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Interview with Dr. Philip Lee
Date:  September 17, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  I'm Don Lindberg.  I'm Director of the National
Library of Medicine.  It's my privilege today to interview Dr.
Phil Lee as part of the National Library's studies of Regional
Medical Programs in the United States.  
     Phil, thank you so much for being with us.

Lee:  Delighted.  

Lindberg:  You were Assistant Secretary of Health, Education and
Welfare from 1965 to '69, is that right?

Lee:  Right.  

Lindberg:  So those were the beginnings of Regional Medical
Programs.  You must know all about it, and we're glad that you're
going to tell us.  I would like to ask you a few simple questions
to start out with.

Lee:  Sure.

Lindberg:  From the vantage point on top of it all, which you
were, did you find the administration enthusiastic about RMP? 
Were they trying to make it succeed?

Lee:  Certainly in the early days of the Johnson administration,
very definitely.  Because of [Dr. Michael] DeBakey's direct
connection with the president, with the president's support for
the notion of moving research results out to benefit patients,
there was strong impetus for the program, even from the White
House.  Then you had people who were closely involved with
drafting the legislation, like Bill Stewart, who became the
surgeon general, who was then responsible for the initial
organization and oversight, very strong support in the early
days.

Lindberg:  So you would from time to time reach down your hand
and help things along, would you?  Or didn't you need to?  

Lee:  When I was assistant secretary initially, it was a staff
job advising the secretary, and the line responsibilities were in
the surgeon general.  In 1968, those were moved so that the
surgeon general reported to me as assistant secretary.  At that
point we did a reorganization.  We then moved RMP from NIH
[National Institutes of Health], to the newly created Health
Services and Mental Health Administration (HSMHA) to try to
connect it more with the service delivery systems and with other
programs related to delivery of services, whereas the initial
relationship with NIH was to tap into the research and feed that
out into the community.

Lindberg:  That's very interesting, because I didn't understand
the connection of moving RMP out of NIH and the reorganization of
PHS [Public Health Service].

Lee:  There had been two reorganizations.  One, initially, that
Bill [Stewart] instituted, and because Secretary [John] Gardner
felt that hadn't gone far enough, part of the reason they had the
Public Health Service then report to the assistant secretary in a
line relationship was because he felt that there wasn't enough,
as a matter of fact, self-renewal as a result of the earlier
reorganization.  He was a great believer in using organizational
change to stimulate response within the bureaucracy.

Lindberg:  So did moving RMP mean that it took on a more service
basis and left behind its research orientation?

Lee:  Not so much, because Bob [Robert Q.] Marston, of course,
moved with it.  Then he moved back as director of NIH.  But it
was organizationally trying to link it more actively to the other
service programs in the Public Health Service, whereas at NIH it
was rather removed from those programs, and this was an effort
organizationally, at least to facilitate that link.

Lindberg:  There's another question related to this that I'd like
to put to you.  It is said that the emphasis in RMP shifted from
heart, cancer, stroke to general and perhaps somewhere in between
and, of course, did accumulate others--kidney and emergency
medical and so forth.  How did that look from your point of view? 
Were you conscious of changes in emphasis?

Lee:  Those came mainly after the Nixon administration, when
Finch was secretary and the emphasis that they tried to make on
primary care, emergency medicine, and some of those other areas
came more during that period than in the early period.  The early
period, the emphasis still was very much on heart, cancer,
stroke, and what were called allied diseases.  But that was the
emphasis.  
     The big challenge was really linking RMP and Comprehensive
Health Planning.  Because Bill was involved in both of those, in
the drafting of the legislation and in the ideas, he would be the
best person to talk to.  It was interesting.  As the programs
were implemented, and Jim Kavanough was head of Comprehensive
Health Planning, I think that at least in the period '67, '68,
before Jim went over to the White House, there must have been
meetings almost every week between RMP and Comprehensive Health
Planning, at that level, to try to coordinate the approaches. 
Because Comprehensive Health Planning had somewhat greater
flexibility, it was possible in some areas for it to move ahead
more rapidly than RMP, which had been, from the very beginning,
constrained because of AMA [American Medical Association]
opposition and in the House Interstate and Foreign Commerce
Committee, language that was written into the original
legislation which changed it from regional medical complexes in
an effort to really take the centers of excellence and move those
ideas out to community hospitals, to these cooperative
arrangements, and language that specified that there would be no
interference with the financing or the patterns of practice.  
     So that anytime anybody wanted to do something very
innovative in patient care within a program, immediately that
language was brought up, and it really stifled a lot of the
innovation in the field.  

