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EXECUTIVE OFFICE OF THE PRESIDENT
BUREAU OF TIE BUDGET
SASHINGTON, D.Co |

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Address of Irving J, Lewis
Deputy Assistant Director of the Bureau of the Budget
before the
Confescnce-Workshop on Regional ! Medical Programs
Te. D.C,
January 1 1968

A NON-PROFESSIONAL LOOKS AT REGIONAL MEDICAL PROGRAMS

I am pleased to have this opportunity to be at the Conference-Norkshop on
Regional Medical Programs. I always welcome an occasion to show to an
unbelieving public that the men in the Budget Bureau do not wear green eye
shades or sit upon high stools in their counting houses. In a recent talk
at this same hotel, Dr, Ivan Bennett, Deputy Director of the Office of
Science and Technology and one of my principal mentors in the health field,
described us in these words: |
"Some of you, I know, have had experience with the Bureau of the

Budget, where, since the multiple-crack system does not exist and there
are no fissures that allow for penetration of local interests into
national policy decisions | to p anzmuens* decision-making and allocation

of resources, one has recourse only to putting together a balanced,
persuasive, and fact rqunent. It is with real respect and admiration
| that 1 say that here a8, the beady-eyed, ‘hard-nosed skeptics, receptive
to opinion but deinanding iron-clad factual details--a demand which for

me, and indeed, all of m my colleagues who have been exposed to it in

depth, has meant a reorientation of thinking, a new level of objectivity,

and above all, a lasting respect for a muchenal igned and Little understood

 

- executive agency,"

 

 

GREET Le

  
 

a at ape

I quote Ivan at lenpth so that I may publicly accept his cornpiimer!
while at the same time deny that we are beady-eyed, and hope that

are better understood as a result of his efforts, Also, Cespite

 

passion for anonymity, we now find that the stage on which Federal
programs are played has become so vast that we do have to allow fc
a few occasions which permit us to see local interests at work, or,
as we say at the Pureau, the real world, For it is to heip in shapsr-
this real world that Presidential goals, policies, purposes, and
proposals are eventually fused into what is termed "the program of ti.
President,"" It is the translation of that program into dollar terns
which leads us in the Budget Bureau to pursue the facts, to questicn
the purposes of programs, to analyze--alas, all too imperfectly--their
‘costs and benefits, so that the decision-maker--in our case, the

, , .

President--can look at alternatives and evaluate relative payoffs from

different kinds of Public investments,

As availability of public funds for public purposes becomes tighter,
the need. for questioning ds heightened, Our thirst for knowledge is
quickened as we understand that when budget decisions are made we are

affecting not anly 3

 
  

in which society : ites its people and its naturel or physical + ie

by
qed

pecvites:or social purposes which these resources

 

 

resgurées, and the.
| product. The allocation process is never ending--the larger the Federal
budget. the greater the ‘responsibility that Government assumes to channel

and direct its resources according to rational choices.

ES RRR RR ee mem oogpaeman

 
 

I have no crystal bell to tell uc how large the level of Federal spending
will be or ovght to be, I would caly be speculating, and ] would be
especially speculative if LT enpaycd in the game of “whet if we had no
Vietnam?” The leyel will renain hich, however, and the competition for
the dollars increasingly acute, ‘lis acute covpetition means that we in
the Budget Burcau rust concern ourselves with the goals and objectives
“and the hoped-for results of health and other progrems, We try to refuse

to go along with the proposals that shoot from the hip.

What I am saying is that while we in the Budget Bureau heave no special
wisdom or formulae for sorting out our budgetary goals and priorities,

the President wants his program to be tuned to the problems of our society
and the need for developing solutions to those problems, He wants his
final choices to be not only good choices, but better than other proposals
to accomplish the same end, and to show better returns for the same
investment of public funds, To be sure, the budgetary process is neither
clear-cut nor infallible, and, as I have indicated, our analytical

techniques are still probably not as solid as we would like.

