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Interview with Dr. John S. Zapp
Date:  September 23, 1991
Interviewer:  Dr. Donald Lindberg
Location:  National Library of Medicine
           Bethesda, Maryland
Transcriber:  Techni-type Transcriptions/DDR



Lindberg:  I am Donald Lindberg.  I am Director of the National
Library of Medicine.  It's my privilege today to interview Dr.
John S. Zapp, who, in the days of Regional Medical Programs was
Assistant Secretary for Legislation in the Department of Health,
Education and Welfare.  The National Library of Medicine is doing
a series of these interviews to help explore the history and the
ramifications of Regional Medical Programs and the legislation in
the U.S.
     Dr. Zapp, thanks so much for being with us.

Zapp:  My pleasure.  

Lindberg:  We're interested in the origin of RMP and its various
accomplishments, or lack of accomplishments, its demise, and the
lessons for the future.  So we welcome your remarks about all
those.  I know, of course, that you were present at the demise,
maybe even a major spokesman for the administration as it phased
out the program.  Is that right?

Zapp:  That's correct.  I was at that time Deputy Assistant
Secretary for Health Legislation.

Lindberg:  You got to deliver the messages, good and bad.

Zapp:  I get to deliver the messages, good and bad, although
sometimes others in the department got to deliver more good
messages.  A very combative time between the administration and
the health committees, so most of them were relatively
contentious types of hearings.

Lindberg:  In the case of the oversight hearings, the news for
RMP was pretty darn bad, although I think in carefully rereading
the testimony, you pointed out that there were certain highlights
in the program, as well as, in the view of the administration, a
lack of overall achieving of the goals.  

Zapp:  I think if there was a common perception in the
department, I think it was one of which people weren't really
anti-RMP.  First of all, I was in the secretary's office and not
in the program area, so my dealings came with mostly the
political people, the secretary, the under secretary.  OMB
certainly was a harsh critic of RMP at that time, but that was
not uncommon.  They were basically a harsh critic of most of the
categorical programs.  Maybe that was one of the problems that
RMP was suffering at that time within the administration.  They
just didn't seem to be able to withstand the constant
requirements for justification that OMB was throwing at the
secretary's office on the re-authorization for each year.

Lindberg:  I've gotten the impression from some of the earlier
interviews, and reading, too, that there really was a problem of
lack of money.  That's what brought it all to the fore.  But
there are certain other elements, actually, which were
highlighted in your testimony that I must say others brought to
attention as well.  One of them was the question whether there
was a certain deviation from the original focus of heart disease,
cancer, and stroke, the so-called categorical focus, to a more
general or perhaps unfocused attention to health care in general. 
Did you find that that was a serious problem, or was that just
secondary?

Zapp:  No, I think it probably was a serious problem.  First of
all, I think all the programs at that point in time suffered
money problems.  That period of time in the economy, in the early
seventies, there had been too many programs enacted, too much
program expansion.  All programs were getting a hard look there,
taking the PSRO and turning it into a cost-cutting tool at the
same time.
     I think in some ways the RMP probably suffered as much on
this lack of focus from the fact that they became almost
competitors with other programs, and the more assignments that
they had, the more entities' involvements they had, the more they
began to compete with other programs within the department. 
Still, they had a base that probably provided them with the
weakest constituency in the secretary's office and within the
administration.  That was basically a medical school base, where
the perception, if you will, was that an awful lot of that money
just seemed to be going to the faculties in the different health
science centers.  That was a perception that was very difficult
for the program administrators to overcome because, rightly or
wrongly, there was a lot of faculty support built into RMPs
around the country.  

Lindberg:  Of course, in the best programs there was a kind of
convener function that, in my view, nobody else was performing,
that was getting practitioners and faculty and so forth together
around the same table, at least in many settings where it hadn't
happened before.  Maybe that doesn't generate a constituency.

Zapp:  I think the constituency in a case like that is those who
are convened at the table.  There's no Washington constituency
for that, or there wasn't at that time.  You had the war on
cancer, which began to get a singular focus on cancer.  You began
to do the same thing in the heart area.  Emergency Medical
Service (EMS) programs were beginning to have their own identity
as yet a separate PHS service.  So it really was such a broad
mandate, it was beginning to have competitors within the Public
Health Service.  

Lindberg:  That's an interesting view.  We haven't heard it said
quite that way before.  Wasn't EMS sort of added to RMP along
with the kidney programs?  I'm not sure how that happened.  