Lindberg:  It faded the program right at the outset.

Lee:  Absolutely.  It was obviously a deliberate effort on the
AMA's part to really--because they were almost more exercised
about Regional Medical Programs than they were about Medicare,
and that's saying quite a bit.  They were coming along at the
same time.  Medicare was passed, then here was Regional Medical
Programs, and they were determined not to have a program that
could really restructure the organization of the medical
community.  Medicare was going to do enough about the financing
they were worried about, and then here were Regional Medical
Programs, which, as it was originally contemplated, would, in
fact, have done some of the things that are now happening really
thirty years later in terms of centers of excellence.  Heart
transplant is probably the best example of centers where only a
few centers in the country are really authorized to get payment
for those services.  So that the ideas were maybe ahead of their
time.

Lindberg:  Interesting for our viewers to think back twenty-five,
thirty years ago, to some of the ideas then that were limited to
the very few academic centers.  I mean, the intensive care units,
the vascular surgery, the coronary units didn't exist in most
places.  They were not community resources in those days at all.

Lee:  No, and I think one of the big contributions of RMP,
although you could say that it was driven by technology
(certainly RMP fostered it), was the coronary intensive care
unit.  That was a major advance in terms of clinical care and in
improving outcomes.

Lindberg:  Then emergency medical programs and kidney dialysis,
which was not available as a community resource or anything like
it.

Lee:  Absolutely not.

Lindberg:  So there have been lots of changes.  That, of course,
is tied to this issue of shifting from specific to the general,
but as you say, that occurred in the Nixon times.  In your view,
was it appropriate to concentrate on heart disease, cancer, and
stroke initially?

Lee:  I think the report of the President's Commission made it
very clear why you could do that.  The percentage of deaths
that were due to cardiovascular disease and cancer just
overwhelmed other causes of death, including trauma, diabetes,
things of that sort.  So in terms of priorities, in dealing with
what were massive public health problems, in areas where there
were interventions that increasingly were effective.  Again, the
commission's ideas were a number of years ahead of their time in
the sense of what was coming, because if we'd created that
infrastructure, we could have much more quickly disseminated the
treatment improvements that have subsequently occurred.  

Lindberg:  I think I can understand what you are saying.  If we
think back, actually the idea that controlling blood pressure was
a way to reduce--cut in half, as it turned out--the incidents of
fatal stroke, was an idea known then, but not well implemented at
all.

Lee:  Absolutely.

Lindberg:  It was ahead of its time by several decades.  So if I
understand you correctly, your thought is that RMP might have
been a mechanism for disseminating, or even testing out these
clinical improvements.

Lee:  If you take the hypertension treatment program, when the
Heart, Lung and Blood Institute instituted that national program,
which did have a significant effect on mortality, not only from
hypertensive cardiovascular disease, but from coronary disease,
the kind of dissemination infrastructure wasn't there the way it
would have been had RMP been in place.  I think, again, you could
have had a more efficient movement out.  As other ideas developed
in that way, gradually those networks and relationships have
evolved in some areas, but not to the extent that they should
have.  We'd, I think, be saving very significantly in terms of
expenditures for very high tech.  You compare a place like Kaiser
Permanente in Northern California, let's say, which regionalizes
their coronary artery bypass surgery to one center, their
neurosurgery to one center, those kinds of regional decisions
make it possible to provide care more efficiently.  Of course,
that was one of the things that was very much in the minds of the
commission, and, again, an idea that was well ahead of its time
because people weren't as concerned about costs in those days,
although that was a consideration.

Lindberg:  Cost wasn't as overwhelming then, no.  From the point
of view of NIH, one can look back and think of this as what might
have been almost a permanent outreach program, which each of the
institutes now is trying to reinvent.

Lee:  Right.  