Still, I hope you will accept that this budgetary effort is no simple
accounting task, but one in which after we fall back exhausted--incidentally,
that will occur for 1969 very shortly--we have helped the President find

a balance first, among the national goals of national security, foreign
affairs, education, health, abolition of poverty, environmental quality,

recreation, housing, transportation, science and technology, and so on,

 

 

 
 

 

ananesanunp eet coon toe

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as :
and second, arong the programs rost likely in action to give hin progress
toward these poals, ‘There is pever enouch to pu itowid, and it is little
wonder that Maurice Stans, Presicent Eisenhower's lost budget director,

4

called tudpeting the uniform distribution of dissatisfactions,:

There is ample room to demonstrate that the worth of social investment
is subject to quantifiable assessment, There is rather a widespread
effort today in the Government to produce these assessments, going under
such names as systems analysis-or program planning and budecting. Thus,
investment in education is said to be more than socially "good"+-we

Say it is economically productive, and we can even say by how ruch,

We can, by better analysis, show that the rehabilitation of the’
handicapped is not only socially useful but economically, advantageous,
In medical science,” similar reasoning can and has been applied to show
favorable cost/benefit and cost/effectiveness ratios--for example, it

has been done in studies in the Department of Health, Education, and

Welfare of the health of the poor and the health of children,

But let me quickly hasten to disabuse you of any idea that. budgeting
and its associated decision-making is strictly for budget professionals,
This is no system of pushbuttonSor whirring magnetic tapes, Public
policy is still made in the political arena, and it is in this arena

that the budgetary decisions are made,

A better grasp of the role of public expenditures in creating social

assets does not by itself tell us when to spend or how much to spend, -

 

 
 

 

 

Our pluralistic society responds to pluralistic dewands whether they
are supported by a dispassion:te array of facts and figures or not,
Many huran needs clamor for prs jonste attention, ard many problems
cry out for solutions as neplectcd areas of public concern, Certainly,
our planning and analytical capability is not great enough to have given
us in sostwrt a time rationality to develop ovr present array of Federal
‘ human resource programs, About 459 such programs are described in the
annual catalog of Federal assistance programs produced by the Office

of Economic Opportunity. I commend this catalog to your attention.

It; may help you not only to find out ‘whether there is a grant program
wd finance your favorite project, but it will also rather forcibly

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‘impress upon you the sweep of Government activity in the social field.

The use of the phrase “human resources" has become fashionable in
today's intellectual parlance, bat 1 think it signifies that the
programs grouped under this banner constitute a new type of governmental
effort, not to be compared with social legislation of the past--either
the New Freedom of Wilson or the New Deal of Roosevelt, That
legislation--fair labor standards, child labor laws, food and drug
controls, unemploynent insurance, social security, to mention a few--
reflected a simpler social philosophy that Government should provide

a basic underpinning: by interdicting various behavior patterns or by
providing certain minimum income guarantecs, Today, the revolution of

rising expectations in the less developed world is paralleled by unrest

 

in our own society, and Government is responding by provision of services

 
 

on a very broad front, ‘fhe 69th Congress alone produced 21 new health
programs, 17 new educational propyams, 15 new cconcemic development
programs, 12 new programs to mews problems of citics, and 4 new

ranpower pr OPTaMms «

From our carly days, we Americans have been a ractical" people, And

_50 our society tends to, bring into being human resource programs that

arc targeted to specific action areas, These may be catepories of disease
or specific population groups, and-~-I may add--are too often controlled

by the professional specialists. Too often, the professional insists

on assumptions, approaches, programs, or technolopy of universal
applicability, Lest we "dehumanizo” human resource programs, may I

stress that the primary focus of Government in managing this array of
programs ought to be on the individual no matter who he is--underprivileged,
poor, aged, migrant, veteran, child, mother, nonwhite, retarded, rural,

uneducated, or other statutory category.

