When T was thinking about what to say  to  this  group
         today. several ideas came to mind. First, I  could  have  told
         you about bow many and what kind of projects were  funded  with
         the $10 million Supplemental Appropriation, what  the  various
         final phaseout arrangements were, and how  the  continuing
         projects w-uld be administered. Then, too,  I  could  have
         preached another funeral oration for RMP, but that  has  been
         done too many times already, so many in fact, that it  is  now
         probably more appropriate to hold a memorial service, and
         that's about the last thing that you want to listen to at
         this juncture. So. I'm going to try a  new  and  different
         approach, and I hope that it will help to capture  that  essense
         of the RMP experience and lead to some useful conclusions.
              Those of you who have been to Washington lately  may  have
         had an opportunity to visit the Smithsonian  Institution's  new
         Air and Space Museum which opened on July lst  this  year.  If
         you haven't make it a point to get there next  time  you're  in
         town. Tt's worth it. When my family and  I  visited  the  museum
         on opening day, I was particularly impressed with  one  exhibit
         that sort of growg on you. It's in a hall  devoted  to  space
         flight and particularly the missions to the  moon.  The  exhibit
         itself consists of a relatively small, many-sided  room  with
         outward sloping walls.  The visitor stands on a low step,
         1.6ans back against the carpet covered wall and watches a  slide
         show projected on three screens near the  ceiling.  There's  a
         neutral musical background" nothing more.
              The pictures are familiar. They are those  that  we  have
         all seen before, the faces of the astronauts whose  names  we
         can no longer remember, the console-filled room, the  lift  off,
         the vehicle shining in space, the white suited  man  floating
         at @-he end of a golden cord, the cloud- capped earth  receding,
         the desolate moon, the footprint in the sand.  At  first,  how
         banal. how commonplace it all seemed - like  yesterday's  ball
         scores, and then suddenly after a while watching  the  slides
         clicking on and off with no captions, no  narration,  no  even
         the familiar up-and-under music that signals  important  moments
         in film and TV.it strikes you - the enormity of the achievement.







              So what I will try to do today is to present  a  sort  of
         verbal slide show to carry you back quickly through the ten
         years of the RMP program through old, familiar  scenes,  and
         to flash before you some verbal pictures that  perhaps  will
         bring to you as it has to me some new perspectives and insights.
         I will begin with the last period of normality  just  prior-to
         the 1973 phaseout directive, then look at the'program  in  a
         larger context, and finally try to devine some meaning from
         the experience.
              In January. 1972, the President budget for  Fiscal  197
         requested $130.3  million for RMP.  Subsequently two separate
         Appropriation Bills were passed by the Congress in August and
         October, 1972 respectively and vetoed by the President.  Each
         of these would have provided $165.4 for RMP.  To  keep  HEW
         programs going until an Appropriation could be enacted, the
         Congress passed a continuing resolution on October 29,  19720,
         permitting RMP expenditures at the $150 million  level  set
         by the House   Until January 29th, 1973 it was  expected  that
         the program would continue at least at this level.  The 29th,
         however was a fateful day.  On that day the President's Fiscal
         1974 budget was released.  Smashing all expectations, it
         recommended zero appropriations for 11 health programs including
         RMP. The budget gave the following as the  reasons  for  RMP
         phaseout:
              $'Despite Federal expenditures in excess of $500  million
              for these activities, however there  is  little  evidence
              that on a nationwide basis the RMPs have materially
              affected the health care delivery system.  Further ex-
              penditure of scarce Federal health resources  on  this
              program, therefore cannot be justified  on  the  basis
              of available evidence."
         Immediately after the budget publication  announcemen  of  the
         RMP phaseout was made by telegram. On  February  6th,  another
         tbl.egram advised all MIPs with August 311, 1973 end dates that
         these had been shortened to .3une 30th.  On February 22nd final
         phaseout applications were requested and on April 4th phaseout
         awards were issued stipulating that no RMP  expenditures  were
         to be made after September 30.