Lindberg:  Phil, you must have had an opportunity to travel the
country while you were assistant secretary and certainly, of
course, subsequently.  Did you see any outstanding examples of
RMP achievements?

Lee:  I thought there were some very good programs.  Chuck Lewis
in Kansas, for example.  I thought Paul Ward in California, over
the years, not only in terms of program structure and content,
but his political sophistication, the survival of the program
into the seventies, beyond what anybody thought possible.  I
think Bill McBeaath was another.  There were leaders that emerged
around the country.  There was a physician in Idaho, who was in
the intermountain program.  I think his name was Dr. Pauma
[phonetic], if I remember.  Again, you'd see these sort of
islands of innovation and excellence that were really, I think, a
reflection of the way Bob and Karl Yordy and the others
administered the program.  In other words, the notion of let
1,000 flowers bloom.  In fact, there were a number.  Vermont was
another one where there were some very innovative things going
on.
     Much of that, because of the constraints initially, were in
continuing education, not only for physicians, nurses, dentists,
other health professionals, and that was the direction the
program had to take because of these early restrictions. 

Lindberg:  Karl Yordy said that this was originally imagined to
be a $500 million-a-year operation.  Is that your memory also?

Lee:  There were some very large ideas in those days.  You had
the neighborhood health centers.  We were thinking very
expansively about those as a way of inner city and rural poverty
areas.  The Regional Medical Programs was this network all over
the country for dissemination and for improving the quality of
care.  But those visions didn't persist into the more austere
seventies.

Lindberg:  I'm surprised that if Jim Shannon knew that, he ever
let it get outside of NIH.  

Lee:  You see, by the 1969 appropriation, the Vietnam War was
very much a depressing effect.  As a matter of fact, it's one of
the things that led the president to decide not to go forward
with the beginnings of national health insurance, a proposal that
Wilbur Cohen called "kiddie care," which brought pregnant women
and children into the Medicare program and then incrementally
expanded it.  So at the end of that period, at the end of the
Johnson presidency, beginning inflation, but the expenditures,
our budgets were really constrained almost for the first time. 
Every year before that we were asked how could we spend more
money, generate more programs.  It was just an extraordinary
period compared to what we've seen in the 1980s.

Lindberg:  It was the right time to be in Washington.

Lee:  Absolutely.  So those notions were considered to be not
unrealistic.  Jim was very much concentrating on the research
side and didn't, I think, feel any great loss of having us move
the program.  

Lindberg:  There's always been a pull and a push between the
basic and the applied.  That's natural enough.

Lee:  Right.  

Lindberg:  What do you think are the lessons one can learn from
this program?  The country is said to be considering, once again
perhaps, a broad approach to health care legislation.  What can
we learn from RMP days?

Lee:  I think one of the things we learned, going back to the
commission report, you look at the influence of the special
interests and how the special interests undermined the purposes
of the legislation.  I would say that we didn't sufficiently
consider what the impact of those influences might be on the
authorizing legislation at the outset.  
     There was a lot of optimism, and we just didn't sufficiently
consider that downside.  I think once the legislation was
enacted, I think we saw the problems of divided government, and
we see those problems very definitely still today.  You had,
during the seventies, except for the Carter period, you had a
White House that was Republican and a Congress that was
democratic.  In the early period, particularly, there was much
more of an adversarial relationship.  Again, when we were there
in the sixties, there was none of that.  There were very cordial
working relationships.  There were clearly very differences
between Congress and the executive branch, but the legislation
was drafted, often in the executive branch.  There were very
small congressional staffs, so that much of that work was done in
a cooperative way with people on the Hill.  You don't see
anything like that kind of cooperation.  So a divided government
causes serious problems in terms of implementing what was clearly
the intent of Congress.  
     I would say in terms of the long range, what we learned out
in the field, I think we see the benefits of that kind of
potential, that kind of planning, and we see the benefits of
linking the academic medical center to the practice community. 
Particularly as we get new technologies that can improve the
quality of care, those need to be disseminated.  We need to have
effective ways to do that.  We had some very good models early. 
One of those was through continuing education.  There wasn't
enough demonstration of how to do that, and I think, as a result,
we've had more influence by the technology industry on the
process, I think with the result that costs are far higher than
they would have been had we been able to sustain a mechanism like
RMP, to evaluate those technologies and say, "These are the ones
that ought to be out there."  Instead, you've got manufacturers
all over the place telling not only physicians in practice and
hospitals, technologies so that they're proliferated in a very
inefficient way currently, at very high cost.