’

These proprans, and I include Regional Medical Programs, have created

a new dimension for Federal management and for relations with the private
sector and State and local governments, Unfortunately, for those who
approach governmental relat ions simply, no one has contrived a simple
formila for the execution of these programs, On the contrary, we have
adopted, probably not always consciously, the approach of pragmatic
experimentation, There is not always tine to wait for the perfect

solution, So, we grope toward it, accepting some risks, We place a

 

 

 
 

 

 

high premium on close cooperation and a flow of information among equals,
and, above all, we are wil ling to sce institutional chonge come about in

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many forms, le have had to try to move more end yore decision-naking

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out into the field, recopnizing thet coordinetion of prograns cannot
all be achieved by Federal action, The benefits of dccentralization,
however, rust be accompanied by the costs of anomalies, diversity,

inconsistency, and even downright error, But deep-rooted social and

economic problems are complex in nature and cannot be attacked by simple-

minded, single-shot approaches,

In jhis report to the President and the Congress on Repional Medical Programs,
the Surgeon General set forth at length a number of issues and problems

which face the Regional Medical Programs, Sone derive from characteristics
of the general health setting in this country--for example, its essentially -
voluntary and private nature, the magnitude and complexity of what is

often termed a $43 billion industry, manpower limitations, and rising
medical costs, Others relate to the law itself--dcefinition of a region,
significance of disease categories, use of advisory groups, dissemination

of information relating to advances in diagnosis and treatment, and

others,

In time these and other issues will be dealt with in the public, executive,
and legislative forum, But, as I see Repional Medical Programs in the |
context that I discussed earlier--our problem of allocating resources of
men, money, and materials--its prime worth to our society will be in its

capacity for improvement of our system--or systems--of medical care for the

 
 

 

 

people served, Let me stress the word medical because too oftcn in the

past in this country we nave used "health" as ea cuphemisn for medical

in view of our unwillingness to confront on a public level the problens

of medical carc,

By now it is established that Government has set its face in the direction

of tackling the problem of assuring to all its citizens the access and

‘availability of high quality medical care, I regard as idle the

discussion whether we mean such care js a Yight, like public education,
or,a privilege, The goal is clear, and if we are serious about it, we
must constantly make painful choices as to where we will put our monies

and equally painful decisions on how to arrange cur institutions.

1 do not anticipate that we will experience najor trade-offs in Government
spending between previously well-funded activities that were of less
public controversy--such as biomedical research and academic science--

and new activities designed to finance and make available the medical
knowledge we have, However, it is also clear that extremely high on

the health agenda is the distribution of our medical knowled ge--what we
call the organization and delivery problem, I think that it is in

solving this problem and in bringing medical care to people that the

Regional Medical Programs potential lies.

Medicare and Medicaid alone account for over $8 billion of the Federal
expenditures of $15 billion for health programs. They have virtually

eliminated financial barriers for the aged and have made it possible

 

 
 

 

 

 

oo

 

 

for poor and near-poor in three-fourths of our States to receive an
increasing volume of medical services, These lancrark laws of 1965

are accompanied by others in maternal and child health,

Ironically, rany people--and especially medical professionals--are
troubled over this outpouring of Federal funds to diminish the financial

burden of paying for medical care, and they are rightly troubled, because

with demand for medical care now effective, as the economists say, the

pressure is on the profession to deliver. In addition, of course, there
is the vocalized but as yet not effective demand of citizens not yet
covered--for example, the disabled, the migrants, or the rural and

urban poor not eligible for Medicaid, None of us needs to be an economist
to know that when more funds are poured into the arena for purchase, the
selling system must be more efficient or its supply must be enlarged or
the infusion of funds may simply be eaten up by price inflation, Debate
cont inues--and I am no expert--on the extent to which Nedicare contributed
to rising medical costs, but the rising costs are with us and therefore

spur us to examine our system of medical care,

Many speak of Regional Medical Programs as a unifying focus for the health

resources of a region, linking patient, physcian, hospital, and medical

centers to provide the latest advances of knowledge to the people in this
region, But health functions. are a continuum, and Regional Medical

Programs will have to consider the problems of distribution, cost and

“organization of health care, JI would think that, because of the tremendous

 
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va . . . :
scope of heart discase, cancer, stroke, and related discases, the task
of improving organization and delivery of medical care through Regional
Medical Prograns has to be viewed in the context of comprehensive health

Eiaiuo

services and not in a narrowly-based disease aporoach.

