventually,
and in terms of changes in the organization and delivery of
health care in this country, and that's why it made great sense
when there was a reorganization in 1968 in the Public Health
Service to have RMP move out of the NIH orbit into the health
services orbit.

Whaley:  That's when you became actively in charge of RMP?

Lewis:  I don't know if I was actively in charge, but I was more
directly involved than I had been in the Bureau of the Budget.  

Whaley:  Do you recall circumstances, the operation, how it went
in the early period in HSMHA?

Lewis:  It was a bit of an orphan.  In the early days, it was not
an orphan, because Bob [Robert Q.] Marston, who had been the
director of RMP, was the first administrator of Health Services
and Mental Health Administration.  So he viewed it as a very
important program, and he viewed it, as my recollection, in terms
of its eventual impact in the delivery of care in this country. 
So did Stan Olson, who was one of the early directors of RMP. 
Subsequently, as HSMHA began to focus more on problems of the
poor and the delivery of care to the poor, RMP became less
important.

Whaley:  RMP picked up some special divisions along in there,
didn't it, like emergency room operation?

Lewis:  I don't remember about emergency room operations, but it
picked up the chronic disease programs.  RMP's categorical
approach, the approach of RMP or the justification of it, the
rationale, was in terms of cancer, heart disease, and stroke,
which, as DeBakey's report pointed out, caused 70 percent of the
deaths in this country.  "Related diseases" was a catch-all
phrase.  So it made great sense, when RMP was moved into HSMHA,
for RMP to be combined with the Division of Chronic Diseases,
which had run a grant program generally out to communities and to
community hospitals in the field of kidney dialysis, heart
disease, and stroke programs.  So it made sense for that to be
combined.  But I don't remember about emergency rooms.

Whaley:  Yes, I think that came along maybe even subsequent to
the others.  It was about this time that the Yarborough
Committee, that later became the Kennedy Committee, made strong
recommendations about the war on cancer.  There was a legislative
battle that went on in the early seventies.  Do you think that
had any effect on the ultimate history of RMP?  Do you remember
this created a sort of competition between Nixon and Kennedy?

Lewis:  It might have been a competition between Nixon and
Kennedy, but others who may be more closely involved in the
particular legislative developments would have a different
recollection.  The categorical disease approach became less and
less important in the RMP framework as time went on.  The general
service approach and the capacity to respond to service needs
across the whole medical care world became more important.  For
example, I found myself working in New York in connection with
RMP, working on projects studying the availability of health
manpower, allied health manpower, in the Bronx under a grant from
RMP.  We did a study which led eventually to the improvement of
relationships between the various units in the Bronx.  We created
a little Bronx health manpower consortium which was designed to
focus on the use of non-physical manpower.  So the nursing
school, Layman College, began to play a very important role in
it.  
     So I didn't see that cancer, as such, as a disease, or any
of the diseases, became critically important to RMP.  What became
critically important was its capacity to contribute to the
improvement of the delivery of services, whether they were for
the poor or for the rich, whether they were for one disease or
for another disease.  

Whaley:  Mary Lasker and her associates had been very strong
supporters of the original DeBakey Commission and the RMPs, but
by the time of the war on cancer, I think there was a good deal
of their strength over on the war on cancer side that may have
diminished their support of RMP.  I don't know.  

Lewis:  That goes to the question of whether or not the
categorical disease approach, in funding and establishing new
legislative and funding programs, really makes sense in this
country.  The categorical disease approach is what undergirds the
whole NIH arrangement.  That's what undergirded the proposal of
Mike DeBakey to create medical center complexes in heart disease,
cancer, and stroke.  
     The RMP, however, in time find itself working across a broad
front, particularly when it was designed under legislation to
create regional cooperative arrangements, and it was not really
inhibited by the fact that it was originally spawned out of the
Mike DeBakey program.  I don't think that in the long run there
was a fight between the categorical disease people interested in
the war on cancer and RMP.  I think that RMP's demise lay rather
in its inability to function in the health planning and
organization front, which takes you to the problem of competition
in the health planning field of the states.