Lindberg:  Phil, when you say we should have been more systematic
and careful and thorough and so forth in preparing the
constituencies, who is the "we"?  I mean, here was LBJ, one of
our most incredibly skillful presidents in domestic policy, and I
guess you're saying, even so, he misjudged this one. Is that
correct?

Lee:  Mike DeBakey was also very skillful.  He's not only an
outstanding surgeon, but he was very savvy politically about what
you could do and what you couldn't do.  But I think we
underestimated in that period, in 1965, as that legislation was
going forward, the reaction that the AMA had.  They lost
Medicare.  They weren't about to lose this one.  So they put a
very big investment in terms of the influence on Congress.  Of
course, I think we just underestimated that.

Lindberg:  It's incredible to me that they would even view it in
the same breath.  I mean, that's amazing!  RMP was the golden,
wonderful program.  It's also very tiny.

Lee:  Right.  It produced tremendous apprehension on the part of
organized medicine, as contrasted with Comprehensive Health
Planning, which didn't.  They saw that more as a public health
program, as more health planning, not as a threat to doctors in
practice.

Lindberg:  Whereas it would have been, had it actually worked.

Lee:  Absolutely.

Lindberg:  It would have totally redefined practice.

Lee:  Yes.  I think Paul Ward, in his writings on the subject,
has differentiated--and I think that's why the threat seemed to
be there--the difference between pure planning and
implementation.  RMP was really concerned with implementation,
and that is, I think, one of the reasons that there was so much
fear of the program.  We just underestimated that.  That was more
a responsibility within the department.  We had many other things
going on.  There was lots of other legislation.  There were areas
where the AMA was very cooperative on health manpower, for
example, and some other areas.  This was an area where we just
didn't appreciate it.

Lindberg:  Amazing.  Somebody recently said about this, quoting
some other older, wise man, that health policy was ten percent
legislation and ninety percent implementation, emphasizing just
what you said.

Lee:  Whether the percentage is correct, implementation is
absolutely critical and it's a very understudied part of the
policy process, because the balance shifts from the policy
makers, which are Congress, to the administrators, and they, in
fact, set a great deal of policy.  

Lindberg:  In terms of this emphasis between heart disease,
cancer, stroke, and the more general, I was surprised to discover
recently there was an LBJ Health Message to Congress, which
conveyed, in part, the heart disease, cancer, and stroke
commission, but other things as well.

Lee:  Right.

Lindberg:  This was like January, I guess, in '65, and already he
was saying "and other appropriate diseases."  [Laughter]

Lee:  Right.

Lindberg:  So to him, it was an answer to a lot of things.

Lee:  It was a beginning, but it was to put that infrastructure
in place so that if it really did work, then you could, in fact,
bring other diseases.  Like his approach to NIH, where he had
everybody over to the White House and admonished us to get the
discoveries out of the laboratory.

Lindberg:  Did he really?

Lee:  Oh, yeah.  That was sort of a Mary Lasker-generated
meeting.  But he was very concerned about that.  He was very
concerned about getting these things out.  He visited NIH
subsequently, very successful visit, and it was described in
papers all over the country.  He described NIH as a billion-
dollar success story.  Well, it's now quite a bit more than that. 
But he was very interested.  As John Gardner said about him, he
was more understanding of how the government worked than any
president John Gardner had ever seen, and he really did.  It was
extraordinary.  His, sort of in a sense, reaching down, not in a
way to manipulate the bureaucracy, but to influence and say,
"This is really what I want to see happen," and to know where
those levers were.

Lindberg:  Mike DeBakey emphasized his feeling that LBJ was very
interested in health affairs all his career, that it wasn't just
an adventitious or adventuresome token.