«

This task will have in the long ran serious implications for medical
centers and medical schools, The comfort of biomedical research and

, individual case treatment or tcaching may be replaced for many by the
raging controversies over medical care costs, doctors' fees, etc.
“Interesting medicine’ may become not disease-oriented, but the area
of organizing the system of care, of course, another impact, still only
seen in general terms, will be seen in the need for production of more
doctors faster, The President's Health Manpower Commission recommended
that we develop economic incentives to make this possible, Oliver Cope
wrote somewhat despairingly of this problem of medical education a few
months ago in Harper's Magazine. I would hope that in time we could

- overcome his despair by responding to the prod of the Commission.

Through the National Center for Health Services Research and Development,

| « Regional Medical Programs will pet invaluable assists through a rising level
of supporting investigations and experiments, Another significant actor

on the scene is the “Partnership for Health,’ and I guess we still have

to establish with more clarity how we want this experiment to tie in

with Repional Medical Programs, There is a tendency to regard this

 

program as ‘just another State support program, This is an error in

judgment, and you will find that it is regarded here in Washington as a

   
 

 

 

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pilot program of some significance, It is a major breakthrough in changing

the proclivities of professionals and their exceutive and legislative
supporters to opt for narrowly-bascd categorical programs, There is

a serious effort afoot in this toim to create wore ronageable packages
which pernit the local private and public sector to act decisively while

preserving the right of the Federal Government to establish priorities

of national sipnificance,

In the Budget Pureau we have read with considerable interest the Surgeon
General's priority statement for Partnership for Health issued in November.
This priority statement is very topical, and I suggest that it has great
meaning for many of you, This statement establishes three budget
priorities that are relevant to Regidnal Medical Programs?

First~--The requirement for comprehensive health care, directed to
individuals and families, not diseases}

Second--Improvement of the health status of the indigent; and

Third--Use and training of neighborhood residents, and involvement of

neighborhood residents in planning and implementation of health projects,

I would only bore you were I to recite statistics about the health status
of the poor. The evidence of unusual disease and high prevalence of

ill health identifies them as a high-risk population, While the middle
and upper classes in this opulent society have a malaise and uncertainty
about their own lives, the health status of the poor is part and parcel
of that complex called poverty which is much greater than just lack of

income, It is what Colin McLeod, in his recent AAMC address, eloquently

 
 

 

 

by the “medical radicals," as Marion Sanders calls them, of Neighborhood

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called "the lack of hope that one can ever rise beyond the despair of

being forever a hewer of wood and a drewer of water; it is the despair

  
  
   

of being uneble to aspire to the expression of his potential as a human being;
it is the despair of having no future cxcept thet of nena survival in misery

loaded enclaves surrounded by an opulent society."

There has now been mounted in the Office of Economic Opportunity a program

 

Health Centers, Today, 46 centers are in operation or to be funded, and
medical schools at all levels are in the business, Thisis more than an incidental
change in attitude, It is recognition that the Nation's health business

lies in making medical care available to all, and the role of medical

schools and centers is crucial in this, May I as a layman suggest that

heart, stroke, cancer, and related diseases--significantly related or not--
will be found among the poor in the Neighborhood Health Centers, Undoubtedly,
many medical schools are or will be deeply involved in both Regional
Medical Programs and Neighborhood Centers and both programs should profit

‘

from each other,

If I am right that Regional Medical Programs has not been sufficiently
concerned thus far with the problems of the poor, I can extend this lack
of concern to the cities generally. Not that I ignore the rural poor.
The Breathitt Commission reminds us most forcibly that urban poverty has
deep roots in rural poverty, But the crisis of the cities is a human
resources crisis and the cities are where we will find most starkly

the poverty of which Colin McLeod spoke.
 