Whaley:  Yes.  I think that chapter, if you can bring us in on
that a little bit, on Comprehensive Health Planning (CHP) and its
relationship.  

Lewis:  There were two separate worlds.  There were a number of
different worlds in 1965, legislative worlds--I could say 
W-H-I-R-L-S--going on in to President Johnson and the
establishment of Great Society programs.  One was the RMP front,
which created a power base for the medical schools in the health
services front, but with a focus on medical care and cooperative
arrangements.  The other was a health planning front, with a
focus on health, called the Comprehensive Health Planning
legislation, which went down the route of state and local
governments.  There was a completely different political power
base, and my feeling is that they never came together.  The two
power bases never jointed hands.  

Whaley:  I suppose in BoB, you were the focus of lobbying from
within and without the government.  Did you feel pressure for
RMPs?

Lewis:  No.  Actually, my period of service in the Budget Bureau
really precedes heavy lobbying by outside interests.  We didn't
have that.  We felt a great need to work out rational
arrangements in the kidney field, for example, and I spawned,
along with Ivan Bennett, who was then Deputy Director of Science
and Technology, a committee called the Gotchalk [phonetic]
Committee, which studied the whole field if kidney dialysis, and
which recommended in the late 1960s, 1967 or '68, that we not
have too extensive a program, which the Congress promptly
disregarded and enacted as an amendment to the Medicare
legislation.  So we now have a very extensive kidney dialysis
program.  
     But that's another example of the fractionation that existed
in the federal government health programs.  There was no real
connection between RMP, which had a focus on heart disease,
cancer, stroke, and related diseases, including kidney disease,
there was no focus between that institution and the Medicare
program, which had a very special piece of legislation that had
been pushed for and lobbied by the National Kidney Foundation. 
To my knowledge, there was no extensive contact between the two.

Whaley:  When you were deputy administrator or HSMHA, did you
visit RMPs around the country?

Lewis:  To some extent, but not an awful lot.  I didn't make
extensive field visits.  I particularly concentrated on
coordination in Washington with the financial institutions.  I
did speak to working groups and conferences of Regional Medical
Program coordinators, though.  

Whaley:  I was interested in your comment about the people in the
medical schools who were involved.  I assume you were saying that
you felt maybe the strong leadership in the medical schools, at
least after an early period, more or less left the RMPs to
others.

Lewis:  Either that or the medical schools' representatives at
the RMPs had a basic goal to protect the flank of the medical
school and see that the medical school was not too heavily
involved in service programs.  
     There is a basic ethos in the American medical school which
makes the research the dominant ethos and the dominant value, not
teaching, which is education, and not patient care, which can be
community service.  If RMP was to be successful and the CHP
programs were to be successful, and given the role of the
American Academic Medical Center in American medical care, the
American Academic Medical Center was to have played a big role in
delivering medical care to the poor, the rich, the middle class,
and all groups.  The American medical school has not played such
a role.

Whaley:  The various service plans that were developed in the
medical schools, where the faculty could take care of patients
for pay in institutions, many of which had not done that before,
was that in any way related to RMP?

Lewis:  I'd have to take a by on that.  I don't recall them.  

Whaley:  It was a period when it began to be at least usual for
medical school faculties to be in actual practice and, as they
are now, getting a lot of their income from it.  

Lewis:  Yes, but the question is, were they developing their
practice arrangements within some framework that had the blessing
of a Regional Medical Program?  I'd have to take a by on that,
Storm.  I just don't know.

Whaley:  It's probably a pretty far stretch, I suspect.  