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            It was not till later that moves were begun in the
        Congress to reprieve the programs marked for extinction.
        On May 31.st the House passed an extension Bill Authorizing
        $159 million for RMP.  The vote was 372 to 1.  on June 5th
        the Senate passed the House Bill by 94 to 0, and on June
        1.8th the President signed the extension Act providing  another
        year of life for RMP and the other health programs.  A tele-
        gram on June 28th formally notified the RMPs of  the  extensions
        and telegram assured RMPs of viability through September 30,
        1.973.  On July 10th a $6.9 million balance of 173 funds was
        distributes, but the awards prohibited their expenditure
        except for purposes to be specified later by  HEW.  (They  never
        were.)
            Meanwhile, the appropriation process had begun in the
        House which approved an RMP Appropriation of $81,953 million
        for Fiscal 1973, and at the beginning of Fiscal Year 1974 on
        July 1, 1,973, the President signed a Continuing Resolution  in
        the same  amount.  During August various spending plans were
        developed for support of RMPs during the Fiscal  1974  extension
        period and on August 23rd $41,236 million was  approved  intern-
        ,ally in HEW for RMP grants in Fiscal 1974.  on the same
        date  $17.1 million was release to keep RMPs in business through
        December 31, 1973. An additional $2 million  was  reserved  for
        continued support of pediatric pulmonary centers.  on September
        7th each RMP was notified by telegram of its share of the $17.1
        mil.lion and on September 20th a letter went to all RMPs  again
        extending the program's termination date, this time through
        June 30, 1.974. All of the decisions about Fiscal  1974  funding
        apparently were made at the Assistant Secretary for  Health  or
        higher levels within the Department.
             On November 12, 1973, RMPs submitted applications  for  the
        remaining Fiscal '74 funds.  These were awarded on December
        28th for a 6 month period, January thru June  1974.  The  awards
        included $24,136 million for RMPs (the full amount allocated
        by HEW in August minus the $17.1 million already  awarded)  and
        $74.444 for pediatric pulmonary centers.  The $6.9 million
        Fiscal '73 balance awarded on July 10th, however,, continued
        to be restricted.






                                       (3)









             While the application and award  process  for  released
        Fiscal 174 money had been going on, there  were  other  important
        developments on the judicial and legislative fronts.  on
        September 21st the National Association  of  Regional  Medical
        Programs filed suit for release of all  appropriated  funds.
        On December 13th Congress actually  appropriated  $81,953  million,
        including a 4.5 million arthritis earmark, for  Fiscal  '74.
        This was almost twice the level allocated and awarded by HEW,
        and on February 7, 1974, the Federal District  Court  for  the
        District of Columbia ordered the release  of  all  impounded
        Fiscal 173 and 174 RMP funds. The  Court  Order  also  prohibited
        placing restrictions on the expenditure of  the  released  funds.

             Action to carry out the Court  Order  followed  quickly.  On
        February 22nd HEW release $89,631 million  in  previously  im-
        pounded Fiscal '73 funds. On March  6th  a  letter  rescinding
        the phaseout per the Court Order was sent to  all  RMPS.  On
        March 7th the $6.9 million Fiscal '73 balance  was  released
        for expenditure and reallocated among the RMPS.  Simultaneously
        al.1 RMP budget periods were extended through  June  1975.  on
        March 7th instructions were sent to all RMPs on  how  to  apply
        -for the unimpounded Fiscal '73 and 174 money.  Two  review  cycles
        were established, one for June and one in August.  A quarter of
        the released funds were reserved for  2nd  cycle  applications.

             on June 13th $84.4 million was awared to  51  RMPs  and
        $4.3 million was awarded for  arthritis  projects.  On  August
        8th $27.3 million was awarded to 47 RMPs and  on  October  20th
        $5 million in contracts for "planning  technology"  was  alloc-
        ated under Section 91.0 per a modification of the Court Order'.
        This completed the distribution of the funds released  as  a
        result of the lawsuit.