Zapp:  You had a series of these categorical programs.  You had
the heart, stroke, and cancer program, the EMS started in the
mid-sixties, and then after that you had one after the other,
even into the Nixon administration, other categorical entities
that were formed.  In some cases, these were sort of in RMP's
domain of making that transfer from research into actual practice
of medicine, delivery of services.  But you also had a certain
service component that went on with cancer and others, so that
each of these were, in their own way, a little bit competitive
with each other.  There were a lot of programs that certainly
were competitive with the 314 programs at that time.

Lindberg:  What's that?

Zapp:  That was the Comprehensive Health Planning programs.  

Lindberg:  I want to ask you about that for sure.

Zapp:  But they were just one of the many.  Then, of course, you
had the kidney dialysis and the kidney program, which was to have
been a very low cost initiative.  Obviously it wasn't.  It began
to get a very large constituency and take a lot of money out of
the federal budget.

Lindberg:  No one with the sense to come in out of the rain could
possibly believe that was a low cost program at the outset, any
more than you could believe Medicare was a low cost program. 
[Laughter]

Zapp:  Each of these others seemed to have more of a centralized
focus, and I think they tended to work against--certainly in
spite of what people might say in the programs at that time, I
don't think any of the administrators or constituency groups for
the other programs were about to step forward and probably try to
advocate the continuance of a program that in a tight dollar time
may be a competitor for some of their own dollars.  

Lindberg:  Yes.  You know, one thing is interesting to me, namely
the AMA [American Medical Association] relationship.  You are
now, of course, a Vice President for Government Affairs for AMA,
so you're seeing it now from the AMA point of view, and you used
to see it from the government point of view.  Several people we
interviewed, Dr. [Michael] DeBakey, Dr. [Merlin] Duval,
emphasized that AMA didn't like the commission report and
exercised influence to--I won't say water it down, but to change
it, to alter it, in the form that it took in the legislation.  I
had gotten used to that idea.  Now, we talked with Dr. [Robert
Q.] Marston this morning, and Dr. Marston said that, in the end,
AMA was extremely helpful to him in running RMP.

Zapp:  I think that's true.

Lindberg:  Are both of those things true?  [Laughter]

Zapp:  Well, could be.  The first predates when the program was
being started at the same time that the private sector, AMA, and
mostly a country of solo and small partnership practitioners
throughout the country, where first you had Medicare and
Medicaid, and then you seemed to have one big program after
another.  So I think it probably is true that there was a lot of
criticism of the original commission's report.  
     But during the period of time when I was in the secretary's
office over on the legislative side and RMPs were beginning to
have a real hard evaluation and were moving on to the point where
it was clear that they were going to go along the wayside, the
AMA was an advocate and a supporter.  

Lindberg:  Interesting.

Zapp:  I think this had been built up through some period of time
of a constituency out there in the health science centers and in
the outreach.

Lindberg:  So had they been on the positive side to start out
with, the thing might actually have survived?

Zapp:  I don't think so.

Lindberg:  No?  [Laughter]

Zapp:  I think that there was a time, just like the CHP program
that eventually was phased out, there were programs that were
created in one time.  The large health financing programs and
very small targeted categorical programs are the kinds of things
that have survived.  That plus programs, putting aside all the
biomedical research and so forth.  But you take a look at what's
going on in the Public Health Service now, the kinds of programs
you're dealing with that are targeted, they're regulatory,
they're safety for individuals, and you gradually have seen less
and less involvement in federal support for education.  

Lindberg:  That's true.

Zapp:  I think they were just a forerunner to that because they
were one of the first of those that was on a bubble without a
real sound definition or perception that people could understand. 
I can recall at one time taking that plane trip back with Eliot
Richardson from Mayo.  We were there for a benefit for Anchor
Nelson [phonetic], who was then the ranking minority member on
the Rogers Subcommittee.  He had been going through a lot of
program evaluations and asked me what my impression was of the
RMP at that time.  Well, it was clear to me, knowing Eliot
Richardson as long as I had at that point, that really he had
one, and it was really more my job not to answer that, but to try
to get it out of him.  
     What I got from him was that he really couldn't find
anything that he felt he could go to OMB and really defend over
other programs.  He felt that that's what he was having to do. 
He couldn't get the definition of it, other than the fact that a
little bit of what it did, everybody else did.  As a secretary
who had to compete for dollars, this was a problem for him.  

Lindberg:  He would have liked to have had a little bit more
drama to comment on?