Lewis:  Again, it's a little bit the three blind men and the
elephant, but my sense of the medical school world is that to the
extent that pressure for patient care involves service, which
means medical care to define enlarged populations on a continuous
organized basis, the medical school runs away from it.  I'm not
speaking about a particular medical school; I'm saying the
medical school, the American medical school, and, thus, the
hospital which is in combination with it, runs away from it.  If
RMP was to have succeeded, it had to succeed in the health
planning and organization front.  
     In 1974, some four years after I'd left the government, but
after I'd had plenty of time to reflect on what I had done and
what I had not done, and what I had done up at the medical
schools, I spoke to a group of RMP coordinators on the questions
of the public interest in health, and one of the messages that I
communicated then, and that I've recently communicated in this
book that I wrote that you and I were talking about, was that the
public interest is not the sum total, or a bargain that's struck
by private interest with government giving its blessing.  The
public interest in a period of shrinking funds always has to
involve the ordering of priorities.  
     In health, you can't do that without some effective regional
health authority mechanism, which we don't have, which RMP was
not, which Comprehensive Health Planning was not.  But there's no
question in my mind, as we now deal today with, again, the crisis
in health care, that if we don't emerge with some sort of
effective regional health authority that has power to order
priorities, then we will not put together the various pieces
which is sometimes in the health planning phase and sometimes in
the health financing phase.  

Whaley:  I think you may have answered the two questions I was
about to.

Lewis:  I didn't mean to.

Whaley:  No, that's fine.  My first question was going to be,
what led to the sort of dwindling-down and the final
disappearance of RMPs?  Perhaps you've said that.

Lewis:  Not quite.  It's part of the whole process that seems to
be of the excessively "pluralistic" character of the American
society, where increasingly government has had less and less
sanction, whether one is a liberal or whether one is a
conservative.  It's had less and less sanction by the citizen,
and there has been a tendency for us to say that the action of
government doesn't have to be anything more than the best bargain
that the private interests or lobbies can strike as they sit
around the table with one another, and even, at times, with the
federal government sitting at the table with them, giving a
sanction to it.  
     What we did not face in this country in health, and we still
aren't facing, is the need for an effective institutional
mechanism to allocate resources.  You can't allocate resources at
the national level and you can't allocate them just at the state
level.  You have to allocate them down at a level which makes
sense in terms of the way in which health care is actually
delivered, which is some kind of a regional mechanism.  The
American Academic Medical Center is the core of the American
health system, and it is natural.  DeBakey's report was right in
its recognition that regional medical complexes should be built. 
He called it heart disease, cancer, stroke, and related diseases. 
It should be built on the regional coverage of the American
medical school.  Perfectly all right.  But we have not yet come
to focus in this country on the need for such an authority, and
every other country which has an effective health care mechanism
and health insurance mechanism has some type of regional
authority.  

Whaley:  Then you would say that for the lack of that, this
program, which was incomplete, really didn't continue.  

Lewis:  It's a very involved political analysis that comes to
stress the role of the provider in the insurance mechanisms and
the employers.  What we did is to concentrate on the financing
mechanisms.  Once we shifted our interest in this country, from
1965, interest from access to care, we shifted it to the cost of
care, and since 1974 or '75, we've been focusing on the question
of cost of care, which means we've been focusing on providers and
insurance mechanisms, not on planning and organization
mechanisms.  

Whaley:  You were in at the beginning and almost at the end of
this chapter in history that we call Regional Medical Programs. 
What do you think we may have learned from this chapter?

Lewis:  I'm not sure.  I've been trying to communicate to you the
idea that what we should have learned is that we can't fix up the
health care system, whether we're talking finance or organization
or manpower, whatever, unless we have effective regional health
authorities, which would be a descendent of what we were trying
to do in Regional Medical Programs.  
     One thing that we should have learned is that you can't get
from A to E by romance.  In the 1960s, I think the Comprehensive
Health Planning legislation was set on a sea of romance, and I
think the RMP legislation was set on a sea of romance.  No
pragmatism, no effective decision-making authorities in either of
the pieces of legislation.  You can't get there when you're
dealing with a $500 billion, $6 billion health industry, which
was only about $50 billion to $60 billion when I started.  

Whaley:  Ten times, at least.  

Lewis:  Yes.

Whaley:  This has been an interview with Irv Lewis about the
history of the Regional Medical Programs.  Thank you very much.

Lewis:  Thank you, Storm.

[End of interview]