 

 

 

a
For too long our society has invested resources in only the physical
aspects of the city, but the Model Cities program is axple testimony
that human and social needs are the dominant thee today, 63 cities
have been selected for first gencration grants under this top priority
program, designed to improve the quality of urban life, declared by
Congress to be the most critical domestic problem facing the United States,
These 63 citics now have the initiative by law to develop programs for
sclected neighborhoods so as to remove or arrest blight and decay, to
make marked progress in reducing social and educational disadvantages,
ill health, underemployment, and enforted idleness, and to provide
educational, health, and social services necessary to serve the poor in
the Model City area, You should be aware that this is a program run,
through the Department of Housing and Urban Development, but that HUD

places primary reliance on other agencies for evaluating the human

resources program proposals of these Model Cities plans.

~ The Model Cities program, bom iu the inspiration of a few, dealing with the

institutional arthritis of Federal, State, and local bureaucracies and
frustrated by the professional isn in health, ‘education, and welfare, may
yet turn out to be our boldest experiment. Regional Medical Programs
tries to develop, on | the basis of local initiative, new institutions

and techniques to solve health problems, In a sense, Mode] Cities is
Regional Medical Programs writ large upon the total human resources
scene.

The Model Cities program has another lesson for Regional Medical Programs--

the necessity of citizen participation in program developrent and his

 
 

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access to the decisionemcking process, There are eny roles which we can
attempt to d fine as being logics 1 end effective fur the private citizen
in health affairs, Pospital tra.tec or planning Lois merber are obvious

ch as

Laps somewhat pore nelulous is the role of

roles, Not so clhvious and per

&
a r

the private citizen as a member of the hoard of directors of a regional
medical program. 1 know many of you are thinking about this role of the
“citizen which, incidentally, would parallel the consuner representation
found in the Partnership for liceith program, In any case, the non-
professional role in planning a regional medical program warrants

expansion and the community members, to play this role, will have the
responsibility for asking a number of unpleasant questions about the
quality of the medical care in a region, the availability and accessibility
of comprehensive hgalth services, or the usefulness of Regional Medical

Programs in inhibiting the rate of cost increase in medical care.

May I suggest, however, that there is another consumer role which mst
be considered, It is an inevitable role if human resources programs
are to reach the people whom they are designed to serve, I am speaking
here of the citizen in the neighborhood who will not be satisfied with
past patterns of consumer representation, but wishes rather through
neighborhood organizations to make his views known, The requirement

of participation of the citizens in the neighborhood in determining the
programs which serve them is found increasingly in Federal law, Nodel
Cities and Office of Economic Opportunity being only highlight examples,

The prescription of the participation may vary in differing statutes as

 
 

 

15
may its administration in practice, Put one thing is certain: the voice
of the citizen consurer will be he ed at the crassroots level in the

deliberations affecting his future,

The need of commundty involvement end citizen participation is unfamiliar
to the nedical profession, which has survived a long time in this country
under the slogan "you are the doctor," Put Paul Ylvisaker very astutely
pointed out at last year's conference in this hotel thet the Regional
Medical Programs has too narrow a professional base, and he stated that,
if the health professions do not become consumer oriented, "within two
years your medical schools will be picketed by a combination of the
American Mayors Federation and CORE, And I wonder," he said, "if your

medical faculties are ready for that experience,"

Not too long ago Public Broadcast Laboratories televised the sharply
polarized views of the police and the militant Black Power advocates
regarding law enforcement by police, It was a fairly chilling experience
for the advocates of moderation, But I found provocatively thoughtful
the minister from Atlanta who calmly told a nationwide audience that

all our social, education, and health efforts were hampered by an
essentially negative attitude of Americans toward the poor and the Negro.
If we expect human resources programs, including Regional Medical Programs ,
to realize their investment potential to serve human beings, the
professional's attitude must be one that not only permits him to help

the poor and Negro, as he did in the past eras of social legislation,

but also motivates him to urge their involvement and give them access

 
 

 

 

 

 

Office of Feonomic Opportunity, and Pertnershin for Health,

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to the decision-making process, That is our goal in Model Cities,

It should

mae

be no less ia Regional Medical brogranms.

May I thenk you for this opportunity to be present at this Conference,

and wish you well in your endeavors,