Zapp:  He would have liked to have had some drama.  He'd like to
have had something that was more specific to demonstrate in
Washington the uniqueness of the program.  I don't care if you're
dealing with a rural health program or Indian health.  You have
much more definable types of things that can be demonstrated
before a committee.  You talk about the Regional Medical
Programs.  In the education community and in the health services
delivery community, that probably meant a lot.  In the budget
circles in Washington, it had to compete with other programs. 
There began a contraction of dollars going into new programs.  It
didn't have that kind of focus.  

Lindberg:  I never thought of it as anything to do with
education, but I understand now from the reading that some did,
and I guess, amongst other things, the idea of subsidizing the
education of wealthy physicians wasn't well received.  Do you
remember that being a thread?

Zapp:  A little bit.  A little bit.  I think the amount of
faculty salary that went from RMP was probably the larger one. 
There was a little bit on the continuing education side, but
basically so much of the money seemed to be going into faculty
salaries.  I can recall on several repeated program reviews,
which were a year apart, that this was a growing Achilles as it
related to the people who were doing the examinations.

Lindberg:  But isn't that basically what all research grants end
up doing?  

Zapp:  Well, that's true, except that if you take a look at the
type of basic entitlement grants and so forth that were going on,
they were starting to go through a contraction at that point in
time, even in health manpower.  The basic entitlement grants and
the mandatory enrollment increases, all these kinds of things in
health manpower, were also being contracted down at that point in
time.  But they had their own focus.  Again, RMP, I think,
suffered at that point from having lost--with the establishment
of the National Cancer Institute (NCI), it sort of lost its
central being, and its purpose at that time was the definition of
a lot of other programs.  

Lindberg:  But there was an NCI to start out with, wasn't there?

Zapp:  There was an NCI, but there wasn't the war on cancer.

Lindberg:  There wasn't the war on cancer.  I see.

Zapp:  That usurped all the money, and I'm sure, justifiably at
that point in time, NIH [National Institutes of Health] was
concerned about the establishment of the war on cancer because of
a concern of the dollars that would take away from other
biomedical research.  

Lindberg:  In retrospect, that wasn't the way it worked.  

Zapp:  No, it's not.  It set up competition for establishment of
yet new wars on other diseases.  

Lindberg:  Yes.  How about the question of Comprehensive Health
Planning?  You referred to that before.  In your testimony, you
said, although you introduced it by saying it's the
administration's position, but you said that much of what RMP did
could be picked up by Comprehensive Health Planning and other
existing programs.  Is that a serious belief?

Zapp:  I think the belief at that time was of the things that
were not identifiably picked up in other areas, in other words,
with the health manpower, large research budget on cancer, on
heart, etc., and NIH was really expanding at that point in time,
one of the few entities that really was expanding at that
particular point in time, that the kinds of things that CHP could
do, when you considered they had the grass roots constituency
that RMP didn't, that they would be able to fill in for those
areas that RMP was trying to work in, that really weren't a
part--certainly wasn't a part of the original charter, at least
as far as I know.

Lindberg:  Wasn't CHP centered on health departments?

Zapp:  There were AB agencies, state and local.  Basically it was
to plan the system, and you also had the establishment of the
National Center for Health Services R&D, which I think was
another inherent competitor to the RMP program.

Lindberg:  That did last.  CHP didn't last at all.  

Zapp:  Yes.  Well, CHP, by itself, because of the fact that it
became dependent on local support for matching money.

Lindberg:  Of course, in many states, the governor simply folded
CHP and turned it over, turned the problems over to RMP.  

Zapp:  That's true.

Lindberg:  A perfectly sensible procedure, in my view.  

Zapp:  Well, CHP was regulatory.  If it did its job right, its
job was to say no.  After a while, programs like that are not
very popular because you have to say no to a lot of people who
want to do a lot of things.  As a result, people were always
trying to push CHP someplace where they could find a way to do
away with them.  Ultimately they did.  I don't think RMP suffered
from that.  I think RMP suffered more from the fact that they
didn't have the overall identity that people could affiliate
themselves with, and they didn't have any type of regulatory
authority.  They couldn't help save money.  You couldn't
demonstrate whether it was 80 or 100 or $140 million that went
out, which was a lot of money at that point in time, that it
actually was going to impact on federal outlays, that it was
going to make them either better or that it would begin to make
them more efficient, or that it would begin to restrict them. 
CHP offered that, because supposedly they were supposed to keep
down capital expenditures.  As a result, that was to save the
federal government money.  

Lindberg:  A wild system.  Whatever we've done hasn't saved the
federal government or anybody else any money.

Zapp:  It certainly hasn't.

Lindberg:  But I must confess that the problems of access to
health care, cost of health care, quality of health care, the
same things we talked about in '65, seem to be uppermost in
concern right now in 1991.