             on January 4, 197-@, the President signed P.L.  93-641,
        the National Health Planning and Resources  Development  Act  which
        replaced the RMP, CHP (Comprehensive  Health  Planning)  and
        Hill-Burton (Medidal  Facilities  Construction)  programs.  The
        new law, however, had special transitional  provisions  in  Section
        5 (a) permitting continuation of RMPs until the later of June
        30. 1976 or establishment of successor Health Systems Agencies.
        This set of developments required  additonal  appropriations  for
        support during the transitional year.




                                       (4)






            Although a Continuing Resolution passed in March 1975
        provided $75 million for RMP transition, accompanying Con-
        gressional reports recommended delay in obligating this full
        amount before the passage of the actual Appropriation.  The
        latter was not enacted until June 12th and contained only
        $150 million for RMP including a half million earmark for
        Public Accountability Reporting (PAR).  The appropriated
        funds were awarded on June 27th to support RMPs for a full year
        through June 30, 1976. The earmarked funds were awarded  for
        a two year evaluative study in accordance with Congressional
        intent.
            As June 1976 approached, final preparations were made
        for RMP phaseout.  The National Association of RMPs met on
        March 15th in Kansas City and proposed a common July thru
        September 30th phaseout period for all RMPS.  On April 9th
        RMP and Federal officials met in Boise to develop and  agree
        upon phaseout guidelines which were issued on April 30th.
        These were followed by meetings for eastern and western RMPS,
        respectively, to review closeout procedures.
             Then, on June 1, 1976, Congress appropriated another
        @10 million additional to continue "exemplary" RMP  projects
        like those identified in a PAR report issued earlier in April.
        The RMPs through their own committee structure  organized  a
        series of regional meetings and a national meeting to review
        projects  and priorities for applications and submitted total
        requests for funds within the $10 million available for award.
        Essentially the funds were awarded on the basis of a formula
        recommended by the RMPs themselves.
             Finally on July 10, 1976, instructions were issued  for
        reauthorization of balances for support of continuing projects
        and all necessary arrangements for use of these funds were
        made in a frenze of paperwork prior to September 30, 1916,
        the termination date for RMPS. Over $16 million  in  special
        project giants will be available for final support of the
        remaining projects over the next year, with a few continuing
        beyond that.
              Having reviewed recent history, perhaps it will be useful
         at this point to go back over the whole life span of the RMP
         program,, to  ut these and other events into a la rger context,
                     p
         and to see if any useful conclusions can be drawn.

                                     (5)






              In this regard, perhaps a review of  the  whole  period
         will be helpful. Beginning with the  passage  of  P.L.  89-239
         in 1966, the RMP program spanned 10 years  during  which  it
         allocated about 3/4 of a billion dollars.  During those years
         the country focused its attention on many  major  issues  includ-
         ing the "war on poverty", the activest phases  of  the  Civil
         Rights movement, the Vietnam War, Watergate, the energy crisis,
         inflation, and the rise of consumerism.
              The era encompassed all or part of 3 Presidencies, those
         of Johnson,, Nixon,, and Ford. -During that time there were  6
         Secretaries of Health, Education'and Welfare: Gardner, Cohen,
         Finch, Richardson, Weinberger and  Matthews.  There  were  5
         Assistant Secretaries for Health:  Lee, Egeberg, Du Val,
         Edwards and Cooper.
              The RMP program successively was in  3  different  agencies,
         NIH, the Health Services and  Mental  Health  Administration
         (HSMHA), and the Health  Resources  Administration  (HRA).  It
         also was located in 5 different Bureau or  Division  level  units
         within those agencies. At NIH,  the  program  was  administered
         by the Division of Regional Medical  Programs.  In  HSMHA  it
         retained the Bureau level status as the Regional Medical
         Programs Service, and within HRA it has  been  placed  success-
         ively in the Bureau of Health Services  Research,  the  Bureau
         of Health Planning and Resources Development.
              The RMP program has been under 9  agency  Directors  (some
         of whom acted only for very  short  periods):  Shannon,  Marston,
         Lewis (acting)4 English, Wilson, Sencer (acting)., Laur (acting),
         Buzzell (acting), and Endicott. The  program  itself  has  been
         managed directly by 7 Directors or  individuals  who  effectively
         were in charge: Marston,  Olsen,  Margulies,  Pahl,  Chambliss,
         Gardell, and Baum.
              The program, at different stages,  had  two  essentially
         different modes of operation, initially  project  by  project
         technical review at the Federal level,  and  then  roughly  since
         1970, a form of revenue sharing in which  project  review  re-
         sponsibility was decentralized directly to  the  grantees  who
         acted within Federally prescribed standards.