Lee:  I agree with that.  Of course, he was responsible for
getting Medicare enacted.  Had he not made that an issue, had he
not had a landslide victory, brought in sixty new members of
Congress, many who lasted certainly one term.  I can remember
once we had a meeting on a task force on nursing homes, and he
met with this task force and described in detail what he'd like
to see in a nursing home.  It was extraordinary.  With all his
gestures.  He could communicate very effectively.  But it was
down to details that were just--you couldn't imagine a president
being interested in that kind of detail.  He knew old people, he
visited nursing homes, he understood the problem, and he had an
opinion about it.  

Lindberg:  Did you ever actually hear him discuss RMP?

Lee:  Not that I recall specifically, but it may well have been
that he would have talked to Mike DeBakey about it, I'm sure.  Of
course, Mike had really direct channel to the president, and that
was one of the things that made the commission.  The department
was eager to move that forward.  Ed Dempsey, who was the special
assistant, had been anatomy professor at Washington University in
St. Louis.  It was put in his hands.  I wasn't given that
responsibility because I was new.  I went over in the summer of
'65, in August, about the same time John Gardner got there.  So
the momentum of that program was very much really in Ed's hands
and Bill Stewart's.

Lindberg:  Unfortunately, Ed has just died.  

Lee:  Yes.

Lindberg:  I hadn't had a chance to talk to him about this.  Do
you recall personally seeing any RMP activities in the field?

Lee:  Yes.  It's hard to recall now, but I do recall places like
Montana, Kansas, California, Vermont, were areas where I
recollect were what I thought were very, very positive things
going on.  I can't now recall the specifics of those, but those
are areas that very much come to mind.

Lindberg:  How about the ending of the program?  You, of course,
weren't in office at the time.

Lee:  I was back at UC first as chancellor, and there, of course,
I was familiar with the people who were administering the
program.  Al Watts was very actively involved in that.  There
were others.  I would talk periodically with Paul [Ward] about
the problems that they were encountering, but because I had my
hands full with other administrative matters, didn't have a
chance to really get engaged in those issues at the Washington
level, working with Paul or others around specific lobbying
efforts, and probably wouldn't have had much influence, because I
was a little bit too far removed from it at that point.  

Lindberg:  One of the interesting pieces of continuity, of
course, is your going back to UC as chancellor and then founding
an institute, that still exists, for health policy studies, and
all the experience you yourself have had in forming and
implementing health policies.  Must this not be very gratifying
to you?

Lee:  I must say I've enjoyed it enormously, and in some ways
it's a lot easier to sit in a university and think about these
issues and be involved in research on the issues and teach
postdoctoral fellows or med students about the issues, than it is
to be on the firing line, although obviously there's no place
like actually being there when it's happening.

Lindberg:  For your students, what are the hot topics now?

Lee:  I would say there's been a tremendous increase in the
interest of med students in health policy.  We've taught that UC
for twenty years.  In the early seventies there was a lot of
interest when health insurance was an active issue.  Then the
interest subsided, except for a few students.  Since the early
eighties, a growing interest among postdoctoral students, and now
a very big increase in interest in med students.  It's around
what's happening in medical care, both the issues around the
uninsured, what some have called the hassle factor, all these
things that are happening to doctors that seem to be out of their
control, what can they do about it, can they learn something
more, can they go to business school, can they go to law school,
is there something they can do to have more influence on the
practice of medicine beyond just being in practice.

Lindberg:  That's rather a good sign.

Lee:  It is a good sign, and it's one that I'm really delighted
about, because we're getting absolute crackerjack students
interested in the issues.

Lindberg:  Maybe you've trained a couple of secretaries and
assistant secretaries already.

Lee:  Well, you never know.  The problems are there, and the fact
is that the students are really responding to that.  Very smart
and, I think, still very enthusiastic, despite the problems that
many of us see.  They say, "Oh, it isn't like it was in the old
days."  They see opportunities because the opportunities are
fantastic.

Lindberg:  The med students still are marvelous.

Lee:  Absolutely.  

Lindberg:  Phil, thanks so much for being with us.  I think your
students are very lucky to have you as their mentor.  I'm sure
you'll turn out some good ones.

Lee:  I'm delighted to be here.  Thank you very much, Don.

[End of interview]