Zapp:  There's a certain touch of irony when you take a look at
the testimony that I delivered eighteen years ago, when the
administration thought that they and everybody else was sitting
right on the very edge of the enactment of a comprehensive
national health insurance.  

Lindberg:  Yes.

Zapp:  What they wanted to do was to have in place, in theory, at
least, things like CHP, which would help control expenditures in
a comprehensive national health insurance program.  They didn't
see where RMP effectively fit into that, and that's the big
advantage, I think, that CHP had over RMP at that point in time.

Lindberg:  You had to definitely be out where the people were to
see RMP in action.  It didn't come through very plainly in
Washington.  I can see that.

Zapp:  No, it didn't.  Except for certain things that were
happening in some members' districts, there were bigger dollar
entities beginning to occur in a member's district.  

Lindberg:  That's true.  It never was a really big program.

Zapp:  It never was big enough to develop the constituency that
would make a member of Congress be willing to go down on the
sword for it over some other broader programs that they saw
developing much larger.  

Lindberg:  Some people say that the country is once again looking
at the possibility of legislation to cure these various health
ills nationally.  Do you think that's possible?

Zapp:  Well, I tend to think that the same things that kept the
enactment of a comprehensive health insurance then are probably
even living with us in larger focus today.  

Lindberg:  Yes.

Zapp:  One of the interesting things that was just starting to
occur at that point in time, where they were beginning to try to
get money from the providers to help make programs that really
meant to regulate them go--and the CHP was a prime example of
that.  It's important because it was such a competitor to the RMP
programs at that time.  We see now, when we're trying to expand
coverage for people who are in employment base and out setting
the government's answers, by and large, to find some way to make
the employer pay for it, because the government can't afford a
national health insurance program any more now than they could in
1973.

Lindberg:  And yet in a way, there seem to be fewer people
covered now, even, by our insurance schemes and so forth.  Maybe
that's because we discovered Medicare in the meantime.

Zapp:  I think so.  I think the percentages are probably about
the same.  About 85 percent of the population was covered then,
and I think Medicaid perhaps is less expansive now, not covering
the same numbers of people that Medicaid did at that time.  

Lindberg:  If there were a kind of good answer, and there will
always be new legislation on health--we can't see the end of
that--what's the trick in making it work?

Zapp:  What's the trick in making it work?  I think the trick in
making it work is to have an effective constituency behind any
program.  If you take a look at the programs that have had real
problems, it's been the ones that have lacked, whether it's
public assistance programs that have had the terrible problems
through the years because of the lack of organized constituency,
I think RMP suffered from that, ultimately CHP did because they
had to get their money from the provider community and from the
governors who got tired of saying no, and they lost their
constituency.  I think we're beginning to see some of that now
and probably in some other programs.  But if you were to have a
new program, it's got to have identification, it's got to have a
constituency.  

Lindberg:  One of the curious things is that RMP was one of the
recommendations of the heart, cancer, stroke report, but also one
of them was what became Medical Library Assistance Act, also
created in 1965, continues to this day.  It made possible the
development of what's now the National Network of Libraries of
Medicine and so forth.  Much more modest, of course, but
consistently supported.  I've often wondered why it worked and
RMP didn't.  I've always thought it was because it was more
modest, but maybe it's because it was more easily understood.  

Zapp:  I think it was more easily understood, and it's also here
in Washington, for one thing.  That helps.  

Lindberg:  That's true.  We're here in Washington, but 100
percent of the money is spent elsewhere.

Zapp:  I understand that.  That's true.  But a member of Congress
and the appropriating committees can understand what a library of
medicine is and the fact that it's able to keep up on a high tech
basis with information today and information transfers and
storage.  They understand that.  It's relatively easy.  Maybe
they don't understand what you've got in your files, but they
understand the process and the need to archive it.  Notice the
support they give the Library of Congress.  

Lindberg:  Oh, yes.  They are ten times as big as we, and
excellent, as well, but also provides some direct service to
Congress, which is understandable.  

Zapp:  But yet you take Congressional Research Service and a
number of others that are a little more diffuse, and you'll find
that they're not near as well funded as the National Library.

Lindberg:  Well, we'll keep trying to make sure that what we do
is understood.  What areas do you think the future holds?  Where
are the problems now?