                                        (6)







              'What good did all the money and effort do? What  lessons
         can be learned? What does it all mean? In  the  brief  time
         available. I'd like to suggest a few answers.  Change,  once
         it occurs, is often taken for granted, and those who are  in-
         volved often fail to experience and recognize the change  an
         evolution that is going on around them. In the last  10  years
         there have been many institutional changes in health and  RMP
         has contributed sometimes minimally, and sometimes  signifi-
         cantly. to a number of these.

              What do I mean when I sp eak of an institutional  change
         in health? Let me illustrate a few examples more  related  to
         RMP. When the Courts converted alcoholism from a cr3  e  to
         a disease, that was an institutional change in health.  'When
         the birth rate drops and behavioral standards change  because
         of the pill, that is an institutional change in  health.  When
         psycho-active drugs and early treatment reduce the  population
         of mental institutions, that is an institutional change  in
         health.  But there are other examples closer to home.

              A few months ago, for instances, my nine year old
         daughter spent a day with me at the office during a  school
         holiday   I took her to lunch along with  some  coworkers.
         We were sitting in the "no smoking" section of the  cafeteria
         when someone at the table took out his pipe and lit  it.  My
         daughter pointed to the "no smoking" sign and said,  "This
         is the 'no smoking' section, and anway smoking isn't  good
         for you that.is an institutional change in  health.  Similarly
         when I was offered a choice of the "smoking" or "no  smoking"
         section of the plane coming here yesterday, that is an  in-
         stitutional change in health. Also, on a  personal  level,
         when I go to the supermarket, like many others, I read  labels
         for cholesterol, additive content, and caloric  value.  The
         advent and use of nutritional food labels is another  inst3t-
         utional change in health.
              While ten years ago, coronary and intensive care  units
         were relatively new, they have now become commonplace and  are
         familiar to a large part of lay public through personal  ex-
         perience of that of a relative or friend.  The  proliferation
         of these units is also an institutional change in  health.




                                       (7)







            Where I live, we have a well equipped  emergency  medical
        system that supposedly can respond to a call within 3 minutes.
        There is now a national effort to establish EMS systems,  and
        that is an institutional change in health.  Likewise,  kidney
        dialysis and transplant networks are being established nation-
        ally and financing mechanisms have been set up under  Social
        Security.  Just as an example of how familiar this is becoming,
        only recently an Archie Bunker episode on T.V.'had to do with
        signing an organ donor card. When  transplantation  becomes
        subject matter for a popular T.V. program, that, too, is  an
        institutional change in health'.
             Now, I don't want to suggest that RMP has been responsible
        either wholly or even primarily for all the noted changes  or
        that this brief recitation is an exhaustive list, but  RMP
        certainly was a force, that together many others, helped  to
        raise national consciousness about smoking and diet  habits.
        it equipped myriad coronary care units and trained  thousands
        of professionals to serve in them. It likewise  trained  many
        an EMS technician and gave impetus to initiating and improving
        the nation's EMS systems. It also provided a head  start  for
        the kidney program currently institutionalized under  Section
        '299 (i) .
             In general in our society, it seems to me that what needs
        to be done usually gets done even though the  institutions
        through which change is accomplished change themselves and evolve
        over time. Therefore, any given program should be  seen  as
        part of a continuum of events rather than an isolated  phen-
        omenon. Most programs inherit from their  predecessors  and
        hand things on to their successors.  The current planning law
        P.L. 93-641, for instance, can trace its ancestry  o  non-
        governmental planning efforts in Rochester and New York  City
        about 40 years ago. These gradually spread to about  a  dozen
        other places and in the 50's the Hill-Burton Medical Facilities
        Construction Program, encourage and financed the proliferation
        of planning agencies to about 85 areas.  The Hill-Burton effort
        was succeeded by the Comprehensive Health Planning  program,
        and planning now presumably will be institutionalized in  a
        stronger and expanded form under the new Health  Resources
        Planning legislation.




                                     (8)







             If one looks at RMP activities, these too form  a  part
        of a continuum    The spread of specialized  coronary  care
        units is, at least in part, an outgrowth of  prior  intensive
        Hill-Burton efforts to popularize "progressive patient care"
        a concept in wi@ich the complexity of services is scaled  to
        patient needs from "intensive care" to  "home  care".  Inten-
        sive care and coronary care units were just starting  to  catch
        on at the time RMP came into being and.as I have  noted,  the
        program played a major role in  their  institutionalization.
             Likewise, there was a specialized kidney effort  in  the
        Old Chronic Disease programs. Dialsis  and  transplant  efforts
        were picked up by RMP after the kidney amendment,  and  now
        these two have been permanently institutionalized.
             The Diabetes and Arthritis program which  also  existed
        under Chronic Diseases effort was phased out in  the  early
        1970's but Arthritis activities were  initiated  once  again
        through the earmark two years age, and now it  appears  that
        the Arthritis effort too, will continue under  NIH  through
        new legislation.
             HSEAS, emergency efforts and many  activities  spun-off
        from RMP to local funding over the years will  also  continue
        to operate.
             A man in our office has a sign on his desk  that  says
        "you can get a helluva lot of work done if you don't  care  who
        gets the credit." and that is probably true.  Even  if  the
        world little notes what RMPS, in concert with  other  forces,
       "have done, nevertheless the products are there and  in  many
        cases the work will continue though in  different  settings,
        and under different financing mechanisms.

             Now that the program is over, there is no  reason  for
        sadne s at its parting. It has done its job  in  relation  to
        the times the resources and the problems at  hand.  In  the
        future there will be new problems and new issues.  Ten years
        from now current health issues like swine flu, right to die,
        malpractice insurance, occupational  and  automotive  safety,
        national. health insurance, etc. will disappear from the  head-
        lines because new and accepted institutions will  have  been



                                     (9)'








        created through evolution of rules, technology and  attitudes.
        In the future as now, when the changes occur, the agents  of
        change, the Governmental programs, the voluntary efforts,  the
        private philanthropy all will be forgotten. Only  the  results
        of the work will survive adn really that is all that  matters.

             In the last years of the program it has been  reprieved
        from extinction 4 times and been buffdted with changing
        directives.  In this time the program has displayed great
        resiliency largely because it had a dedicated staff and
        volunteers who believed in what they were doing, because  it
        had positive purposes, because it was decentralized and  able
        to operate largely without Federal interference, and  because
        the RMPs themselves picked up on evaluation and administration
        when the Federal Government dropped the ball.

             The RMP program, looking back, has had a long and  useful
        existence and much of what it has done has been woven into the
        fabric of American life. That is a record of which  all  who
        participated over the years can be jtstly proud.  But, for
        all those who are here today, and all who worked through  the
        .final trying period of uncertainty, confusion and chaos,
        there is that special pride that belongs to those who know
        that through it all they have done their 'obs, and done  them
        well, and served the public and survived   with honor.
























                                      (10)