Zapp:  I think the problems now are in being able to effectively
continue programs such as Medicare and Medicaid in a way that's
efficient.  It's becoming more and more difficult to do both for
the providers and for the patients and beneficiaries of the
program.  I think that a situation such as AIDS, which will
continue to draw large sums of money, would go elsewhere, will be
a problem and a deterrent.  I think the fact that the state
governments who, four or five years ago, looked like maybe they
were going to be the ones that were going to put together some
programs on a state basis to take care of some health services
delivery, their financial woes now are such that they're not a
viable alternative, and you see them rebelling against mandates
that have been put on them by Congress.  
     So I think it's going to be dollars and the maintenance of
some type of federal private system, but certainly not a fully
federalized one in this century, I wouldn't think.  

Lindberg:  No, I would hope not, too.  There are, though,
interestingly, some things that probably are best approached
nationally.  This cure for AIDS, I suppose, is one of those.  I
mean, we don't have enough talent no matter where we look there. 
But thus far, I would say NIH and CDC [Center for Disease
Control] have responded pretty darn well.  We hope there won't be
many more as big as that.  

Zapp:  Well, I think we all do.  But it's interesting that you
see many things turn, and I think you'll see the private sector
in many cases now looking federally for support and assistance in
such things as professional liability and tort reform, which used
to be a state-based issue.  So I think there's a certain
dichotomy out there of (legitimately) the private sector saying
some things, in fact, can be handled and should be handled better
on a national level, and some things they simply can't afford.

Lindberg:  Vaccine development is a problem again with liability. 
We can see that.  

Zapp:  That's been one of the more majorly publicized ones
recently.  One of the other problems is just the fact that you've
had so many different states overturn tort reforms piece by piece
across the country to where it's gotten to the part that you
really now have to have a federal solution to it.  

Lindberg:  Dr. Zapp, I appreciate you being with us, and I have
appreciated, myself personally and on behalf of NLM, the support
of AMA in this and many other activities.

Zapp:  Fine.  Thank you very much.

Lindberg:  Thank you for being with us.

Zapp:  Thank you.

[End of interview]
                           Addendum to Interview

Q:  Tell us about the demise of RMP and what it was up against.

Zapp:  I think one of the things that led to the demise of the
Regional Medical Programs was the competition from other more
identifiable programs within the Public Health Service and HEW
that it had to compete with.  RMP had to compete with Emergency
Services, Migrant Health, Rural Health, Indian Health.  It had to
compete for dollars with the entities and the Food and Drug
Administration.  There was beginning to be the development of
different area health education centers.  These were all
identifiable competitors to the RMP at that point in time--
kidney.  Cancer, of course, was the big one that had been formed
and was the most identifiable one, but certainly heart and lung
came right after that, the war on the identifiable things.  RMP
didn't maintain the same identification in the seventies that it
had in the mid-sixties.  

Q:  One of the things that RMP was criticized about--and this was
in your testimony in '73--the percentage that went to faculty
salaries.  Can you give me a short statement on that?

Zapp:  I think there was a perception at that point in time, with
all of the money, the funds that were coming into NIH and going
out to their extramural grants, that there was doubling up in
many of the health science centers between the funds that were
coming from NIH and from the RMP, and that, in fact, there were
people out there--the perception was that there were people out
there that were on large salaries, that were either from the
different institutions at NIH or from RMP or from both of them,
that as a matter of fact, they were supporting the state
institutions. 

Q:  One of the things that didn't get touched on was the suit
that was filed to pull the funds that had been impounded.  What
was the reaction to the suit and the fact that the courts
ultimately said, "Pay the people the money"?

Zapp:  Of course, that was a period of time when they were just
beginning the impoundment process, and OMB and the
administration, I think, were quite willing to run that route. 
Remember that the family practice grants were the first ones of
which they went through this process of going back and suing to
have funds released.  So during the period of time that I was in
the administration (I left it about that time and went on to the
private sector), I don't think it was any great surprise about
the suit.  I think they were quite prepared for it.  I don't
think they thought they were going to lose, but they were
prepared to have the suit.  That was my perception.  

Lindberg:  I neglected to ask whether you believed at the level
of the president there really was any awareness of RMP as a
program per se, whether he favored it or didn't favor it or was
even aware of it.  

Zapp:  I would think that he probably was not aware of it.  I
think at that time the health areas that he was involved with,
there was also the HMO, the other categorical ones that we didn't
get into today, which had started out as a competitor and turned
out to be an initiative of the administration.  All
administrations have a way of taking things like that.  That and
the war on cancer and other things, it seemed to have much more
public appeal.  If programs like RMP or others that didn't have
that public appeal or identification got caught in the way, then
sort of so be it.  That was not the kind of thing that on top of
the administration they were really spending any time, so I doubt
the president had any awareness that it existed.  

Q:  Cut.  That's it.

[End of recording]